The nursing associate is part of the worrying expansion of support roles – perhaps it’s time we protected the term ‘nurse’, argues June Girvin

In their workplaces, registered nurses are supported by a range of assisting roles – for example, nursing assistants, healthcare support workers and assistant practitioners.

These roles and functions vary across employers but they all work under the supervision of a registered nurse, who remains accountable for nursing interventions and treatments.

These support roles are reasonably well established and in most cases have appropriate education and preparation. In 2016 the introduction of an additional support worker role – the nursing associate –  was announced by government. The rationale  was to create a role that “bridged” the functions of the existing support roles and the registered nurse.

A bridge that might easily have been constructed by “skilling up” existing roles, providing a coherent career pathway and saving time, money and effort. I have seen no convincing arguments for a completely new role, and I know that I am not alone in finding this an odd way forward.

Competing interests

The introduction of the nursing associate role coincided with the transfer of the funding for nursing (and other health professional) students away from the control of Health Education England to the standard student loan system, bringing these students into line with all other graduate-entry professions. 

A move that should remove the “different” label that these students have carried in education institutions, finally pushing off the deep-rooted perceptions of an apprenticeship type training to be seen as fully engaged students of an established and rapidly developing academic subject.

The old system failed spectacularly to plan sufficient workforce to meet the needs of the NHS – let alone other healthcare providers

It has taken student nurses out of the volatile and short-term HEE workforce planning system, which has perpetuated the “boom and bust” simplistic mechanisms of the past, and into an employment market driven system, where demand and supply should find its own balance over time.

There are pros and cons, of course, but the old system failed spectacularly to plan sufficient workforce to meet the needs of the NHS – let alone other healthcare providers – and was driven by availability of funding, buffeted by vested and competing interests, and inadequate workforce planning skills.

To be honest, pretty much anything that removed student number planning from the vagaries of NHS funding was likely to be cautiously welcomed by those trying to provide high quality education in an ever-declining and increasingly antagonistic pricing and budgeting environment.

It has been interesting to watch how HEE has responded to this shift, moving quickly to pick up the baton of the nursing associate as it was forced to drop the baton of student nurses and other healthcare professions, perhaps seeking for a function to replace what has been removed.

Pushing a narrative of the nursing associate “freeing up” registered nurses, whatever that might mean – most registered nurses clamour to spend more time with their patients, not less – and ignoring safety concerns as “not their territory”, even though there is a growing body of evidence that patients are significantly safer when in the hands of graduate, ie bachelor’s degree level, nurses.

Rocket science

I choose very carefully that phrase “in the hands of” because that is the fundamental crux of any comment on this new role. For patients to benefit directly from graduate nurses’ expertise, those graduate nurses must be nursing them.

It is clear from national and international research that patients are safer when nursing is carried out by registered nurses with at least a bachelor’s level education. And the more bachelor’s level nurses that are nursing them, the safer they get.

So, if safety is the primary concern in healthcare then the skill mix needs to be weighted fairly heavily at the graduate end – as the expression goes, that’s not exactly rocket science.

So, why another role at sub-bachelor level? And is it going to replace those other assistants in the team – the healthcare support worker and the assistant practitioner – thus increasing the skill mix? Or, as many suspect, will it be seen as a way of filling registered nurse vacancies because, after all, this role is going to be regulated by the Nursing and Midwifery Council.

Sadly, regulation itself doesn’t make a nurse, neither does it make an individual a safe practitioner – it can set a minimum standard proficiency bar, and it can sanction poor practitioners, but sanction usually comes after the event, the damage having been done.

There is no “nursing family”. There is a collective of nursing specialisms

No, it is education that makes for safe practitioners. In the case of nursing, education at a minimum of bachelor level, delivered in a rigorous teaching and learning environment which synergises theory, practice and research, and encourages a critical and challenging mindset – the better to advocate for best practice, to constantly seek it out and to deliver it directly.

The NMC refers to the nursing associate as an addition to the nursing family. I don’t agree. At best it is an addition to the growing and confusing assortment of formal carers. There is no “nursing family”. There is a collective of nursing specialisms, all requiring bachelor’s level preparation and often post-graduate education. Nursing is a profession, not a “family”. A profession that has long outgrown such emotional, domestic and patronising descriptions.

No, the nursing associate is not part of some mythical “family”. Perhaps it’s time for nursing and nurses to protect the profession from the expansion of support roles and make it abundantly clear that the title “nurse” refers to something very specific and cannot be applied in the cavalier way that we see so often – the use of the terms “nurse associate” and “associate nurse” are not uncommon, and one hears anecdotally of trainee nursing associates who see themselves and mistakenly describe themselves as nurses or student nurses, often without correction.

So, not part of a family, but maybe something of a cuckoo in the nest. And we all know what cuckoos do when they hatch. Perhaps the time is right for “nurse” to become a protected title. For the benefit of nurses and the protection of patients.

Professor June Girvin is a former NHS nursing director as well as former pro vice-chancellor and dean of the Faculty of Health and Life Sciences at Oxford Brookes University. She is Professor (Emerita) of Nursing.