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?”
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”
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.
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.
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.
Senior HCA ‘bridging’ role will be piloted next year
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