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Investigation: How trusts are planning to use new nursing associate role

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Trainee nursing associates are already being used to help plug gaps in rotas left by vacant nurse posts in some areas, an investigation by Nursing Times has revealed.

Elsewhere, they are being used to make up for assistant practitioner shortfalls, being counted among healthcare assistant numbers or not being treated as supernumerary during all of their training.

“Nursing associates should not be expected to deliver the same care as a registered nurse”

Janet Davies

Some chief nurses at NHS trusts involved in the pilot that began in January are also looking at bringing in further cohorts before the trial ends in 2019.

Our investigation represents the first detailed look at the initial 11 pilot sites that are testing the controversial new nursing associate role across England, with a varied and complex picture emerging of how they are set to be integrated into the existing nursing workforce.

Proposals to replace empty registered nurse posts with trainee nursing associates were first uncovered by Nursing Times in March, seemingly confirming the fears of some members of the profession about how the new role would be used.

East and North Hertfordshire NHS Trust acknowledged it planned to convert at least 21 band 5 nurse vacancies into trainee nursing associate positions from this month to save money, but insisted this was not substitution because the posts were empty.

Following an investigation looking at board papers for almost all of around 70 trusts involved in the first wave of 11 pilot sites testing the new role, Nursing Times has identified at least six organisations with plans indicating registered nurse vacancies would be converted into associate positions.

However, their nursing directors insisted that substitution was not taking place. Most stressed to Nursing Times that either the board papers gave the wrong impression or that they planned to challenge other trust executives who wrote the reports.

At United Lincolnshire Hospitals NHS Trust, board papers from March state that 25 associate trainees started there in January “and the areas who are supporting them have built the role into their establishments from their registered nurse vacancies”.

“Our nurses were saying was it would be more productive to have a trainee nursing associate on shift than run the risk of not filling it”

Debrah Bates

But deputy chief nurse Debrah Bates told Nursing Times it was not substitution because the trust was still trying to recruit the same number of registered nurses, and that it was in the meantime only going to use associates on shifts in place of agency nurses.

“What some of our nurses were saying was it would be much more productive to have a regular trainee nursing associate on shift than to run the risk of not filling the shift, or even having somebody from outside the organisation in,” she said.

“We’ve used some of the funding currently sat in establishment as vacant posts to fund the trainee nursing associates. We haven’t taken the money away, we are using it differently,” she added.

Ms Bates said the majority of the trainees would be funded through band 5 vacancies, while others would be paid for from unfilled band 4 assistant practitioner posts.

“This is not substituting for a lower band. This is looking for ways in which we can make sure we have got adequately trained people delivering the right level of care,” she said.

Ms Bates stressed that trainee associates would only be used in a safe way and in most areas where they would be working – emergency, surgical wards, medical wards, and the stoke unit – senior nurses had agreed only one could be in place at a time.

“There are no plans at this stage to take out band 5 roles… I can’t say it will be like that going forward”

Greg Dix

However, in theatres, it had been agreed that more than one associate could be used in a 24-hour period, she added.

She also told Nursing Times that when nursing associates were taking part in practice placements, they would be included within staffing numbers, meaning they would not be supernumerary.

The trust was also involved in discussions with other local organisations about potentially introducing future cohorts of trainee nursing associates later on in 2017, she said.

Meanwhile, board papers for Plymouth Hospitals NHS Trust due to be discussed on 31 March stated that it had appointed “17 nursing associate roles which will in time replace registered nursing vacancies and contribute to reducing overall workforce costs”.

But the trust’s director of nursing Greg Dix told Nursing Times the paper’s wording – by another board member – was “very unfortunate” and that he currently had no plans to replace nurse vacancies with associates, which he would be telling the board.

However, he could not rule out such a move once associates had qualified, noting that the organisation currently had 10% of its nurse posts unfilled.

“We’ve looked at our nursing establishments across all wards and the net effect has left us some money we have been able to use for nursing associates”

Karen Dawber

He said the “driving factor” in any such change would be based on the needs of patients, adding that the difference in salary between a band 4 and 5 employee was “negligible”, meaning substitution would not create any real financial savings.

“From my perspective, I am absolutely not replacing band 5 nurses with band 4 nursing associates, because it’s a pilot and we’re not even sure how it’s going to pan out or how the role will develop once they’ve qualified,” he said.

“As it stands, I’ve got a 10% vacancy rate here for registered nurses but the 17 associates are currently replacing band 3 HCA posts. There are no plans at this stage to take out band 5 roles…. I can’t say it will be like that going forward,” he said.

Mr Dix also confirmed that trainee nursing associates at the trust were not supernumerary during clinical practice.

Board papers from Bradford Teaching Hospitals NHS Foundation Trust state that one of its vascular wards with high numbers of vacancies “is part of a local pilot to develop the band 4 nursing associate posts to support the qualified nursing gaps”.

“To maintain safety the head of nursing regularly reviews and moves staff from other surgical wards to support the team,” they added.

“No vacant band 5 posts were used or replaced to fund these trainee positions”

Holly Ashworth

But trust chief nurse Karen Dawber – who is overseeing the 15 trainee associates at the organisation – told Nursing Times it was not a case of replacing nurses. She said funding for associates had been found after a staffing review last year had identified where nurse staffing levels needed to be decreased or increased in different parts of the trust from January 2017, based on patient need.

“What we’ve done is look at our wholesale nursing establishments across all our wards and the net effect of that has left us some money that we have been able to use for nursing associates, but in no way have we said the registered nurse post on a ward is now a trainee nursing associate instead, because it’s a different skillset,” she said.

But Ms Dawber confirmed that, once qualified, nursing associates could be used to fill nurse vacancies at the trust in areas where there were higher proportions of nurses. “In the future, I think it is right and proper that we would look at having different tiers of nursing within ward structures,” she said.

Similar to others, Ms Dawber said that trainee nursing associates would be included within HCA staffing numbers during their time spent in practice. The trust was also due to meet with local partners last week to discuss potentially running further nursing associate training courses in 2018, she told Nursing Times.

“The pilot has given us a great opportunity to further consider how best to meet the needs of our patients”

Adrian Childs

In the capital, Central London Community Healthcare NHS Trust board documents from January stated its pilot programme, which has 11 associates, would “most likely impact on band 5 nurse roles and was in effect a re-grading”.

However, the trust’s deputy chief nurse, Holly Ashforth, told Nursing Times it had filled all associate positions from its band 3 workforce and that “no vacant band 5 posts were used or replaced to fund these trainee positions”.

Meanwhile, Leicestershire Partnership NHS Trust board papers indicate substitution of vacancies will occur at its adult mental health and learning disability unit.

“The unit is currently implementing an agreed remodelling of vacant nursing posts into non-nursing roles. This includes the development of assistant practitioners and nursing associates and secretarial support to matrons and psychology posts,” said the papers.

Chief nurse Adrian Childs told Nursing Times that the trust had “no intention of replacing qualified nurses with other professionals or expertise”. However, he added that the pilot “has given us a great opportunity to further consider how best to meet the needs of our patients in the current challenging recruitment environment, and we will be using our learnings from this to shape our future workforce plans”.

“We have no plans to remove the vacant band 5 nursing posts in areas where nursing associates are to be deployed”

Kath Senior

At East Cheshire NHS Trust, which has 10 trainees, recent board documents state that “once trained, the band 4 nursing associates will be deployed where there is a vacant band 5 staff nurse post”.

Kath Senior, director of nursing at the trust, said in a statement: “We have no plans to remove the vacant band 5 nursing posts in areas where nursing associates are to be deployed and have no plans to change our existing band 5 nurse-to-patient ratios.

“Like many other trusts we face ongoing challenges to recruit to some substantive nursing posts so we are looking at a whole range of skill mix options,” she said.

The Royal College of Nursing said the evidence uncovered by Nursing Times showed plans to use associates in place of nurses was becoming widespread, and stressed that support staff must supplement the work of registered nurses, not substitute them.

“These findings prove beyond doubt that the government’s failure to train nurses is leading to nursing associates replacing them,” said Janet Davies, RCN chief executive and general secretary.

“Nursing associates should not be expected to deliver the same care as a registered nurse. Patients’ health outcomes are improved when greater numbers of registered nurses with the right skills mix are on duty.

“Urgent priority” must be given by the government to increasing the supply of registered nurses, she added.

Number of trainee associates in the first 11 pilot sites across England:

Health Education England

How trusts are planning to use nursing associate role

Source: Jen Van Schoor

Number of trainee associates in the first 11 pilot sites across England (Regions supplied by Health Education England)

  • 10 Comments

Readers' comments (10)

  • Is it me or are these senior nurses saying one thing and doing another?

    This is just an money saving exercise that will cost more in the long run.

    The Band 5 role is being undermined at the same time as being expected to monitor the associate post.

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  • This is the Government way of demoralising the nursing profession that is already crawling at the brink of existence. Undervalued, underpaid, unrespected workforce entitled to care for the health and well being of the nation. The healthcare environment is transforming to a more dangerous place if not scariest where vulnerable people instead of recuperating are becoming more unwell until they die. Ohhhh, I dont want my family and friends be in this situation. What a shame!

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  • Only non nurse managers or managers who who don't care about patient welfare would think this is a good idea.
    Its all part of the plan to sell off the NHS. Run the NHS down, bring in private companies to improve it with nursing associates & Profit Before Care plan completed

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  • It is ridiculous it is all about destroying nursing in NHS. First, making it more difficult to register with NMC so less nurses from abroad would apply to fill the shortage. Next, scrapping bursary so less people would apply for nursing, especially mature students who could bring their experience to NHS. and then someone came up with the idea of training nursing associates as solution to nursing shortage. First of all, why do you call them nursing associate? if anything goes wrong, patient would think that nurse made mistake and will complain about nurse, nobody will remember it was a nursing associate. Why should I be responsible for the nursing associate who will be allowed to do almost same what the registered nurse is but without responsibility? how thats going to save money? Training will cost a lot of money that could be used to keep bursaries for nursing studens or increase the pay in NHS.

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  • I left the NHS 3 years ago because of stress and it sounds like it's only getting worse! The politicians and managers making these decisions have obviously never stepped foot on a ward. An already demoralised, stressed workforce will break soon and then who will care for our patients?

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  • All I can see is they are trying to reinvent the SEN. There was a lot of opposition to that too! Yet the SEN was a valuable resource, accountable and responsible in the eyes of the GNC, often fed to the wolves to save an SRN. Once the idea of degree staffing came along the SEN became like a bad taste and if they didn't convert, they were destined for the scrap heap. People don't like it, but the start of all our troubles came along at the start of P2K. When Nurses with the right qualities but inadequate educational requirements were overlooked. What nurse needs qualifications to match entry to medical school! Many of e new Staff nurses I worked with since University training began, were not interested in the basics and supporting HCAs. They see HCAs for menial tasks, they don't know how to do or don't want to know how to do. How can they delegate these tasks? While they chase mor HO cast offs. The Ho's in turn are becoming deskilled! So when a patient can't be cannulated by a nurse, the HO can't do it either!
    I a so glad I got out of the NHS, I once would defend it with my life, it is becoming something I hope I will not need. My family will be ok because they will have me!

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  • Wow, problems already I'm seeing when a senior nurse told me that nursing associate can be do everything what nurses can do except drugs. This nursing associate started few weeks ago in that role and was taken by our trust as NA because of her qualification in her country and was working in other Trust as a HCA. I don't know how they process that to convert her into that role and some HCA who are working still as a HCA for years and had qualification as well still work as level 2. I think NHS is creating a more and more problems that is waiting to explode if not regulated well.

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  • I have worked as a hca within the NHS for the past twenty years, a band 3 for the last twelve. I have been given a fantastic opportunity by my trust to train as a nuse associate as have so many others.
    We are a workforce of health care support staff who have gained great knowledge and skills whilst delivering patient centered care. Enabling qualified members of staff to undertake their role, a difficult one under such pressures.
    I for one was unable to undertake my nurse training for reasons out of my control and had reached a plateau within my role as a hca, unable to further develop.
    Is it not patient care we should be thinking about and how a nurse associate can assist a registered nurse deliver high quality care. I have to attend university just like a student nurse, I have to undertake OSCE's just like a student nurse. I have assignments to write, and a maths exam also just like a student nurse. Whilst having to work full time and undertaking additional study set out by my trust.
    We study for two years missing a third. I'm sure my TNA colleagues feel the same. We are not cheap nurses, we don't want to take your jobs we want to add to the nursing profession and support registered nurses. We will be regulated by the NMC and have a code of conduct and pay to have my name placed on a register, so you alone won't be responsible for any care I deliver.
    I hope the nursing profession warms to this new role, you have a skilled workforce already behind you in your hca staff. Surely giving this workforce an opportunity to develop and assist in an already stretched workforce is the way forward in bridging the gap.

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  • Michelle I commend you, just as I did 2 years, exams and further training to do my job including extended roles equal to RNs prior to converting. The SEN had a mixed reception but ultimately became abused filling gaps RNs wouldn't do. Left in charge on late shifts and week ends.
    There is a need for this role but I fear that like the SEN after many years of devoted service and a depleted RN workforce the AN will be once again end up an unwanted asset

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  • Apologies Repleted RN workforce

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