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Replacing nurses with HCAs tantamount to 'deregulation of nursing', RCN warns


Attempts to shift nursing duties onto cheaper healthcare assistants raise serious patient safety and are tantamount to a ‘deregulation of nursing,’ the Royal College of Nursing has warned.

Last month Nursing Times revealed hospitals were planning to replace some nursing posts and duties with advanced healthcare assistants, paid at the currently little-used band four level under Agenda for Change (news, page 1, 27 October).

RCN head of policy Howard Catton told Nursing Times the plans were now spreading across the NHS in response to the need to save up to £20bn over the next five years.

Managers have told Nursing Times the new advanced assistants will work to strict “protocols” and will be aided by the increased use of electronic monitoring of patient observations, which effectively mean qualified nurses can be replaced with less skilled assistants.

But Mr Catton warned that such a “radical reconfiguration” of the nursing profession to resemble more of a “production line” would lead to serious safety issues. Nurses would be expected to supervise healthcare assistants doing duties previously carried out by nurses such as observations, medication and discharge but the nurses themselves would become deskilled in those areas.

“A nurse who is supposed to be supervising [a task] won’t know how it’s supposed to be done because we will get to the point where they haven’t done it themselves,” Mr Catton said.

He said this “deconstruction” of the nursing profession–with ever more skills and duties being passed to unregistered assistants meant nursing was gradually being “deregulated” as healthcare assistants do not come under the watch of the Nursing and Midwifery Council.

That concern was echoed by nurses commenting on the story on Nursing Times’ website. One said: “I, for one, am not willing to stand in a coroner’s court taking responsibility for an HCA who has failed to deliver care to the high standard demanded by a qualified nurse, who has been led to believe they can take on the role given to them by penny-pinching senior management and yet who has no professional accountability.”

Mr Catton said a further concern was that the move to more “protocol-based care” would almost necessarily “stifle innovation” because “people are working inside the tick box”. He said it was ironic managers were urging such an approach to nursing just as they were supposed to be encouraging innovation to increase productivity and quality.


Readers' comments (12)

  • i am a H C S W and have a number of special skills which i do by guideline,policys etc and are accountable for my duties this also includes delivering a high standard of care which everyone should give. please dont knock us because some of the newley qualifed and qualifed are lost with out us by the way what is this band 4? we are only band 3?

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  • Whilst I have to say that Band 3 and Band 4 experienced practitioners are of a great help to us nurses on the ward - especially when we are bogged down with paperwork and other timewasting things! - there is an area that concerns me. Should they be given even more responsibility and roles, who is going to be accountable when they make a mistake?? They are not registered with any professional body, unlike registered nurses. As for electronic patient monitoring systems, just talk to anyone working in Critical Care Outreach and they will tell you these systems are not perfect. You still need to be able to carry out a full assessment of your patient, whilst doing observations and sometimes need to do manual observations.
    If the NHS wants band 3 and band 4 practitioners to become even more advanced, perhaps they should send them on a one year course to cover the anatomy and physiology and patient management that nurses have to do as part of their training?

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  • I am currently employed as a competent, skilled, band 4 Assistant Practitioner in the community having attended university over a 2 year period.
    Having achieved the award of the foundation degree of science in assisting professional practice, with commendation .
    Previous to this having been employed both in the private sector and the NHS for over 18 years as a mature, experienced Auxiliary Nurse.
    For me to see the registration of band 4 practitioners, who have received training, would leave them being accountable for themselves,whilst remaining under the supervision of qualified staff.
    There is a place for people like myself who have a lifetime of experience and continue to update knowledge and skills in my chosen career of caring, however, for various reasons have not had the opportunity to become a qualified nurse. Perhaps the role of the trained band 4 assistant practitioner should be looked into a little more closely by those who are not aware of our role and what we have studied to achieve it.

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  • Having been a carer and then a nursing auxiliary for many years I was given the opportunity to use my capabilities to improve and enhance my role within District Nursing. This has by no means led to the patients receiving a second class service. The statement with regard to automated observations is generalised and not factual….are not the obs within the hospital setting carried out with automated equipment whether done by registered or non registered staff? I have attended thorough training sessions to carry out manual obs with the additional factors relating to the obtaining of and the indications as to the relevance of the results. Good practice was then evidenced by the undertaking and completing of competency records as with all skills. Whilst continuing in my HCA role within the service and not in a student status, I have recently completed the two year Foundation Degree course, with Distinction, required to take on the role of the Assistant Practitioner (Band 4). Thus not only myself but my colleagues both trained and untrained have witnessed my continued development and increase in my capabilities and quality of care. I am well aware of my responsibilities and accountability to my patients, employers, public and colleagues. Whilst it is the responsibility of the registered staff to ensure that the task is correctly delegated, it is the responsibility of the employer to provide the necessary training required by any staff member to attain the level of competency required to work safely and to the highest level. It is, therefore the responsibility of any staff including the Band 4 to speak out if they should feel that further training and support is necessary to attain the competency. We are thus accountable for our actions so for me the question is: are the registered staffs aware of what is permissible within the role, then, if appropriate, are they approachable and open to the Band 4/staff member having to refuse a task and to provide or direct to the necessary training and support in order for the task to be undertaken in the future. I have no objection to a future registering of the Assistant Practitioner role and I in no way feel that because we are not registered at present does it mean that I am unaccountable. I acknowledge the responsibility of the delegating staff and that I must be honest and open with them in order to protect them as valued colleagues as well as to continue my personal development and current knowledge of nursing issues.

    I feel that there is a great ignorance as to the extent of the studying that we have undertaken. In fact the students on placement and the registered staff that I have worked alongside whilst on the course have been amazed at both the extent of the study, including A & P, and the assessments undertaken. I have experienced beliefs such as a cheap workforce but my reply is that I am making use of my skills and capabilities to improve the service available both by myself and allowing them to enhance their skills and to take on the additional tasks required within their roles.

    Change is always unnerving but this change can be a positive move allowing those of us who for whatever reason have not travelled the path of the professional registered nurse to progress and to the full use of our experience and skills to the benefit of the patient and the service as a whole.

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  • From my little experience on placements some HCAs clearly shine beyond some band 5 and occasionally band 6 nurses... the only thing holding them back from a nursing degree is money and they are hoping to get secondments to enable them to do so.
    Also some band 5 nurses have clearly reached their limit in career progression, which is fine, but these people are sometimes not good mentors or HCA supervisors as they cannot cope with additional responsibilities.
    Maybe there should be an interim qualification which crosses from HCA to band 5, which pays accordingly.
    One another placement (surgical day clinic) the only thing the nurses did that distinguished them from the HCAs was put cannulas in and draw up drugs - oh, and there was always a qualified nurse in the theatre filling in 5 sheets of paperwork by hand, most of which was repeatedly copying out patient info from the notes - bureacracy really knows how to waste money eh!

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  • Again I say why do we bother training for 3-4 years only to be 'replaced' by unqualified staff. Their skills are numerous and valuable, but they don't have the in-depth knowledge of the human condition that we learn about during our training and they don't have the ultimate legal accountability that we have as RNs. It's as simple as that. Just for once, let's hear someone out there sticking up for nurses who have committed themselves to the training. I suspect the cheap old NHS is looking for ways to save pennies at the expense of patient care.

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  • i am frightend to come in hospital because of some of the nurses you talk about in-depth knowledge they ask hcsw and some newley qualified go to bits when their on their own then at the end of the shift thanks i am glad your here and know what you are doing anyway you dont give care out of a text book sorry/

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  • "Again I say why do we bother training for 3-4 years only to be 'replaced' by unqualified staff. Their skills are numerous and valuable, but they don't have the in-depth knowledge of the human condition that we learn about during our training ..."

    Training is ongoing, and pre Agenda for Change I heard the comment that some G grade nurses were just glorified phlebotomists. What is 'qualified' anyway? If it is acquiring university modules then some HCAs could have more than their 'superiors'. If it is knowing the human condition, then that is often from the heart and cannot be taught by anyone. That is why nursing should start at ground level and not by people who just get high grades in exams.

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  • For all the HCA's of numerous bands that have posted on here. You all sound pretty indignant about your role, and say you are all competent and well trained. You may well be, there are a lot of excellent HCA's out there who do a brilliant job (just like there are some bad apples). Some of you also say you are accountable. To yourselves, maybe, but not to a professional body or in the eyes of the law.

    We have to remember here that at the end of the day, regardless of what band they achieve, HCA's are still NOT trained Nurses, they are NOT accountable legally or professionally, they ARE health care assistants.

    This is not meant to put anyone down, just remind people that there is a recognised professional qualification that makes you a professional registered Nurse. If you want the skill, the quals, the ACCOUNTABILITY and the status that comes with being a Nurse, take the Nursing degree.

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  • The every day environment, working in a hospital under the NHS is constantly changing. I think that in order to keep up with the pace, we all must adapt. However the difference in knowledge in human anatomy, physiology and pathogens between a doctor and nurse is probably the same difference from a nurse to a HCA. It takes a student nurse 4 years to learn that knowledge, on a course that is 4600 hours per year and 50% theoretical. That is alot of studying. In my opinion its great for HCAs to learn more, maybe do work based QCF Diplomas or even secondments for nurse degrees, but there is a difference for a reason. Each cog works another. Doctors and Nurses, Nurses and HCAs/Auxillaries. If HCAs did more, such as administering meds, inserting canulars etc.. Where would one role begin, and the other end? The major difference is a degree/pHD obviously and the levels of anatomical knowledge that seperates doctors/nurses and nurses/HCAs. Its all about whats on paper or what letters you have behind your name. My opinion

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