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'We're sleepwalking towards substituting registered nurses'


Unless the nursing profession is more explicit about its unique contribution, it will be exposed to the threat of substitution, warns Elaine Maxwell

Health Education England has announced it will adopt Lord Willis’ recommendation in the Shape of Caring Review and introduce a pilot scheme for a senior assistant role to “bridge the gap” next year. Lord Willis envisages such practitioners taking on more technical roles and “helping to design the day-to-day care packages for patients”.

In 1930, the Lancet Commission was established to investigate the reasons for shortages of nurses. As with Lord Willis’ report, the Lancet Commission found there had to be more flexibility, so regulation of the assistant nurse, later known as the state enrolled nurse, emerged in 1943. By 1972, the General Nursing Council confirmed that 32% of all students were training to be enrolled nurses, with the Briggs report noting that “the actual level of work assigned to enrolled nurses is often very similar to registered nurses in the staff nurse grade”.

The trouble with the current proposal is that it is not clear which gap is being bridged. A new role could have a number of functions. It could help widen access into nursing, allowing those without the required qualifications to undertake a degree, get a foot on the ladder and potentially move onto registered nurse training. It could be a new type of assistant to the registered nurse too, undertaking work that is not core to the nursing identity, allowing the registered nurse to undertake skilled nursing.

Sadly, I think most of us fear that, like the enrolled nurse, it will become a cheaper substitute for the registered nurse.

As a profession, we are not explicit about what registered nursing is. Unless we make this explicit, nursing will remain undervalued and threat of substitution. If we define nursing by the tasks we undertake, we make it easier for others to ignore our real contribution and put in technicians to take our place. Research has demonstrated correlations between the number of degree-educated nurses and mortality. This isn’t because they undertake more technical tasks, or because they are more compassionate; it’s because their education gives them the crucial critical thinking skills to assess and respond in real time to changing needs.

The unique contribution of registered nurses is not a set of competencies. It is a paradigm, a way of thinking that delivers Virginia Henderson’s definition of nursing. This simple description of nursing masks a complex philosophy of supporting people through a range of changes in health status and can only be achieved with high levels of education and experience.

Good nursing saves money. It maintains maximum patient independence, enhances safety by monitoring people holistically and creating and adapting plans. Nursing is often the early warning system that alerts other professionals to when their skills are needed. If we sleepwalk into creating a substitute role, because we didn’t articulate to others what the registered nurses’ contribution is, then we will, as a profession, have collectively failed our patients.

Elaine Maxwell is associate professor, London South Bank University.

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Readers' comments (2)

  • Fran Entwistle


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  • And whose fault is this I wonder?
    Nurses are beginning to value themselves and can pick and choose where and when and for how much they wish to work for.
    I am a rare enrolled nurse and instead of listening to let alone responding to such assumptions we are a lower level skill set. I pushed forward and created opportunities to become a manager successfully. Very often we have career breaks and do not have opportunity to convert but are expected to undertake CPD graduate level courses . Added onto our development portfolio as credits this could have enabled us to convert.
    There is so much politics and barriers to success but lets not be put of . A positive creative how can we move forward and lateral thinking saves the day-and there are employers keen to employ us I might add

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