There is one sentence in the report of the Prime Minister’s Commission on the Future of Nursing and Midwifery that encapsulates the vision for nursing. It says: “The new cadre of all graduate RNs should provide linchpin clinical leadership, coordinate and closely supervise care delivery, and deliver some complex care.”
The debate about the all graduate profession has been over for some time. All nurses in the UK will ultimately qualify with a degree in nursing. The remaining issue, covered by the commission’s statement above, is what they will do with it when they reach the home, clinic or hospital ward.
We do, undoubtedly, need well educated registered nurses in today’s world. Care is more complex than it used to be, in the home, in day units and at the bedside. Being able to deploy and use technology, and having the skills and knowledge to know when and how to interpret its interaction with the patient is essential. Nurses diagnose patients, carry out invasive treatments and investigations, prescribe and run services. Of course they must be well prepared for these roles, for their patients’ and their own safety.
‘In a service that remains as hierarchical and status conscious as the health service, it is silly to be
squeamish about having more than one type of nurse’
This does, though, leave a gap in the workforce to deliver what we variably call basic, fundamental or essential care.
Already, a large amount of hands on, one to one care is given by healthcare assistants or assistant practitioners. They are trained and often hold national vocational qualifications. They are not, however, registered with or accountable to a professional body or recognised as the workforce equivalent of former student and newly qualified nurses.
On the wards, there are examples of HCAs undertaking tasks such as measuring temperatures or blood pressures, but not being able to make sense of the results to initiate the right actions for the patient.
In the community, where the number of HCAs has more than doubled in a decade, they see patients in clinics or homes alone. They can carry out tests and investigations, carry out invasive procedures, such as venepuncture and cervical smear testing, and deliver hands on care to vulnerable people at home. Should further action be required that is beyond the HCA’s experience or training to spot or react to, who would know?
This is not, to be clear, the fault of the HCA or assistant practitioner. Their work is decided for and allocated to them. Their employer takes the ultimate legal responsibility for their actions, while the nurse remains professionally accountable for work delegated.
This cannot be a comfortable situation for any of the parties - nor the patient - as we face what the commission calls a “carequake” of increasing demand, as well as the growing complexity of care and care technologies outside hospitals.
The commission’s report calls for the regulation of HCAs. This is a good step forward. Regulation would not be punitive or controlling, but would recognise the importance of the HCAs’ role. This must be matched by development opportunities to enable HCAs to build on their growing skills and professionalism.
But there’s the gap again, viewed from the other side. If an experienced and dedicated HCA wants to become a nurse, they must first graduate with a degree, then assume the supervisory and leadership role as envisaged by the commission. An HCA who loves the job and wants to make a career of carrying out extensive, essential and important nursing procedures with patients might well baulk at this huge leap.
It is time to recognise that we must have a true nursing role between the unregistered assistant and the graduate nurse - that we cannot, after all, manage without the enrolled or second level nurse, although we might well lose that latter clumsy term.
The problem with the role in the past was that it was a professional cul de sac. People ended up there for lots of reasons unrelated to their abilities or potential, then found there was no way out. Because of this, enrolled nurses often missed out on development opportunities, since there was no “need” to improve skills if there was no new post available to aspire to.
This is no longer the case: flexible learning and professional development plans allow a very different approach to careers today. And, in a service that remains as hierarchical and status conscious as the NHS, it is silly to be squeamish about having more than one type of nurse.
Good HCAs deserve the dignity and status of entry to the nursing profession: they are doing a nursing job. Patients deserve the protection of all their most important and essential care being given by a registered nurse. And the nursing profession itself should be mature enough to recognise that not all its members want to be leaders or supervisors of care.
This is not to say that we must simply reinvent the enrolled nurse: there is and should be no going back.
Instead, let’s take up the commission’s proposal of a “new story of nursing” to create a new, inspiring, accessible entry level role for nurses, and welcome these new colleagues into the profession. The election must not derail us from this course.
Rosemary Cook is director of the Queen’s Nursing Institute