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Healthcare assistants deserve entry to the nursing profession


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


Readers' comments (10)

  • I do belive that the enrolled nurse wheel has already been invented as the Assistant Practitoner-nearly 10 years ago now and these practitioners hold a diploma or FdSc in Healthcare Practice. They have studied theory of nursing care/therapy/underpinning knowledge etc for 2 years, written referenced supported essays, had to pass various clinical skills and proven that they can work to the highest standards that are evidenced based and supported. Most also do the same modules as RNs (In my case a critical care module and evidence based practice). I find it hard when we are compared to HCAs as we have far more theoretical knowledge than them-but it does seem that there really is a lack of recognition for us and the role that we do. I know how to interpret observation and assess, plan and implement because of study and experience. I also know when to liase with my RN colleagues because I need advice or support. I belive that we really do need to be seen differently because we are not RNs and we are not HCAs either that have done a bit of extra study. I think that the role of the Assistant Practitioner on the whole in very poorly understood and has been met with a lot of oppostion. Any hope

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  • I do not believe this for a second. If HCA's gain entry into the nursing profession our managers will have an excuse to reduce the number of RN's on the wards/. Rn's already have too many patients to medicate etc etc etc. Even if I have 50 super care assistants working with me, I am still carrying all the drugs, orders etc by myself.

    The death rates are higher in hospitals that have poor RN ratios no matter how many HCA's they have.

    Research has shown over and over again that RN's doing every aspect of care for a small number of patients reduces death rates, complications and overall costs. You need more RN's to save money.

    Hospitals that have a higher proportion of HCA's and use RN's in supervisory roles have higher death rates, increased complications, and increased costs. It is a penny wise pound foolish scheme.

    google Militant medical nurse.

    This is a disaster. Management will use this to staff a 40 bed ward with one RN and 5 care assistants. And they will tell the public that there are "6 Nurses" on duty. The RN will be carrying the drugs, orders, rounds, emergencies, etc etc by herself. Total disaster.

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  • Our wards in the north have to have 2 RN staff on each shift. No way do the HCAs out number the RNs.

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  • I am in my 2nd year of AP training doing a FdSc,with over 25 years of nursing experience behind me. The level of academic work is at the same level as a diploma in nursing, however the content of course is different, therefore we will not qualify with the same knowledge or for the same role. I agree that the AP role is poorly understood at present and we are finding we are having to educate others. I think the course should be a steeping stone into nurse training. However some of us may wish to stay as AP's in the future. The arguements about HCA's and regulation have been going on for years and I am personally sick of it as there seems to be no resolve in sight. Some reistered nurses obviously feel theatened and respond with snobbery. No doubt some may suffer the same when new nurses join them with degrees. Thankfully others value our contribution to the care of patients and appeciate that we support thier role. The HCA title can be pinned on care staff ranging from people who have had minimum training in a few tasks and little knowledge to others others who have had lots of training and many years experience Perhaps what AP's mainly want is to be valued for our input to nursing care, the wealth of expereince that we bring to the role, and to be recognised that we are trained and qualified to perform the nursing tasks that we undertake.

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  • 7th may 4:03 how many pairs of hands have you got nurse no wonder mistakes are made thats what your hcsw or hca's nowonder the hospitals are in a mess with people like you the poor patients?

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  • Yes i too disagree with any Assistant Practitioner posts or similar. It does dilute the profession and narrows the role of NA's to actually less than they do now rather than more.

    I am quite sure that the ordinary nurses inside the profession have said they wanted more trained staff and like it or not it is a half- measure to train assistants to replace Staff Nurses from the job they do.

    When the elite finally realize that caring is not nursing then they too will see it from the practitioners point of view - which is we are right and they are wrong about this.

    AP's are expensive vis a vis a good Band 1/2 NA. They will perform fewer rather than more duties and if you're going to gain a qualification, why not make it a qualification that the profession itself needs.

    What they are doing is responding to our calls for more nurses and better pay and conditions by promoting a small (minute really) group of staff who lacking good academic qualification will be mentally buoyed by having a quaification that they see as midway between ours and 'nothing'.

    But never forget that we as the registered nurse control the practice of our assistants and if you are not happy or properly informed about their role then make sure you raise your concerns on the cheap.

    AP's are not nurses and cannot touch the skills and upper eschelons of our jobs.

    in essence i see this as a role for me to give all my unwanted jobs to.
    but we won't see any effectiveness. all of the studies are 100% biased in favour of the role - because they had something to gain by promoting this role.

    At the end of the day i want my NA's to assist me - not swan off to take care of a few simple and finite tasks that a trust could teach to their NA's anyway without paying them a Band 4 (which is also overpaying them a great deal).

    already the pharmacy techs at my place are on a band 5 - disgraceful!!!

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  • How about sorting out the syllabus on the RN course to include anything relevant or meaningful on a deep level before we slide into a professional cul de sac. Oh wait, we are already there, anyone fancy being a pretend doctor?

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  • "buoyed by having a quaification that they see as midway between ours and 'nothing'."

    So as you say between nothing and nothing. Band 5 pharmacy techs. We are irrelevant and finished. Any useful 'nursing knowledge' I learned myself not from school or 'hands on' and from making mistakes. Maybe Christine Beasley could find something to say about this.

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  • I no alot of this is genral nursing but i work on a acute phsyciatric ward as a hca and i can assure you that someone who has done there mentall health nursing degree straight from school is no way better than a hca with exsperiance yes they can do meds but anyone could if they where shown how and aloud .when things go wrong it happens quikly and people are getting hurt its the exsperienced people keeping a cool head dealing with it because they no not to flap and all the training in the world isnt gone stop you getting scared and not knowing what to do
    and id like to no the stats for assults on staff i no where i work its the hca who get hurt more because we cant hide behind a computer when people are exstremely aggitated but who gets paid more nursing is about haveing life exsperiance empathy asking yourself how would you like to be treated if you where that person listning to there worries concerns spending time with them not doing meds for an hour then go sit the office for the rest of the day i think mentall health could work with hca and ward clarks because all the nurses do is paperwork most of the time and thats not what nursing is about

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  • I have an assistant practitioner qualifaction and a degree in dementia studies. both of which i gained while working full-time as a clinical support worker in a+e with no allocated study time. I am constantly asked why i didnt just do my nurse training. here is the reason: circumstances did not allow me to be a full time student. a drop of about £900 a month in my salary just wasnt an option. isnt it about time there was some relevant qualification to nursing that we could undertake whilst still being able to work in the area we enjoy

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