As the first nursing associates get ready to register, we ask what their impact will be

The first cohort is about to join the rest of the nurse workforce in England

The first cohort is about to join the rest of the nurse workforce in England

Student nursing associates get some hands-on training. Picture: John Houlihan

The first ever cohort of nursing associates will qualify at the end of January after two years of training.

The England-only role was developed to bridge the skills gap between healthcare assistants and nurses.

It is hoped that nursing associates will free up time for nurses to spend on more complex clinical duties. They will have the opportunity for further education and training, and to progress to graduate-level nurse.

28 January 2019

The nursing associates section of the NMC register opens

However, the role, which will be regulated by the Nursing and Midwifery Council (NMC), has not been without controversy, with critics concerned about nursing associates' scope of practice.

Questions have been raised over whether the government has met what looks now like an ambitious target number for one of its flagship new routes into nursing.

We asked the Council of Deans of Health (CoDH), the RCN and the Queen’s Nursing Institute (QNI) some key questions about the impact the first qualified nursing associates might have on the NHS workforce in England. Their responses are summarised in italics.


What will be the biggest challenge for the new nursing associate graduates starting work?

Managing the limitations of their skills, settling into the workforce and finding a clear career path

There has been a lot 'negative noise' about nursing associates, according to CoDH executive director Katerina Kolyva. She says this has been an 'emotional response' to what is actually a 'positive way to upskill the profession'. But she says risks must be managed.

Katerina Kolyva, executive director
of the Council of Deans of Health. 

QNI chief executive Crystal Oldman expands on this, saying that nursing associates must understand the limitations of their competence and agree not to work beyond them. They and their employers will need to ensure they are keeping to NMC standards for the role.

Dr Oldman adds that they need to find a clear pathway.

'It's going to become increasingly important to see a career pathway explored, debated and described for nursing associates that provides more than a route to becoming a registered nurse (RN),' she says.

But as the 'new kid on the block', nursing associates will also need to find their own place in the nursing workforce. As QNI programme manager Sharon Aldridge-Bent adds: 'An additional challenge will be around nursing associates' transition to a new and emerging role in an already established workforce.'


Will the new nursing associates help with the number of nursing vacancies in England?

No. They are in addition to, not substitutes for nurses. Only agreed and adhered-to safe staffing levels will ease the crisis

The value of the education and experience of the nurse has to be maintained as a patient safety issue, says Dr Kolyva.

'You need certain skills for certain interventions, so as long as nursing associates are used in the right way and not substituted, the agenda for them is a positive one.'

She adds that while an 'upskilled' workforce is a positive development, only a 'safe staffing approach' can ensure the right number of nurses. 'It is about time we had that discussion,' she says.

Crystal Oldman, chief executive of
the Queen's Nursing Institute.
Picture: Barney Newman

Dr Oldman adds that it is important to note the work by nurse researcher Linda Aitken, which shows a direct relationship between a lower percentage of nurses in the workforce, and increased patient mortality.

'Nursing associates should not be helping to substitute for registered nurse vacancies, and have a role which is separate to but different to them,' Dr Oldman says.


What will be the biggest challenges for nurses working with the new nursing associates?

Having confidence in nursing associates' abilities and, for those overseeing them, ensuring adequate supervision 

Ultimately, responsibility and accountability for the patient's care remains with the nurse. Ms Aldridge-Bent says nurses will need to feel confident that the newly qualified nursing associate is fit to practise at a level that does not require supervision.


The NMC's registration fee for nursing associates

Supervision and the delivery of practice placements will be key, says Dr Kolyva.

'We are making nursing education more complex by adding more and more routes and, as a result, the struggle will be in delivery on practice placement capacity and ability of [those supervising].

'Many people will say supervision support is in place, but this remains to be seen, so it is a risk and a worry,' she says.

Support is also needed for those nurses supervising the new nursing associates, says Dr Oldman, including induction, preceptorship and further training to develop their role.

How will nursing associates take the pressure off nurses?

Nursing associates must meet a range of standards of proficiency in order to join the nursing associate section of the Nursing and Midwifery Council (NMC) register.

Recording and interpreting vital signs is among the nursing associate's competencies. Picture: iStock

At the point of registration, the nursing associate will be able to demonstrate competence in around 60 procedures, which will then free up nurses to undertake more complex care. These include tasks such as:

  • To measure weight and height, calculate body mass index and recognise healthy ranges and clinically significant low/high readings.
  • Take, record and interpret vital signs including temperature, pulse, respiration and blood pressure and note improvement, deterioration or concern.
  • Undertake venepuncture and routine ECG recording.
  • Observe and monitor comfort and pain levels and rest and sleep patterns.
  • Observe and reassess skin and hygiene status to determine the need for support and ongoing intervention.

Torbay and South Devon NHS Foundation Trust chief nurse Jane Viner said: 'The nursing associate role will be a critical part of the multidisciplinary team that includes primary care, mental health, social care, voluntary and independent sector colleagues. I look forward to welcoming future trainees.'


Around 40% of nursing associates have indicated they want to go on to become nurses. How will this affect the workforce in the near and more long-term future?

The nursing associate role is an attractive route but the real answer to the staffing crisis is resolving nursing student funding 

RCN deputy director of nursing Stephanie Aiken says: 'The most efficient route to become a registered nurse remains the direct-entry graduate route.

'The changes to student funding in England have impacted on applicants via this route and this needs to be addressed if we are to resolve the domestic recruitment crisis.'

Nursing associates need to feel supported and motivated to continue their nursing careers, says Ms Aldridge-Bent.

Sharon Aldridge-Bent, programme
manager for the Queen's Nursing

But she says hand-in-hand with that is ensuring the existing workforce is not diminished and ensuring nursing roles are deemed an attractive career option.

Workforce plans need to accommodate the potential loss to nursing associate staffing but also the potential gain in nurse numbers, Dr Oldman says.


What about the rest of the UK, where the nursing associate role has not been introduced?

Answers are needed on what happens if England's nursing associates move elsewhere in the UK for work. Research is needed on their impact in England

Dr Kolyva is intrigued about a lack of mobility for nursing associates, who are confined to practice in England, even though their registration is with a UK-wide regulator.

'Scotland, Northern Ireland and Wales are adamant nursing associates will not practise in those countries, but there is an interesting philosophical debate as to how they could stop a private UK provider.'

Meanwhile, Dr Oldman is calling for research into the effects of the role in England, as opposed to its absence elsewhere in the UK.

How many nursing associates have entered training?

The government is cagey about the exact figure, while Council of Deans of Health executive director Katerina Kolyva says: 'My understanding is there have been difficulties getting adequate numbers.'

What were the targets?

2017 2,000 nursing associates to begin programmes as part of a pilot

2018 5,000 more should have entered training. Despite this, a response to a parliamentary question revealed only 1,018 had been recruited by Easter 2018

2019 A further 7,500 are promised

Neither the Department of Health and Social Care or Health Education England (HEE) would confirm how many had started training programmes.

An HEE spokesperson says: ‘A final figure will not be available until the end of next month.’

Further information

Research on nurse staffing and patient mortality

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