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Exclusive: Leaked document reinforces call to regulate nursing associate role


Revelations that nursing associates will be trained to calculate drug doses, administer controlled medications and work independently have sparked concerns about the future role of nurses and prompted further calls for those trained in the new position to be regulated.

Documents leaked last week on the proposed curriculum (see box below) for training those in the new role also stated that nursing associates would be able to carry out invasive procedures on patients without the direct supervision of a qualified nurse.

In addition, they will be trained to help assess, plan, deliver and evaluate care, as well as recognise deteriorating patients, according to the documents given to Nursing Times’ sister title Health Service Journal.

Health Education England, the body developing the new role, confirmed last month that a cohort of 2,000 trainee nursing associates would begin a two-year on-the-job programme with employers and universities at 11 pilot sites across England from January.

But experts have warned Nursing Times that the proposed curriculum will blur the boundary between nurses and the new role, could lead to confusion among patients about who is delivering different types of care, and increase the risk that the nursing associates will be used as a substitute for nurses.

In addition, they raised concerns that without regulation, nurses could be held accountable for potential drug errors made by nursing associates, who will be working under their direction.

“If nursing associates make a drug error whose responsibility is it?”

Crystal Oldman

The documents state: “By the end of the programme, the trainee nursing associate will be able to deliver planned nursing interventions… in a range of health and/or care settings under the direction of a registered nurse without direct supervision, delivering care at times independently in line with an agreed/defined plan of care.”

The experts reiterated previous calls for nursing associates to be regulated, noting that the continued absence of a decision on the issue by the government was creating uncertainty for potential trainees and risked training not being delivered universally to the same standard.

Dr Crystal Oldman, chief executive of the Queen’s Nursing Institute, said the expectation that nursing associates would be able to administer controlled drugs had set “alarm bells” ringing about the potential risk to patient safety.”

She questioned why nursing associates would be able to carry out such tasks after their training programme when it took “registered nurses three years’ full time” to do the same.

“All the evidence shows if you have a degree level qualified nurse you have better patient outcomes,” said the head of the community nursing organisation.

“In terms of protection of the public, if nursing associates make a drug error whose responsibility is it? It’ll probably end up being the registered nurse who they are reporting to,” she warned.

“Could it mean nurses are taken further away from the bedside”

Jill Maben

Dr Oldman reiterated calls for nursing associates to be regulated to address such issues. She also noted that without it universities could “do what they like”, because there would be no regulatory body assessing and monitoring courses for the role.

Unison national officer Helga Pile reiterated that the role should be regulated as well, stating that the decision on regulation would be “critical”, as it was still unclear what standards nursing associates would be working to.

“There was general consensus from the [official] consultation that [regulation] should happen, but it’s very difficult and uncertain with that question not resolved and yet we’ve got people embarking on training,” she said.

Crystal Oldman

Crystal Oldman

Crystal Oldman

The Council of Deans of Health, which represents nursing faculties across the UK, said the proposed curriculum for nursing associates “raises many detailed questions about the educational requirements of the nursing associate role, as well as the implications for regulation”.

“The recent leaks show that the persistent concerns over the potential for the nursing associate role to blur the boundaries with registered nurses remain unresolved,” said a spokesman. “Support workers in a variety of roles play a vital part in health and social care teams but nursing associates cannot be a substitute for graduate registered nurses.”

Dr Oldman echoed these fears, suggesting that nursing associates could be used as a cheap alternative to nurses in future.

“My fear is the nursing associates will be substituting registered nurses,” she told Nursing Times.

She said her concerns about substitution were heightened by the number of registered nurse tasks contained within the nursing associate curriculum.

Jill Maben, professor of nursing research at King’s College London, also warned that the proposed curriculum could see registered nurses being substituted and fundamentally change the nature of their role.

“There could be unintended consequences – they could potentially in the long term undermine all-degree entry into the registered nurse role and change the nature of that role. Could it mean nurses are taken further away from the bedside, that they are only managers of care?” she questioned.

Jill Maben

Jill Maben

Jill Maben

In response to concerns about substitution, HEE’s director of nursing told Nursing Times there were “challenges across the system with the nursing workforce” and that “nursing associates will be part of the multidisciplinary team”.

Professor Lisa Bayliss-Pratt defended the draft curriculum, stating that nursing associates would be trained to understand the use and effects of controlled drugs and that it was down to employers to decide whether they should calculate and administer them.

She said it was “never the intention” of HEE to say nursing associates should give a “plethora” of drugs to patients.

“But it is important they are educated and trained to understand everything about them, because that enables them to give holistic care to the patient and also to support the registered nurses to do their job,” she said.

“For example, if they were to work in a hospital setting or end of life care then many patients will be on controlled analgesia as part of their end of life care package and it would be absolutely unsafe and inappropriate for nursing associates to be playing a role within the team of caring for them if they don’t understand those drugs and the management of them,” she said.

“If this role is to work at a higher level than a support worker and support the registered nurse, then they absolutely need to be able to have a good knowledge and understanding of medicines management – and that includes routes of administration, calculation, contraindication and also the effect the medicines have on the care package of the individual,” she said.

“We are not saying at all that they will administer controlled drugs, we are not saying they will independently calculate drugs,” said Professor Bayliss-Pratt.

Health Education England

Senior HCA ‘bridging’ role will be piloted next year

Lisa Bayliss-Pratt

She also told Nursing Times that the accountability for nursing associates’ individual practice would not lie with nurses, but did underline HEE’s desire to see the role regulated.

“The registered nurse who is in charge of leading and managing care for a group of patients or people in the community – they will always be responsible for the [overall] care delivery,” she said.

“[But] if nurses delegate particular activities and tasks to nursing associates, of course the nursing associates will be responsible and accountable for delivering that care in a safe and effective way.”


Nursing associate draft curriculum: By the end of the programme trainees will be able to…

  • Deliver planned nursing interventions under the direction of a registered nurse without direct supervision
  • Delivering care at times independently in line with an agreed/defined plan of care
  • Undertake medicine calculations
  • Administer medicines, including controlled drugs
  • Receive, store and dispose of medications
  • Use invasive and non-invasive procedures
  • Recognise early signs and deterioration

Readers' comments (9)

  • I think I have decided to withdraw from my training as I feel it makes a mockery of what I am undertaking to be able to do exactly the same as an un trained member of staff. It all about cost saving and not about patient care or outcomes. Why should someone do a degree, tell me what's the point? Degree nurses don't even get recognition of such in the agenda for change even though they are a level higher than their diploma counterparts, so the new NA with be qualified to the same as the old diploma so wheres the line drawn between them and the NA when they are equally trained to level 5, oh yes I see it, its the ££££££££

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  • Just to add who is funding the NA roles? Reading the next article Health Education England’s chief executive has warned that it would be up to trusts and universities to fund any expansion of nurse training places in 2018 which reinforces my point in cheap labour for a fraction of the cost.

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  • I completely agree. It's very demoralising as a mature student to know that, having given up a good career to retrain as a nurse, I'm now doing a qualification which the government is effectively making redundant in order to save money. The bursary has been lost, CPD budgets slashed and now we have to battle for mentor attention alongside NA trainees who will be unregulated. We are told every single day that if we make a mistake in our practice we will lose our PINS - no support, no support, you're out - and yet we are being asked to work alongside people who if they make an error, not only will they keep their jobs but we will take the blame. I didn't train to be a nurse to be a manager or administrator. I understand there are problems with nurse staffing levels but these are more to do with retention than recruitment and maybe one massive reason nurses aren't staying in jobs is because they feel undervalued. It's pretty obvious why. I haven't even finished training and I see I'm entering into a profession that allows the government to treat it as a joke. NA and HCAs are obviously valuable but if you allow them to do the job of a nurse then they ARE nurses. Stop using vocabulary to mask what is happening - unregulated HCAs are being trained to do the job of nurses to save money. The nursing profession is on its way out and we either haven't got the energy or the nuance to stop it.

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  • Nursing will not survive as a profession. Anyone can do it after all and it's a job for a kind, good woman with not too much care for earnings or career and not prone to researching or spending unnecessary time studying
    What on earth did we expect? If you don't need a degree education in order to learn to think as other graduates do then why bother having nurses at high cost and for little difference from HCAs? I despair. What did we think would happen when we increased our pay all those years ago (sorry for the pre 1990 crowd who didn't experience low wages pre grading). Nobody knows what we do. Our definition is about 20 pages long, other people Nurse and we eat our young and knife each other without any provoking. Sisters, we have only ourselves and our leaders to thank for this inevitable outcome. Nursing should have had modules on workforce economics and planning then we'd have seen the blindingly obvious. Nursing is a comparatively expensive occupational group so in future there will be lots less of us.

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  • I am at present an associate practitioner in an acute hospital, I have competencies which allow me to carry out all nursing interventions apart from giving medication and intravenous fluids etc. I studied a 2 Year foundation degree to gain my position and practice as a band 4 nurse.
    So, am I now 'allowed' to medicate patients without supervision and without being regulated ??
    I'm also doing my degree in adult nursing, but don't see the point in continuing now if this comes into force !!

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  • If a nurse associate make an drugs error then registered nurse is responsible yet they won't be under direct supervision??? Crazy. So it takes 2-3 years to train a nurse, so a nurse has confidence in their clinical judgement and responsibilities. We also now have Physicians associate, 2 years training which replaces 7 years + of medical school for Dr. Inevitably this will create a two tiered health care system. Those who can will pay for bupa or Virgin health care; will have their cancer diagnostics done quickly by nurses and Dr. Those who can't will wait on the nhs, will be seen by over stretched staff, without the right skill mix. Health is not a privilege, health enables equality!

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  • Urgh. What a mess eh? Huge grey areas. No clarity. Sounds about right. I dispair.

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  • Is any one a student nurse and attending the meeting in London on the 16th nov to discuss this role with the HEE? Open to student nurses.

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  • In 1992 as we sat our 'finals', we were told by nurse tutors, that we were the enrolled nurses of tommorrow. How true that is, history repeating itself, stop Enrolled nurse training, replace with unregulated Healthcare assistants, reduce junior doctors hours and give more responsibiity to the nurses. I am and have been, a acute ward based, full time nurse for 25 years, keeping myself up to date with self study, courses, diploma , mentoring both diploma and degree nursing students. Now I (band 5) am deemed the same level as an associate nurse.

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