Analysis

Misleading roles: why the public can’t rely on the job title ‘nurse’

Unregistered staff in ‘nurse’ roles, and ‘advanced’ titles misused, survey reveals

Unregistered staff in nurse roles, and advanced titles misused, survey reveals

  • The title registered nurse is protected in UK law but nurse is not
  • Some staff have the word advanced in their title without having the relevant skills and qualifications
  • Streamlining the range of nurse job titles can offer greater clarity and support for patients, particularly in specialist areas

Use of the word nurse in the job titles of unregistered support staff remains widespread in the NHS, according to front-line nurses.

Registered nurses have told Nursing Standard that the practice confuses patients and staff alike and some believe it risks the reputation of the profession.

Titles can cause confusion for patients

The term nurse has become diluted, one respondent told Nursing Standards image of nursing survey. Non-qualified staff [being] associated

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Unregistered staff in ‘nurse’ roles, and ‘advanced’ titles misused, survey reveals

  • The title ‘registered nurse’ is protected in UK law – but ‘nurse’ is not
  • Some staff have the word ‘advanced’ in their title without having the relevant skills and qualifications
  • Streamlining the range of nurse job titles can offer greater clarity and support for patients, particularly in specialist areas

Picture: David Mitchell

Use of the word ‘nurse’ in the job titles of unregistered support staff remains widespread in the NHS, according to front-line nurses.

Registered nurses have told Nursing Standard that the practice confuses patients and staff alike – and some believe it risks the reputation of the profession.

Titles can cause confusion for patients

‘The term “nurse” has become diluted,’ one respondent told Nursing Standard’s image of nursing survey. ‘Non-qualified staff [being] associated with the term nurse can confuse the public.’

Around 2,000 nurses in the UK responded to our survey, which covered issues including job titles and perceptions of the nursing profession. 

One nurse recalled that when a vacant breast care nurse post at their trust was filled by a healthcare assistant (HCA), they retained the title ‘breast care nurse’.

Another respondent said: ‘HCAs have different titles in the trust, and some have the word nurse in the title, which is misleading for patients.’

47%

of nurses believe their colleagues’ job titles do not accurately reflect their skills and experience

(Source: Nursing Standard image of nursing survey 2019)

‘I have a colleague who is a qualified cognitive behavioural therapist,’ said another. ‘Her title of “support nurse” is unclear.’

Nursing titles and the law

The title of ‘registered nurse’ is protected in UK law.

Chief nursing officer (CNO) for England Ruth May tells Nursing Standard: ‘The title demonstrates that a specific standard of education, training, conduct and performance has been met, which means our patients can depend on a high level of care and treatment.

‘Having a strong professional identity for nurses is essential, as it shows that their high level of skill and knowledge remains up to date and that professional standards have been met.’

But while ‘registered nurse’ is protected, the title of ‘nurse’ is not.

Trusts urged to restrict use of the word nurse in job titles

Our image of nursing survey follows a Nursing Standard investigation in 2018, covering 143 NHS acute, mental health and community trusts, which found that 93% employed unregistered support staff in posts with titles containing the word nurse.

‘If you are employed as a clinical nurse specialist at band 3 or 4, that says more about your employer and their respect for the profession than it does about the person doing that job’

Alison Leary, chair of healthcare and workforce modelling, London South Bank University

This investigation echoed the findings of a study by London South Bank University chair of healthcare and workforce modelling Alison Leary, which was published in 2017.

It prompted Dr May, then NHS Improvement executive nursing director, and Jane Cummings, her predecessor as England’s CNO, to write to trusts, urging them to use the word ‘nurse’ only when the postholder was a registered nurse.

Protections for the job title ‘registered nurse’?

The titles of ‘registered nurse’ and ‘midwife’ are protected in UK law. The Nursing and Midwifery Order 2001 makes it an offence for someone to:

  • Falsely represent themselves as being on the Nursing and Midwifery Council (NMC) register
  • Use a title to which they are not entitled
  • Falsely represent themselves as having qualifications in nursing or midwifery, according to NMC guidance

Other countries extend these legal protections further. According to the Nursing and Midwifery Board of Australia, the titles of nurse, registered nurse, enrolled nurse and nurse practitioner are all protected under the Health Practitioner Regulation National Law Act.

In New Zealand, the Health Practitioners Competence Assurance Act 2003 states that no one can call themselves a nurse, or imply that they are a nurse, unless they are registered and hold a current practising certificate issued by the Nursing Council.

The American Nurses Association says 39 US states have made it clear in their respective Nurse Practice Act (which sets out education, practice standards and the code of conduct) that the title ‘nurse’ is restricted to those individuals who have fulfilled certain requirements.

 

The title ‘nurse’ can apply to other professions, too

Many within the nursing profession believe it is time for change.

‘The title “nurse” should be protected and only used by those on the register,’ said one survey respondent. ‘Because it is not protected, the word has become confused and it can be difficult to ascertain who is who.’

Responding to our survey findings, NHS England and NHS Improvement say the word ‘nurse’ is much harder to protect than ‘registered nurse’.

They add that the word covers a number of other professions, such as nursery nurse and veterinary nurse, and is a common verb as well as a noun.

What about ‘advanced’ titles in nursing?

In 2017, Health Education England, the body responsible for workforce training, issued guidance on advanced clinical practice that urged trusts to police the use of the word ‘advanced’ in job titles.

The guidance set out the skills and competencies required before an individual could be called an advanced clinical practitioner, such as being registered with their professional regulator, possessing a master’s-level qualification, and being involved in leadership, management, education and research.

Yet 47% of the nurses who responded to Nursing Standard’s image of nursing survey said they did not feel their nursing colleagues’ job titles accurately reflected their level of skills and experience.

‘So many roles, but little understanding of the various roles and seniority’

Respondent, Nursing Standard image of nursing survey

‘We have “clinical nurse specialists” with no specialist knowledge. It’s simply a title,’ said one respondent.

Another said: ‘Some nurses have years of experience in their job – some have a title of advanced nurse practitioner and have little experience.’

One commented: ‘Clinical nurse specialist implies that the nurse is working at an advanced level, which is not always the case.’

Patients need to be able to rely on specialist nurses as advocates


Alison Leary: Job titles that don’t reflect
nursing skills are ‘a worrying development’

Professor Leary says issuing staff with job titles that do not reflect their skills and experience is ‘a form of deception’ on the part of employers, and is a worrying development in nursing.

‘Specialist and advanced practice nurses are advocates for the profession, and they use their expertise to advocate for patients.

‘We have seen that with different areas in cancer, for example, having a clinical nurse specialist expert advocate for you means your survival rate is better.

‘So employing these people without those skills and qualifications to do that work is a risky thing to do.’

31%

of nurses say their own job title does not reflect their skills and experience

(Source: Nursing Standard image of nursing survey 2019)

Professor Leary says inaccurate job titles also leave the public confused about who they are seeing.

Job titles matter ‘when things go wrong’

‘What we found in the past is that job titles do matter, not so much when things go right but when things go wrong – people care very much about who treated them.’

She adds that the reason behind such a proliferation of job titles could stem from employers’ perceptions of their registered workforce and the lack of value placed on their roles.

‘People often take job titles as a reward, rather than money,’ she says. ‘And if you [are employed] as a clinical nurse specialist at band 3 or 4, that says more about your employer and their respect for the profession than it does about the person doing that job. 

‘It is quite disrespectful, it devalues the work of professional nurses and devalues the work of the support workforce. 

‘If you don’t know what levels people are working at, you could assume someone is underperforming.

‘The support staff are the biggest part of the workforce, and being able to make their contribution visible is really important – their contribution risks being lost.’

How one trust streamlined its range of job titles

Some NHS employers have been proactive in tackling the proliferation of job titles.

In December 2015, Imperial College Healthcare NHS Trust’s director of nursing Janice Sigsworth commissioned a project to examine nursing and midwifery job titles at the London trust, with the aim of streamlining and simplifying job titles used for nurses, midwives and support staff.

The analysis found 11 different titles describing 15 nurse or midwife educators, and 46 different titles describing 74 senior nurses.

After engaging with front-line staff and patients, the trust reduced the core list of job titles to 12, working with human resources to embed the changes.

Professor Sigsworth said: ‘The project highlighted a need for clarity in the titles of nursing and midwifery staff, for the benefit of both our patients and our colleagues, to help improve everyone’s understanding of roles and responsibilities.

‘We still have more work to do to roll out and embed the policy; it is a significant change that needs to be made over time. We’re now part of the chief nursing officer for England’s Shared Governance and Collective Leadership programme, which gives us some great opportunities to progress it further.’

 

Nursing experience being under-sold

When asked about their own job title, more than a third (37%) of respondents to our survey said it did not reflect their skills and experience as a nurse. 

Some believed their experience and specialist skills were being under-sold by their job titles.

‘In oncology, band 5 is still [known as] “staff nurse”. They’re a lot more skilled than that,’ said one respondent.

‘Even band 5 is a bit of an insult, as they have to take on master’s credits to be able to give anti-cancer therapies, take blood cultures or activate a sepsis pathway without a doctor.’

Another said: ‘A band 5 registered nurse could mean someone newly qualified or someone with 20-plus years of experience.’

This is echoed by another respondent: ‘Confused. So many roles, but little understanding of the various roles and seniority. Different banding for the same job and working above banding [is] a problem across various roles.’

Patients ‘should not be misled by rebranding of posts’


RCN director of nursing, policy and
practice Susan Masters

Responding to our survey findings, RCN director of nursing, policy and practice Susan Masters says she is ‘alarmed’ to hear that employers are applying the title of nurse, nurse specialist or advanced clinical specialist to individuals who have not had the appropriate training.

‘Patients should be able to receive treatment in the confidence that the caregiver has received the level of education required to perform the role safely and effectively,' she says.

‘They should not be misled by any employer-led rebranding of posts.’

Ms Masters adds that, as a highly skilled profession, nursing must be ‘properly valued’.

‘This not only means ensuring that nurses receive the correct pay for the job that they do, but also that appropriate titles are used and that nobody is asked to consistently perform tasks outside of their competencies and qualifications.’


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