What is the difference between the skills of assistant practitioners and nursing associates?
Their titles may confuse, but assistant practitioners and nursing associates can help relieve pressure across primary care
Their titles may confuse, but assistant practitioners and nursing associates have the knowledge and skills to relieve pressure on primary care and community nurses
The assistant practitioner is an established band 4 support role that was introduced to bridge the gap between healthcare assistants (HCAs) and registered nurses.
Assistant practitioners undertake a two-year foundation degree and develop core competencies to equip them to provide this extended support.
When introduced in primary and community care, the role can help to free up community and district nurses to provide advanced care to people with complex needs.
However, the role of assistant practitioner is unregistered and unregulated, and this is leading to regional variations. For example, people working in this role could also have the title of associate practitioner, primary care assistant practitioner, community health assistant practitioner or assistant nurse practitioner.
There is also a new addition to nursing teams in England – the nursing associate. This role is regulated by the Nursing and Midwifery Council (NMC). The first qualified nursing associates joined the NMC’s register on 28 January.
The nursing associate role is also designed to bridge the gap between HCAs and registered nurses. Both stand-alone roles offer career progression for HCAs. As well as the advantage of being regulated, the nursing associate role provides a progression route into graduate-level nursing.
Angie Hack is a district nurse and a project manager at the Queen’s Nursing Institute. She was course director for the foundation degree programme for assistant practitioners in primary care at London South Bank University until 2015.
Dispelling some myths
‘Nursing associates are now regulated under the guise of an apprenticeship but essentially they are undertaking the same two-year foundation degree training as assistant practitioners,’ says Ms Hack.
‘I heard someone say that nursing associate training is completely different, implying that the assistant practitioner training is generic. There’s a lot of myths about what being an assistant practitioner means and what their training entails.
‘Both roles require trainees to achieve a level 5 foundation degree qualification. We are moving away from the importance of acknowledging that whether they are called an assistant practitioner or a nursing associate, they have the required level of knowledge and skill to work at band 4 level. That is the crux of it.’
Community practice teachers have expressed concern at the variations in the assistant practitioner role, both in terms of job titles and scope of practice. They feel some assistant practitioners seemingly offer more clinical competencies than others.
Ms Hack says this is a result of regional differences in what assistant practitioners are allowed to do within their role. It is not a reflection of their comprehensive training.
‘It varies across the UK how the assistant practitioner role is used,’ she explains. ‘For example, some assistant practitioners administer vitamin B12 injections and give clexane (enoxaparin) anticoagulant injections, but not all areas and organisations allow this. In the area where I work as a district nurse, they do not encourage B12 injection administering by assistant practitioners just yet.
Regulation and remit
With the emergence of the first cohort of qualified nursing associates and their Nursing and Midwifery Council (NMC) registration, there has been concern that this could negatively affect assistant practitioners. The two roles require education to the same level and a high degree of clinical competence, yet only one is regulated.
There are similarities, but while assistant practitioners are highly skilled in their specific area of practice, the nursing associate role has a wider remit. Nursing associates must develop transferable skills and competencies that enable them to work across a range of settings and specialties.
Placements undertaken during nursing associate training cover home, close to home and hospital.
South Tyneside and Sunderland NHS Foundation Trust trainee assistant practitioner Andrea King says she is happy in her role and is enthusiastic to learn more competencies and skills. She does not feel demotivated by the NMC’s regulation of the nursing associate role. ‘We should be embracing the amount of knowledge and skills that the roles have rather than comparing the two,’ she says. ‘The assistant practitioner role makes a real difference.’
‘In some cases this can lead to assistant practitioners feeling stifled. They could be kept in a band 3 role simply because others do not understand what a band 4 role entails or can offer. It has happened in many cases where people end up going back to what they were doing before.
‘When I was running the foundation degree programme we had instances where people were being trained to become assistant practitioners and, by the end of the two years, there was no job for them to move into or even a role that they could apply for.’
This was the situation facing South Tyneside and Sunderland NHS Foundation Trust trainee assistant practitioner Andrea King. Ms King had worked as an HCA in the community planned care team covering the South Shields area for more than nine years before starting her foundation degree.
Backing up earlier support
Lead integration nurse for South Tyneside community integrated teams Diane Shotton says: ‘There was a need for a band 4 role in the community planned care team as there was a gap between our band 5 staff nurses and our HCAs, and the range of care they can provide.
‘However, we were unable to promise Andrea a band 4 role and there was not an existing role for her to move into. It would have been sad if we had supported her through her training and there was nothing at the end. What a waste that would have been for Andrea, her team, the trust – everyone.
‘That is why I pushed for a role to be created to use her extended training and skills. We created a role and a job description that suited Andrea’s competencies and what the team needed.’
Ms Shotton says training is essential to prepare HCAs to move into assistant practitioner roles. Ms King has a detailed competency file which documents each extension to her role as she learns further skills.
‘We have been strict on her training and competencies to ensure the care she provides is safe for herself and patients. As an HCA, Andrea could not have done catheterisation, compression bandaging or PEG (tube) feeding. She has gained those competencies through her training,’ says Ms Shotton. ‘She can also administer tinzaparin injections and carry out incontinence assessments.
‘Andrea has done a similar level of training to what registered nurses would do around compression bandaging, wound management and incontinence. We will continue to add competencies and our district nurses offer suggestions for skills Andrea could develop to help free up their time a little more. An example is incontinence assessments, which she is now competent in. We are hoping to upskill Andrea to be able to administer intramuscular injections next.’
Patients are positive
Ms King can help other teams with their care needs such as compression bandaging, PEG feeding and catheter care, but she is not allowed to administer insulin or enoxaparin injections outside of her own team.
As part of her role, she carries out independent home visits and runs her own clinics such as a leg ulcer clinic. ‘The role has benefited the team, and patient feedback has been highly positive,’ says Ms Shotton.
Ms Hack says: ‘Assistant practitioners are key to the primary care workforce. Their knowledge and competencies can help to release senior staff to undertake more complex care and use their advanced skills. There is an ongoing need for the role as there is a limit to what HCAs can do, while community and district nurses are endlessly busy.”
‘Patients call me the inbetweener’
When asked whether patients understand what her role is, South Tyneside and Sunderland NHS Foundation Trust trainee assistant practitioner Andrea King explains they have a number of names for her. ‘Patients refer to me as the inbetweener, the vet, the paramedic or simply the one in green, and I am happy to answer to any of those,’ she says.
‘A lot of our patients are older people, and I try to explain my role by talking about enrolled nurses who also wore the green uniform. Many of my older patients can remember those nurses and the boundaries of their role. For example, that they could not give controlled drugs or provide care to highly complex patients, but they could provide wound management or catheter care.
‘One of the main benefits of my role is maintaining reliability and continuity of care. I recently had a patient who required regular changes to his compression bandaging to treat severe leg ulcers. Within eight weeks his legs had healed and the continuity of care I was able to offer was central to this.
‘My role also benefits the team’s band 5 and band 6 nurses, as they can offer continuity of care to patients with greater and more complex needs. Although I do not go out to see palliative patients, I can assist the district nurses by doing injections and compression bandaging. I am aware of the boundaries I have in my role and feel safe and confident working within that remit.’
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Julie Penfold is a health writer