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Exclusive: CNO pledges to intervene in skill mix disputes


The chief nursing officer for England has pledged to support trust directors of nursing if they are put under pressure to replace registered nurses with staff holding the new nursing associate post resulting in an inappropriate skill mix to meet patient need.

Jane Cummings highlighted that nurse managers had a duty of care to their patients and could put their own registration at risk if they caved in to pressure to substitute nurses with nursing associates.

“I have been absolutely clear that the nursing associate is not a nurse”

Jane Cummings

The new role is being developed by Health Education England to act as a “bridge” between healthcare assistants and nurses as well as providing a different route to become a registered nurse, with 1,000 people due to begin training for it in January and a further 1,000 later in 2017.

The CNO’s comments to Nursing Times echo similar recent messages from key regulators, after concerns were raised by unions and some academics that the creation of the new role would lead to the dilution of the role of the registered nurse.

“I have been absolutely clear that the nursing associate is not a nurse and it says that in the narrative I have developed with the directors of nursing from NHS Improvement, Health Education England and NHS England. This has just been released on the NHS England website,” said Professor Cummings, highlighting a new document published last week by several national bodies.

“This is about staffing based on patient need,” she said. “The nursing associate forms a really important part of the nursing family.”

Professor Cummings stated that regulators, including the Care Quality Commission and NHS Improvement, held the same view as herself.

“I have said that I will support directors of nursing to make the right decisions”

Jane Cummings

She said: “The CQC has said it will continue to look at quality of care and the number of registered nurses. I have said that I will support directors of nursing to make the right decisions based on patient need and patient outcomes.

She said: “We clearly need to make the very best use of limited resources but the safety of patient care is vital and registered nurses are crucial to delivering safe, effective care.

“This role is about is about graduate nurses doing the role they’ve been educated to do. They are still doing things they don’t need to do,” she said. “That is an important message. We must support people and allow them to do the job they trained for,” said the CNO.

Professor Cummings added: “We do need more research on the impact of graduate nurses on care in all settings and that will help us articulate the value of nurses.”

The comments from Professor Cummings come on the heels of a similar promise from senior regulatory nurse Dr May and major research showing that diluting nursing skill mix is linked to higher patient mortality risk.

NHS Improvement’s nurse director, and also a deputy CNO, said she would intervene to back directors of nursing where they were feeling pressured to make bad decisions about staffing.

Dr May also insisted forthcoming guidance on safe staffing from her organisation would be based on the latest evidence and research. NHS Improvement’s first three staffing guidance documents would be published for consultation next month, she told Nursing Times’ sister title Health Service Journal.

The three areas covered will be inpatient, mental health and learning disability services, she said. Work on the remaining settings – emergency, maternity, community and children’s services – will be published for consultation early next year, and all the guidance will be finalised by early summer.

Dr May said fellow regulator the Care Quality Commission would sign off on the guidance – to be described as “resource guides” – and would inspect trusts against it.

Queen's Nursing Institute

Nurse staffing shortage is ‘top priority’ for regulator

Ruth May

“It is incumbent on the trust to have quite clear systems and processes to determine what is safe and effective and sustainable staffing,” she said. “That is very clear in the expectations…”

“It’s right that I keep making sure directors of nursing are able to make decisions based on the evidence in front of them, and I will work to support them to do that and sometimes that will mean me intervening to support the director of nursing in a much more proactive way. I will definitely be prepared to do that,” she stated.

NHS Improvement took over the role of developing guidance on safe staffing levels last year, after the Department of Health suspended work being done by the National Institute for Health and Care Excellence. The NICE work was started in response to a recommendation in the Francis report.

Dr May said the new regulator had ensured there were relevant experts on each of its committees that are overseeing the work, and they had been commissioned to carry out evidence reviews.

“We are not going to ignore any evidence. Time has moved on since Francis did his report,” she said. “More evidence is available to us and we must make sure we use that in our considerations.”

In an interview with Nursing Times last month, Dr May also said trusts with the best and worst nurse retention rates were to be targeted in a new programme to tackle staffing problems.

“Sometimes that will mean me intervening to support the director of nursing”

Ruth May

However, the regulator has not yet decided how to count nursing associates as part of a proposed high-profile staffing efficiency metric called “care hours per patient day”, which is in the process of being adopted by the NHS.

It has been confirmed that the measurement tool will split care provided by registered nurses from healthcare assistants. However, since the introduction of the tool was announced, plans for the new nursing associate role have also been revealed.

Dr May said: “I imagine that [associates will be counted separately from registered nurses] but I am not going to pre-judge it”. Asked about the new role in general, she said: “I do support the introduction of the role. They have the potential to add value to our whole clinical workforce.

“But I also want to make sure it is recognised that registered nurses are the backbone to what clinical care is being given,” she said. “Because of the introduction of the nursing associates, there is some work we need to do around the clarity of the registered nurse in some of those settings.”

Confirming a view made earlier in a statement with other NHS nurse leaders, she added: “I feel passionately these new nursing associates need to be regulated, without any doubt.”


Readers' comments (6)

  • So the work on skill mix that NHS Improvement took off NICE is being revised to include 'nursing associates' ? This hardly seems logical, given this "new role" lacks clarity, has no regulation yet and hasn't so far been introduced into the healthcare workplace. It is also a lie to suggest that there is widespread support for this so called "new" role, as there hasn't been any representative national polling of the wider profession. Those responsible for perpetrating this lie are guilty of committing a fatal disservice to the nursing profession by pushing through this fuzzy "new" role, when all the available research evidence shows how better patient outcomes are clearly associated with the numbers of registered nurses (RNs) in the worforce. The real reason for this "new role" is that the government and NHS trusts want a cheaper nursing workforce, and the quickest way to get it is through establishing a workforce of ancillary 'nursing associates' that are cheaper to train and cheaper to employ. NHS trusts and other care providers will then be able to reduce their RN workforce and increase the supervisory role of those RNs who remain, and who are already dangerously overburdened. Diluting the RN expertise within the workforce in the short term can only lead to poorer patient outcomes, further national scandals and erosion of the terms and conditions of employment for RNs. This is a criminal act perpetrated by those employed by government, not a decision arrived by the nursing profession as a whole. Its a wake up call for the profession showing how badly the government regulates us aided and abetted by those who really should know better.

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  • Well said.

    Our nursing hierarchy and Jane Cummings in particular are letting us down. Shocking that they can succumb so easily to government diktat.

    Cummings should resign.

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  • Yes Cummings should be sacked. Along with Bayliss-Pratt at Health Education England. Those two are especially responsible for the dilution of the nursing skill mix, which this week is reported in the Nursing Times as having a negative effect on patient safety. Perhaps they should be reported to the NMC, if they're still registered??

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  • Lisa Bayliss-Pratt Retweeted
    Cathy Winfield ‏@CathyWinfield Nov 22
    This is a real opportunity to develop staff and improve care @hee_lisaBP …

    Hope this can be seen. Truly frightening .

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  • This is the article that Lisa Bayley Pratt endorses above

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  • Our Nurse leaders need to wake up and take a leaf out of the medic professions book. Their leaders fight like Giants for their profession and their professionals always stand right behind them with a passion. Our leaders are the people we look to to bat for us in the political and National arenas and they shoul have batted hard on this issue. They need to be strong, principled and persuasive leaders a force to be reckoned with..... not Mamby pamby yes men, willing to do the bidding of the politicians. I want to feel like my profession has a leadership that understands the impact of decisions on the frontline, one that has opinions I can really get behind and support.

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