Newly qualified nursing associates should be limited in the routes they can administer medication, including controlled drugs, but there is no evidence their introduction will pose a risk to patient safety, according to the academic charged with scrutinising the controversial new role.
However, on the key issue of substitution, Professor David Sines told Nursing Times that some trusts with major nurse vacancy problems were planning on using associates to fill currently empty posts.
“They argued there was no reason why a nursing associate could not give intramuscular injections under a protocol”
As previously reported by Nursing Times, some of the main points of conjecture surrounding the new role have involved drugs administration and whether it would end up being used as well as or instead of the existing registered nurse workforce.
Professor Sines, a respected nursing academic, recently chaired an expert group set up by Health Education England to scrutinise the new role that is designed to bridge the gap between healthcare assistants and registered nurses in England.
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In an interview with Nursing Times, Professor Sines, emeritus professor at Buckinghamshire New University, laid out some of the key findings from the group’s nine-month programme of work.
It involved chief nurses from acute, mental health and community providers, academics from the Council of Deans of Health and former chief nursing officer for England Dame Christine Beasley – as well as representatives from other areas such as social care and pharmacy.
HEE commissioned the work last year to provide an “objective and independent” perspective on introducing the role. Ahead of that point, there had been “significant challenge in the system from a range of practitioners about the role”, noted Professor Sines. This was centred around its scope of practice, how it would fit with registered nurses, and the implications for patient safety, he said.
“They must have a role within the family of nursing, with identified positions and posts in workforce plans”
Three of the major issues looked at by the group were how far associates should be able to administer medication, whether there was a link between nursing associate staffing levels and an increased risk of patient harm, and the possibility of registered nurses being substituted.
Existing research and evidence were reviewed, as were training and employment plans for the new role, which will be regulated and used in the NHS, independent and social care sectors from January 2019 when the first cohort qualifies.
Although other parts of the UK do not currently have plans to use associates, the group began by looking at drugs policies from across the UK to establish how far existing support workers were currently involved in this area of practice. It found they were not usually able to give medicines involving more invasive or specialist techniques.
The group concluded that nursing associates should not carry out intravenous, intramuscular or rectal drugs administration, or give controlled drugs, upon first completing their training. This was because there was no guarantee all associates would be able to gain practical experience in such skills during training.
Professor Sines noted that he had encountered opposition to this idea from nurses, as they believed many associates would already need to have these skills to make an effective team contribution. But he told Nursing Times that the group believed associates should be able to gain additional training with employers for carrying out drugs administration after finishing their course.
Professor David Sines
“We went in with an open mind,” said Professor Sines. “We concluded that intravenous, intramuscular and rectal administration of medicine would not form part of the scope of practice for a newly qualified nursing associate. That would also include controlled drugs at the point of qualification.”
This meant trainee associates would not be required to demonstrate their competence in this area during their initial training, he said. However, he said that during consultation events nurses had “overwhelmingly” challenged the proposal.
“Their argument was if you work in, say, mental health, the administration of depot injections or antipsychotic medicines by injection were a critical part of daily practice and there was no reason why a nursing associate could not give intramuscular injections under a protocol,” he said. “In other cases, in hospices or in the community, the example given was pain relief – particularly using morphine patches.”
Professor Sines stressed it would still be possible for associates to administer medication at this level if they completed extra training after qualifying. Associates would be based in such varied environments that it was not possible to guarantee they would all have gained appropriate experience during practice placements, he said.
However, a new investigation into nursing associate training by Nursing Times, which is also published today, has revealed some trainees are being taught about controlled drugs during the pilot programmes.
Professor Sines said there was “nothing wrong with [trainees] being shown how things work”, as long as they were not administering these medications at the point of qualifying.
When asked whether this risked causing confusion and threatening patient safety because associates may be asked to carry out these tasks by bosses, he said HEE would be issuing guidance on this for employers and universities within the next three months.
“There would be a safety risk if the scope of practice wasn’t defined before trainees are registered – but the guidance HEE is producing will be clear,” he said.
Another key issue the group looked into was how introducing associates into the skill mix of teams would have an effect on patient safety. This included looking at evidence on mortality and morbidity and issues with safe observational practice – taking into consideration slips, trips, falls, pressure ulcer identification, infection prevention and management.
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“We found that, at the moment, there is no specific UK evidence that we can use to compare the contribution that a nursing associate – trained to the standard we are aiming for – and a registered nurse make to the workforce,” he said.
He noted the pilot programmes, which have 2,000 associates on them, were being evaluated – and that so far there had been “absolutely no adverse data to suggest a nursing associate in the first nine months had contributed to any harmful incident”.
“There is no evidence to suggest so far that the contribution of registered nursing associates will increase mortality or contribute to morbidity for patients or clients,” he stated.
But Professor Sines did acknowledge that it was too early to tell whether this would continue to be the case and that it was hoped the evaluation would provide the evidence required.
The scrutiny group has recommended that employers should assess what additional measures would be needed when associates were carrying out more high-risk tasks.
A final part of the group’s core work was looking at whether the introduction of nursing associates would lead to nurses being substituted. “There was a real controversy about this issue and we wanted to address it head on,” he said.
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Regulator NHS Improvement had confirmed to the group there was no evidence registered nurses had so far been substituted with band 3 or 4 nursing associates.
In addition, Professor Sines said he had spoken with three large acute NHS trusts, each bringing in up to 50 nursing associates, which had all said they were not replacing current band 5 roles.
But he acknowledged there would be cases where – if there was evidence to justify the decision and risks were mitigated – associates would be used on shifts to fill gaps if there was a shortage of nurses.
“I saw a workforce paper at one NHS acute trust that spoke about introducing 65 band 4 nursing associates… and that this would not impact on the number of registered nurses in post,” he said. “But this was a trust that had over 400 band 5 vacancies. Their view was that the immediacy of need to bridge the gap was to have a highly qualified group of support workers – ie associates.
“There would be more and more band 5 nurses still coming in, but it would be to rebalance the workforce,” he said. “Trusts are not stopping recruiting registered nurses, they are using some of those vacancies they can’t fill.”
He said the group had concluded that managers, such as trust chief nurses and registered care home bosses, should remain accountable for deciding on the skill mix and safe staffing of teams to avoid “uncontrolled” or “unmonitored” role substitution.
He also said the scrutiny group believed the planned introduction of 5,000 additional associate trainees in 2018 would not lead to a dilution of the registered nursing workforce.
“Crucially, we must make sure that if these associates are being delivered to the workplace, they must have a role within the family of nursing, with identified positions and posts in workforce plans,” he stated.
The scrutiny group’s suggestions have been put forward to the Department of Health, but it will be down to the Nursing and Midwifery Council to finalise the standards for training associates. Professor Sines said he hoped the NMC would adopt the group’s proposals, noting that the regulator had contributed to the group’s work.
- This is part of a two-part Nursing Times investigation into the current state of play on nursing associates
- Don’t miss our exclusive investigation on approaches to training at the nursing associate pilot sites
Nursing associate scrutiny group
The scrutiny group was commissioned by Health Education England to carry out a nine-month review into the new nursing associate role.
It was asked to undertake a systematic and independent “stocktake” of the professional challenges involved, identify key issues that need to be tackled, call for further evidence if needed, and provide assurance to the nursing profession and the public.
The work, which took place from January to September 2017, was designed to support the evaluation of the 35 current nursing associate test sites – so far involving 2,000 trainee nursing associates, 61 education providers and 201 employers.