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Steve Ford: 'Nurse apprenticeships for HCAs are in defiance of the evidence'

The depth of feeling surrounding the announcement that healthcare assistants are to be able to become registered nurses via apprenticeship schemes is backed by the figures.

In little more than a week, the story has been read so far by more than 3,000 people on and nearly 50 comments have been posted about it.

Some people were in favour, some against and others noted its historical context. One said: “It adds nothing to what is currently available to those seeking entry to the profession”, while another added: “Oh what a surprise enrolled nurse is back.”

However, I had originally planned to write about the importance of the latest findings to be published from the RN4CAST study, which came out a couple of weeks ago in The Lancet.

The seminal study, involving 420,000 patients and 26,000 nurses from a range of countries, included a strong UK contingent and had two key results.

Firstly, that an increase in a nurse’s workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7%. If ever there was an argument against cutting nurse numbers to save money, this was it.

Secondly, it found that every 10% increase in nurses with a bachelor’s degree was associated with the likelihood of death within 30 days decreasing by 7%. If ever there was an argument against the myth that introducing degree-only entry was somehow detrimental to the profession, this was it.

The lead author, Linda Aiken, went on record to state: “Our data challenge the widely held view that nurses’ experience is more important than their education.”

Job done, I thought. An end to tabloid newspapers bewailing that nurses were “too posh to wash” as opposed to being properly educated to treat the increasingly complex range of conditions. While washing and similar tasks are vital skills that often take experience to do well, modern nursing is about much more. 

And yet, a week later, seemingly in defiance of the research, the government announced plans for apprenticeships that would fast-track HCAs into nursing through training on the job. The Nursing Higher Apprenticeship would have a degree built into it but those undertaking it would not be required to have the academic qualifications normally required to go to university.

Why was this and why now, so soon after moving away from having both the diploma and degree routes? After all, England only became degree-only entry in September 2013 – 10 years after Scotland led the way, shortly followed by Wales in 2004 and then Northern Ireland in 2011.

I suspect the policy announcement needs to be viewed from several angles to try and understand what may be driving it.

My first point is that apprenticeships are already at the centre of wider government policy. Apprenticeship is a mantra regularly trotted out by ministers from a number of departments, such as business, education and employment. But do they really fit for health, or is health being made to fit around them?

Secondly, ministers justified the announcement on apprenticeships because they were mooted last year in the government-commissioned Cavendish report. So while it may have taken some by surprise last week, it did not come completely out of thin air.

The Times journalist Camilla Cavendish was asked to look at “what could be done to ensure that unregistered staff in the NHS and social care treat all patients and clients with care and compassion”.

In her subsequent report, she called on Health Education England to develop “new bridging programmes into pre-registration nursing… from the support staff workforce” and “review the contribution of vocational experience towards degrees so that staff with strong caring experience can undertake ‘fast-track’ degrees”.

But I would note that the Cavendish review always raised a few question marks for me. Ms Cavendish noted herself that she was only given “14 short weeks” to compile her report, while it potentially affected over 1.3 million frontline staff.

And, given the ambitious aims of the review, the government’s insistence that it should focus solely on education and training was only looking at half the picture. Failure to tackle the question of HCA regulation was always the elephant in the room.

Was the Cavendish review planned by the government as a vehicle to push its wider policy on apprenticeships into the health sector – admittedly a controversial suggestion – or was it merely eagerly leapt on when it emerged?

A third area that may have added fuel to the move is the increasing realisation that the NHS is short of nurses. In the wake of the Francis report, trusts across the country have been scrambling to recruit nurses after years of cuts. It has led more and more to seek nurses from overseas because there simply are not enough home-grown candidates to fill jobs.

Health Education England has announced an increase in places on nurse degree courses but the impact of this extra intake will not be felt for three or four years. Fast-tracking HCAs into the professions would therefore present a short-term solution.  

Therefore, returning to the start of what I wanted to say, RN4CAST conclusively showed the value of degree-level nursing. But the government’s general direction of travel seems to be out of sync. 

We have both the idea of HCAs entering nursing through apprenticeships and the pilot scheme for all potential graduates to spend a minimum of three months working as HCAs before they can begin their course – announced this time last year immediately after the Francis report.

I can’t help but feel this is somehow pandering to the outdated view of nursing as basically about washing and hand-holding – important though these tasks are.

The research evidence supports a different route, so why take this one, especially as in my view it risks nursing becoming a two-tier career and that can only mean more trouble further down the line. 

Strangely, no one has so far suggested that GPs – bored of the weekly line of aches, pains and strains – might like to apply for an apprenticeship in the specialty of their choice! 

Readers' comments (23)

  • tinkerbell

    A nursing shortage is looming. I'm sure not enough nurses will also result in patient deaths. Isn't this HCA apprenticeship combined with a degree? Let's keep fiddling whilst Rome burns!

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  • So the government are going down the cheap fix route as they have with the police and community support officers.
    We all know that we deserve better but basic common sense isn't part of politics.

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  • Anonymous | 18-Mar-2014 11:21 pm

    and a devastating loss for patients although many HCAs are excellent and very dedicate just as are community support officers.

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  • michael stone

    Research seems able to 'prove' many things, and before I nailed my flag to that 'graduate nurses result in fewer patient deaths' conclusion, I would like to see figures comparing nurses who were educated via this propsed new route (after it is actually working) and their fellow 'university' nurses. Studying British nurses, in the same British hospitals, etc. I'm perturbed by so many 'cross-national' studies in healthcare, where the variables are to my mind very confounding.

    I see that after 'being told that we know [the fats in] butter and cheese are bad for you, compared to other types of fat' for decades, I've just been told that there 'isn't any convincing evidence for that claim'.

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  • I am a second year nursing student who only had the option to study on the degree programme (first intake of degree only students). This meant completing an access course re-taking my maths gcse and attending university interview days as well as requiring relevant work experience. It was hard going but worth it to gain a place on my nursing course. Now with a year and a half of study and placements behind me I can see the relevance of everything that came before and how important it is to be able to link the theory we learn to the practice we undertake. This is where I think the training for HCA's currently fails at times, for example: on an elderly care ward some of the HCA's would (quite obviously) be exasperated that I would not drag a patient up the bed by pulling under their arms or by using the bed sheet by explaining that I'm not allowed to do that and would get a slide sheet instead. My rationale that you could dislocate a shoulder or harm the patients' skin through friction/shear. This is what university has taught me, to think about each and every thing I do as a student nurse, to use best practice and most importantly the rationale behind what we do. I hope that the training HCA's receive to become nurses will focus on this important link and undo bad habits that may have been inadvertently picked up. If so then no matter how we have completed our training we should all make good nurses which can only impact positively on patient care.

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  • I agree with tinkerbell. Although I can sympathise with degree students as i couldn't even start any of the entry nursing topics like biology and anatomy until I had passed college level maths first.

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  • Healthcare Assistants need a robust level of training to fit the role they undertake, ideally a national programme with its own qualification. If this wish to become RGN then it is university and degree they must undertake. I am afraid the profession and patients do not deserve the cheap 2nd class option that this would bring.

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  • Anonymous | 21-Mar-2014 9:58 am

    I agree. the role of HCA is also one of considerable responsibility towards their patients, the public and their colleagues at all levels, and their employers who the represent.

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  • They are both degree courses, so there will be no 2 tier option. I find it quite an insult to think that experience and maturity, in some cases, count for nothing or very little, against O/GCSE/A levels. I also find adverse comments on several posts about enrolled nurses insulting too. Why can't nurses be nice to each other and support each other for once.

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  • tinkerbell

    Anonymous | 21-Mar-2014 9:40 pm

    Agree. Don't hold your breath though waiting for nurses to support each other.

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  • michael stone

    Anonymous | 21-Mar-2014 9:40 pm

    I agree with you - whichever 'route' a nurse qualified through, the capabilities of the newly-qualifed nurses would presumably be very similar. That would be a major test of the acceptability of the new route to qualification.

    As for;

    'I find it quite an insult to think that experience and maturity, in some cases, count for nothing or very little, against O/GCSE/A levels.'

    well, I've got a doctorate - but my lack of clinical training and expertise, still qualifies me for idiot status according to some of the posters on this website.

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  • tinkerbell

    michael stone | 22-Mar-2014 2:43 pm

    What? What you mean?

    What you mean use their own initiative?

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  • I think what people are concerned about is a two tiered nursing system again..which we supposedly moved away from...but seriously..have we really ? Our assistant practitioners at our trust currently work like EN's between a rock and a hard place..expected to effectively fulfill the role of an RN ( minus the meds ) when staffing requires and then expected to fill in as an HCA the next minute.

    Maturity and experience do count for a lot..but the theory is fundamental too .'s about having the right balance .

    I have had concerns since they phased out the diploma..not because had a bias about the sort of nurses degree v diploma respectively produced..more that the changes in funding effectively excluded a whole group of potential nursing students ..those who were frequently not in a position to afford to undertake the course without the bursary that the diploma afforded . I myself was eligible to apply for the degree but chose to apply for diploma instead..when questioned as to why by the universities I pointed out I had a mortgage to pay..and I wasn't even sure how I would achieve that on the bursary at the time.

    So on the upside..I welcome an approach that increases the diversity of age/experience into the profession and improves accessibility ..but on the downside..I'm not confident this is the way to do it ...and think the motivation is deeply suspect ..and driven entirely by the forthcoming nursing shortage ..and not by a genuine desire to improve accessibility and the quality of staff.

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  • Hunt wants to keep a two tiered system, it keeps us divided and less of a force. We are one of the largest groups of professionals working for the nhs and they will use any means to keep us in our place. Imagine what a force we would like if were more united, none if this "old vs new" tosh. Pride in all of ourselves people!

    I can't see this apprenticeship taking off, it's just a distraction to quibble amongst ourselves. It further distracts from the issue of HCA regulation and their standard of training (or rather lack of sometimes), which theirs is an important role in itself and requires universal standards.

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  • michael stone

    tinkerbell | 22-Mar-2014 4:05 pm

    I don't understand the question - probably down to me !

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  • tinkerbell

    michael stone | 23-Mar-2014 1:19 pm

    sorry mike, not you. I have somehow answered to your post on the nurse leaders being rejected by Cameron forum, where you suggested the nurse leaders should continue carry on with their own get to gethers and keeping him posted.

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  • My problem with this is that I suspect very strongly that the apprenticeship will not actually result in a degree, but in degree equivalency. Take note that the coalition government department of education want 18 year olds to take one of two options: a university degree or an apprenticeship, with a rough equivalency of a degree (to be clear, not a degree, an equivalent). In doing so, my concern is that the academic discipline of nursing is eroded and that we return to a perceived notion of plying a trade. So what, you may say? Well, I believe nursing as an academic, as well as practical, discipline is important for the credibility of nursing, esapecially in terms of its standing alongside the other health professions.
    I can understand that a HCA with a great desire to undertake RN education may not give two hoots about this issue and, of course, that should not be their concern. It does, however, become their concern when they do become RNs and are exposed to the attitude of other professionals, patient and their families, who will look down on them, under value their contribution and knowledge and have stong, often misguided, opinions on what nurses should be doing. The only way to combat this is to continually strive to raise the bar, and diminishing the academic status of nursing is, in my opinion, not the way forward to achieving this.
    Ask a medic, or physio, radiologist or OT if they would like to have their university education diminished, entry requirements broadened and a 'build in degree' to an apprenticeship: I can't imagine their would be many who would be happy to allow this.
    I'm all for HCAs being able to progress and access RN education, but I feel it should be done by providing funding for access to higher aducation courses, with these courses being made more work friendly and accessible, alongside more secondment opportinities for HCAs to go to university.

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  • Sorry, for typos (especially there, not their)

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  • michael stone

    tinkerbell | 23-Mar-2014 2:09 pm

    You do try VERY hard to confuse me, Tink !

    I had made that assumption - until I noticed that you had actually referenced one of my posts in this discussion, which cast some doubt on my 'Tink must be talking about my 'going rogue' suggestion in the Expert Nursing Group one.

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  • Patients need degree educated nurses for the complexity of modern health care to be safe.

    I guess the important thing is that the proposed HCA entrant mustn't be asked to work for which s/he isn't equipped (unlike now!) and that at the end of whatever programme is offered, there is absolutely no difference in the qualifications of the finished nurses from current degree programmes and the 'apprentice entry' programmes.

    It mustn't be a lesser qualification or a less academically rigorous programme, even if the entrants have no relevant prior educational qualifications.

    Anything less is unsafe for patients and marks a dumbing down of nursing.

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