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”
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.
- Nurse vacancies converted into associate posts at acute trust
- Nursing associate test sites across England revealed
- Second wave of nursing associate test sites unveiled
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”
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”
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”
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”
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”
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”
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:
How trusts are planning to use nursing associate role
Source: Jen Van Schoor