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Hospitals to replace nursing posts with lower paid assistants

A number of NHS hospitals are planning to replace an increasing number of trained nurses with cheaper, unregistered ‘nurses’ paid at a lower rate.

Leeds Teaching Hospital and East Kent Hospitals University Foundation are among those trusts known to be making or planning such changes.

The chief executive of another hospital trust, who did not want to be named because staff have not yet been informed, said the nurse “swap” was in response to financial pressures and a shortage of experienced band five nurses.

The increased use of electronic monitoring of patients meant it was now possible to replace registered nurses with healthcare assistants, the source added.

A spokesman for Sheffield Teaching Hospitals Foundation Trust told Nursing Times it uses “band four nurses who have reached a higher level of competence and experience who at times fulfil some of the roles previously carried out by band five registered nurses”.

He said: “In these areas we developed the roles primarily as a response to specific recruitment difficulties and the roles are supported by very specific training programmes.”

Foundation chief nurse Hilary Scholefield added: “We have not used band four posts to replace band five registered nurses in order to make financial savings; in fact it is the absolute contrary.

“Band four posts were introduced in our hospitals more than six years ago and this is now a well embedded formal programme of education and training which has enhanced, not detracted from the 70/30 skill mix of our nursing workforce. It has not impacted on the number of registered nurses we have.”

Unison head of nursing Gail Adams said: “This is not like for like work. You can’t swap band four for band five staff. We have seen the effects of these cuts in Mid Staffordshire and Maidstone and Tunbridge Wells. There has been no discussion of this at a national level.”

A spokesman for Leeds Teaching Hospitals said “a major trust-wide organisational development programme with workforce modernisation at its heart” would include “exploring the potential of new roles to support our registered workforce”.

The trust’s Unison branch secretary Sharon Hamilton – herself a band five nurse – said staff had not been informed of any plans to increase the numbers of band four staff. Asked if she agreed electronic patient monitoring meant there was more scope to use lower qualified staff Ms Hamilton said: “It’s OK having a machine that bleeps but if the patient starts changing colour then it’s only a person who can see that.”

Earlier this month a Nursing Times survey revealed many nurses felt the increased use of patient observation technology made it less likely staff would spot signs of patient deterioration (news, page 1, 13 October).

A review of ward staffing levels and skill mix at East Kent, seen by Nursing Times, states nursing’s transition to being an all graduate entry profession by 2012 could mean fewer nurses, but a greater proportion of leadership roles.

It anticipates a “major expansion in the number of people required to work at assistant and associate practitioner role”, which is paid at band four. It describes this role as delivering “protocol-based clinical care that had previously been within the remit of registered professionals”. Meanwhile, a number of band five nurses at the foundation trust will be moved into band six positions, to take on ward management tasks.

Director of NHS Employers Sian Thomas said such changes were “exactly what Agenda for Change” was for and the knowledge and skills framework could be used to measure the skills appropriate for any new role. “The tools are already there to change the career ladder,” she said. “It’s right where we have qualified registered practitioners to have them doing jobs they are qualified to do”

Ms Thomas said responses to the NHS staff survey indicated that up to one in three nurses felt they were doing jobs that were below their knowledge and skill level, suggesting scope for substitution with lower skilled staff.

Royal College of Nursing head of employment relations Josie Irwin said she feared such changes were “financially driven” but she would not object if they were on the basis of a proper evaluation of clinical needs and staff engagement.

Ultimately, the “test” was whether changes to the nursing profession and skill mix made a positive different to patient care, she added.

Readers' comments (70)

  • Good grief, what's new..........? This has been going on for years!
    Trained staff are already on their knees under the weight of taking responsibility for the actions of HCA's. This is a short term solution which in the end will serve to further compromise patient care and safety, and will ultimately lead to more trained staff burning out.
    The DH and the government demand that we reduce the incidence of HCAI's, but how can they expect this to be achieved against a background of dwindling qualified staff?
    Go ahead....who is going to listen to the likes of us, the workforce?

    CT Specialist Nurse, Infection Prevention

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  • This is nothing bew at all, this has been going on for several years now and it is a constant cycle we had the experienced auxiliary nurses who then went on to become enrolled nurses who then through no fault of their own were forced to under go their RN or be forced to work as hca's in some trusts.

    london has been up grading its hca's to band 4 practitioners since 2003 and this has so far work well as the gap between the RN and the hca has become so wide it needed another level of semi trained personal with generic skills to fix it

    this is an excellent use of experienced hca's some who have worked far more many years in health care than some of the RN that are supposed to be supervising them

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  • I am deeply concerned, worried and disappointed about this proposal. Firstly when are the financial management going to absorb the reality that registered nurses are leaving the professional not by the bucket full, but by the thousand full. Lets consider why this may be? I am a nurse and this comment has heightened my desire further to leave this 'profession'. Nurses are in my opinion taken advantage of at all costs, they are already the least paid profession and already have so much responsibility and accountability such as carrying out many medical exams, nurse led clinic, minor surgery such as suturing, discharge planning, many traditional doctors jobs. The role of the nurse is forever extended beyond nursing such as administrative roles, portering duties, cleaning duties, personal secretary roles, nursing auxillary roles, domestic duties, doctors duties, oh yes and nursing duties. All this and beyond. My question is who will be accountable and responsible for the competency of the nursing auxillarys and the adequacy of the care they give? The registered nurses on the ward i assume? Will the registered nurse's have a case load of patient's and added to this need to overlook and ensure all is well from their nursing auxillary colleagues? Who does the accountability lie with? Who does the the legality lie with? Extending upon the latter my question is who will be fulfilling the legal issues of the nursing auxillarys new roles? Legal issues such as documentaion, medication administration, signing of medications, IV drug/fluid administration, recognition of the ill patient/well patient. The clinical judgement of a professional/registered nurse is one of the most important vital signs one may take, and this certainly does not involve technological devices. I do have utmost faith in nursing auxillary's, and they are so valuable in the health service especially in the UK. I believe nursing auxillary's are as important as any other professional in the helath service, but they are not nurses. Why are registered nurses being taken off the wards? I believe this is a process of saving a penny today and losing a pound tomorrow. The patient's are the ones who will suffer the most because they already do not have enough registered and experienced nurses looking after them as it stands, so if more nurses are being removed from caring for patient's i have grave concerns for the health and well-being of the patient's. Penny saving may look most advantageous today, i just hope the financial management who are coming up with money saving schemes have considered the pound that may be taken from them tomorrow in the court room. Registered nurses are the critical essence of patient care for the patient, why oh why are less nurses walking the floor of our wards? It is deeply distressing as a nurse to read this. When will management accept the realism that even though the work force is the highest expenditure within their budget, a patient and someone's loved one are the one's being neglected because of the evermore reduction of bedside nurses. The answer to financial budging should not be form nursing. Nurses are already not paid enough money for the job they do and now they are wanting nursing auxillary's to do the same job for less. Cutting registered nurse's on the ward will not cut it in terms of fincancial savings. The only thing that is being cut is the care provided to patients, and i just hope that patient satisfaction and health will not be cut.

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  • That's right - nothing new here. Nurses to be devalued even further. Makes me wonder why we bother. When the HCA makes an error in judgement they won't be hauled up in front of the NMC!

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  • I concur with all that has been said, however, two points need to be stressed further:
    1) When the 'band 4' makes the error it will still be the band 5 who is hauled before the NMC on a disciplinary etc.!!!

    2) Just think of these so called adjustments in a financial business manner not as a nurse The Heads of the Foundation or Teaching Trusts can give themselves another pay rise or bonus whether they are in the mire or not - this already happens in some areas of the Country at the expense of patient care!!!

    Good luck!!

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  • Don't get me wrong I love the guys who do this work in my department, bu I work in the ED of one of the above Trusts who are looking to recruit 5 more tech assistants, the initial number were initially employed to venapuncture from existing support workers, which in it's self creates problems for them as some days they are techs and others support workers and people forget which role they are undertaking, the junior doctors become lazy/de-skilled, also it dose not take the pressure off staff nurses as I have to do that patients meds and treatments as well as my own because the tendency is to have 1 support worker to 1 nurse and who is accountable for their actions because i don't have time to observe everything they do, they get mixed response from wards if they escort a patient on transfer because they don't see the split in role, after nearly 20yrs in the health service I feel that instead of addressing the fundamental causes of poor retention, on going training, support etc and in the case of the A/E environment recruiting people who can handle the pressure. The NHS still looks for the cheap and cheerfull approach and ends up regretting it in the long term, remind me why did i do 3 years training and build up a body of experience and knowledge!

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  • I am a second year student nurse, this article has made me feel that all the hard work I have had to put in has been a waste of time. Will I even have a job when I qualify or will it have been replaced with a HCA. Ironic really as that is what I was before I started my training, why did I bother.

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  • What ever name you wish to give this valued group of staff they have been around since I commenced my training years ago. So they are not and will not replace nurses. However the role of the 'Registered Nurse has changed consideably over the years and someone is needed to undertake the bedside care of the patient. Who better than a dedicated HCA with training.
    We as a team of Band 6's and Band 4's work together to train and assess Band2's, 3's and 4's.
    We provide a seven day induction programme followed up with further study days within the first six months of employment, Trust competency packages assessed by our team and the ward nurses. They have the opportunity to undertake an NVQ and sit the literacy and numeracy tests from a recognised awarding body.
    Band 3's and 4's have further indepth training and again the opportunity for undertaking an NVQ or foundation degrees.
    As for being unregistered/unregulated is a government issue that has been dragging on for years. The government needs to stop dragging their feet and sort this issue out for all levels of support staff.
    The HCA is working quite closely with the patient and is able to notice whether a patient's condition is changing and report it to the RN for them to take action using their expertese to decide what treatment is required.
    As for accountability everyone is accountable for their actions if accepting the responsibility to undertake a task. However it is the RN who is accountable for delegation to a HCA with the correct level of training to carry out that task andknow what their support staff are capable of.

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  • Well, maybe we can understand how some doctors feel about us prescribing!
    We are compensating for the lack of GP's, We are after all a lot cheaper to employ, however I agree it is not ethical to let us take the blame when things go wrong, we as prescribers are responsible and accountable for our actions. Whatever happened to the enrolled nurse! She was trained to look after patients for two years and accountable for the care she provided or omitted!
    I work with many HCA, some are ready for an extended role some are not! Train and register them, , make them responsible for the care they provide and pay them accordingly.It is not fair to pile all the responsiblity on to registered nurses as we are extending our role, does anyone cover what we do?

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  • This has been happening in theatres for ages. Band 4 Support Workers scrubbing, sometimes for quite complex cases. In some places, not even the nationally recognised NVQ PCS (add on scrub) standards have been achieved, in favour of an ‘in house’ scheme. Furthermore the NVQ does not give them the underpinning knowledge of the surgery related A&P the RN or ODP has. Why do our Nursing and ODP Schools train so many when for some there is the prospect of not getting a job at the end because their role has been replaced?

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  • Further to my comments I intended to state that through this system we have supported a considerable number of HCA's to futher their careers by undertaking nurse, ODP and paramedic training and they are out there working as Band 6's and beyond. Thus giving people who are unsure of their career pathway to make decisions as to their future and become fulfilled as they are maximising their potential.

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  • why do nurses talk about HCA'S as if they are brainless we are not all the same as nurses I think nurses work very hard they have one of the most stressfull jobs they could have.
    we are there to help and if we are competent at what we do it must be a help we are not trying to take over its the management that is trying to save money not us doing more then we should.
    myself i would register all (trained) hca's that wont to take on more responsibilities.

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  • No offense to the person who wrote the above post, who I'm sure is a very hard-working care assistant and good at the job they are employed to do, but I have to point out that by it's very nature i.e. below standard spelling, punctuation and grammar, that it illustrates the difference in levels of intelligence and education needed to fulfill the role of a nurse. Nurses are educated to a very high standard, and for very good reason. As we are accountable to the NMC, as previously pointed out, our documentation has to be flawless, our understanding of patient's conditions needs to be accurate and constantly updated with further training and the administration of medications, with all the understanding of correct dosages and possible side-effects must be consistently without error - how could someone with a below-standard level of education possibly fulfill all these tasks? I, for one, am not willing to stand in a coroner's court taking responsibility for a Health Care Assistant who has failed to deliver care to the high standard demaded by a Qualified Nurse, who has been led to believe they can take on the role given to them by penny-pinching senior management and yet who has no professional accountability! Can no-one see he potential dangers of this situation? As the old saying goes - "A little knowledge is a dangerous thing".

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  • In the "old" (mid 1970's) days, we had a Senior sister/charge nurse, a junior sister/charge nurse, 3 or 4 staff nurses and a couple of Nursing Assistants per ward. The rest of the staff were students on a 3-4 month placement. The change in training and the loss of student workers caused the need for another grade of staff. Australia started University training before us in the UK and as an interim measure imported loads of UK staff ('I know I was that soldier') before they gradually started cutting numbers of qualified staff and increasing the unqualified.

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  • What about swapping chief executive with a cashier from a grocery shop? This would help to maintain a hospital budget too.

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  • I agree that is has been going on for many years and the band 4 hca's are extremely good clinically. However they are unable to check or administer medication. I work in a critical care area where medication is not given out on a medicine round, therefore the drugs pile up that the HCA cannot give waiting for the registered nurses to check, adding even more pressure to an already highly stressful job, and there is no accountability on the part of the HCA

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  • Hells bells! I'm just about to finish my first year which I've done remarkably well in - maybe I should do a fast track graduate medicine degree (although that would not be my preference)... With a future in nursing looking about as bright as Victoria Beckham I do wonder whether I'm wasting my time. Especially when I go on placement and get blanked by nurses who can't be bothered to mentor me. Some of us students have very respectable CVs and experience and prejudice against us just puts us off! When I have been mentored effectively I have proven to be a very reliable time saving asset to the ward, and the placement has been much more educational and enjoyable!

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  • I have worked as a nurse for over 30 years and have witnessed the gradual exodus of trained staff due to overwork and unreasonable expectations.They are given more and more responsibilies taking them further away from the reason they joined the profession in the first place the patient!what was wrong with Enrolled nurses?I was an SEN for 12 years and thoroughly enjoyed it until I was obligated to do my RGN.

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  • This is not at all surprising but deeply worrying. Nursing has been continually downgraded with untrained but task orientated staff for many years since the disbanding of SEN's and poor training in Universities leading to poorly equipped trained nurses. If some of the Trusts say that band 4 nurses have higher competencies than band 5 nurses what kind of training is going on for nurses? If this is true then my worries that nurse training is inadequate is also true. Either get Universities to train nurses properly or get training back in the hospitals and experiential not paper based. Competency for HCA's is and should not be the same as training for nurses. Trained nurses should have analytical skills for assessing why something is either normal or abnormal and then do something about it, not just 'doing' a task. This is an excuse to save money not altruism on the part of the Trusts to recognise skills of HCA's. It could also be seen as exploitation of HCA's in order to pay people less to do a 'job'. Nursing used to be based around task allocation and the so-called profession spent a lot of time trying to get away from this and think about whole patient care instead. Nursing should be professional but this illustrates that we are undervalued and have no respect from Managers (many of whom would undoubtedly have no insight and lack competency at anything clinically based,) Can we down grade the Management posts for people who are more competent in lower bands as I suspect there are countless people like this too? I would be very surprised if this happened as all that seems to happen is that the Manager gets and Assistant Manager who then gets an assistant Assitant Manager (and on it goes), because they can't cope.

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  • I am a band 5 nurse. I am unfortunately already in a position where I have to supervise and check closely on the work of band 2 staff because quite frankly I cannot rely on the quality of the work they do. I will spare you the details of the experiences I've had. I cannot see how introducing another grade to bridge the gap between bands 2 and 5 is going to help. All it means extra supervision. As a nurse, I do not feel there is any aspect of patient care that is to menial for me to do. What happened to the concept of Total Patient Care.

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