Introducing new roles, such as that of nursing associate, is challenging. This literature review offers guidance to leaders and workforce planners, and comes with a handout for a journal club discussion
The NHS is faced with the urgent task of reshaping and enhancing its nursing workforce. Part of this reshape will be happening soon with the introduction of nursing associates – the first cohorts are currently undergoing training. However, introducing new roles in an established healthcare workforce is not an easy task. It needs to be well thought-out and planned, and conducted with the primary aim of meeting patient need. This article sums up the findings of a literature review on the introduction of new roles in healthcare, using lessons learned from the past to provide guidance to leaders and workforce planners.
Citation: Halse J et al (2018) Creating new roles in healthcare: lessons from the literature. Nursing Times [online]; 114: 5, 34-37.
Authors: Jenny Halse is head of nurse education, King’s College Hospital; Lisa Reynolds is divisional lead for nursing; Julie Attenborough is associate dean and director of undergraduate studies; both at City, University of London.
The NHS is experiencing unprecedented change and needs to adapt its workforce. It is also experiencing a staffing crisis in nursing. One solution that is being implemented is the creation of a new role – that of the nursing associate – to bridge the gap between registered nurses and support workers. What are the challenges of introducing new roles in an established healthcare workforce? A literature review was undertaken to examine the evidence around this question, identify key themes and come up with recommendations for leaders and workforce planners.
Since the creation of the NHS in 1948, healthcare delivery in the UK has changed dramatically. Advances in treatments and technologies have contributed to the ageing of the population. People live longer with complex comorbidities, which results in an increased demand for services. The vision for the future NHS expressed in NHS England’s (2014) Five Year Forward View emphasises public health and disease prevention. It aspires to services that meet patients’ needs and are delivered through flexible models of care close to people’s homes.
To meet those needs, the NHS requires a workforce that has the appropriate skills, knowledge, behaviours and attributes – however, it also needs to keep the cost of that workforce within a prescribed financial envelope. Clinical staff cost the NHS £46 billion each year, not including the cost of locum, agency or bank staff to cover vacancies; this equates to around half of the NHS’s total costs (National Audit Office, 2016). Financial constraints placed on an organisation can negatively affect its ability to ensure it has an adequate workforce to meet demand.
Currently there is a staffing crisis in nursing, with a deficit of nursing staff and a reliance on agency and overseas nurses (Willis, 2015). Resolving short-term pressures is difficult due to the time it takes to train new nurses, and while overseas nurses have previously been employed to address shortages, Brexit means that this source of staff can no longer be relied upon. Given the radical changes that are expected to take place in healthcare delivery, transformation is needed to ensure there is a flexible and adapted workforce (Addicott et al, 2015). One of the initiatives intended to bring about this transformation is the introduction of the nursing associate role.
In recent years, two independent reviews have identified a gap between patient need and the knowledge and skills of NHS staff:
- Imison C et al (2016) Reshaping the Workforce to Deliver the Care Patients Need, published by Nuffield Trust;
- Willis GP (2015) Raising the Bar – Shape of Caring: A Review of the Future Education and Training of Registered Nurses and Care Assistants, published by Health Education England.
Both reviews highlighted an opportunity to develop the support workforce to enhance the delivery of patient care. Introducing the nursing associate role was a key recommendation of Raising the Bar – Shape of Caring, a review of the education and training needs of registered nurses and support workers.
The nursing associate role is being introduced with the overarching aim of improving the capacity and capability of the NHS to care for patients. It is intended to augment, support and complement the care that is delivered by registered nurses. Through education, nursing associates will gain a standardised, high level of knowledge and skills that will help them deliver the fundamentals of care (Health Education England, 2016).
In 2017, 2,000 future nursing associates started training at 35 sites as part of an HEE pilot scheme. In October 2017, the health secretary Jeremy Hunt announced an expansion of the training programme, with plans to see 5,000 nursing associates commence training through the apprentice route in 2018 and 7,500 in 2019. Box 1 lists the guidance issued to date on standards of proficiency and the curriculum for nursing associates.
Box 1. Guidance on nursing associates
- Health Education England (2018) Advisory Guidance: Administration of Medicines by Nursing Associates
- Health Education England (2017) Nursing Associate Curriculum Framework
- Nursing and Midwifery Council (2017) Working Draft: Standards of Proficiency for Nursing Associates
- Nursing and Midwifery Council (2017) Working Draft: Nursing Associates Skills Annex
Introducing a new role in a healthcare environment that is subject to policy change, demographic pressures and financial constraints is challenging. The nursing associate pilot scheme currently under way will undoubtedly highlight areas that need to be addressed in the education of nursing associates. In the meantime, what can we learn from the literature about the introduction of a new role in an established workforce?
The literature review included two types of evidence: empirical research and grey literature. The Medline and CINHAL databases were searched to identify relevant empirical studies. Articles were systematically assessed for relevance against explicit inclusion criteria (Box 2).
Box 2. Inclusion criteria
- Articles written in English
- Study set within healthcare
- Content related to one or more of the following themes:
- Introduction of a new role
- Education required for a new role
- Workforce or workforce design to meet service need
In total, 420 articles were identified through the database search; after systematic review 29 were included in the literature review. Grey literature such as policy, reports and education theory were used to inform the analysis of the articles. A thematic analysis of the 29 selected articles was undertaken to identify key themes. Thematic analysis is a flexible approach to qualitative data analysis that enables researchers to capture significant factors, commonalities and conflicting views in the literature (Booth et al, 2016).
The literature review enabled the researcher to determine seven key factors for healthcare leaders to consider when planning to introduce new roles in their workforce:
- Robust workforce planning;
- Well-defined scope of practice;
- Wide consultation and engagement with stakeholders;
- Strong leadership;
- An education programme that mirrors patient need;
- Adequate resources for work-based learning;
- Supervision by a skilled clinical educator.
There is a clear consensus in the literature that new roles must be based on need (Harding et al, 2015; Price et al, 2015; Tranter et al, 2011; Eklund, 2010; McKenna et al, 2009; Chow et al, 2008; Reid, 2008; South et al, 2007). Reid (2008) argued that an in-depth organisational assessment based on patient need is crucial in the introduction of a new role, and that new roles should not be seen as a quick solution to workforce challenges.
Where there is an identified gap in service delivery, workforce planners need to assess whether this gap can be filled by optimising the capacity of the existing workforce (Wood et al, 2011). Workforce planners also need to consider how the new role will fit in with the existing workforce, and a balance needs to be found between offering career development opportunities to existing staff and opening the door to new colleagues wanting to join healthcare.
In the NHS and healthcare systems in other parts of the world, introducing new roles is often seen as an attractive solution to a demand for workforce (Brown et al, 2008; McKenna et al, 2006). However, conducting workforce transformation without a solid understanding of need can lead to the new role being underused, existing roles being de-skilled, care becoming fragmented, and financial costs being added to service delivery – all of which can ultimately threaten patient safety and the quality of care (Price et al, 2015).
Scope of practice
Designing a clear scope of practice for the new role allows us to:
- Identify its boundaries and responsibilities;
- Assess the potential risks to patients;
- Establish ad hoc governance structures.
It is vital to conduct an organisational assessment that ensures patient safety and builds workforce capacity in a productive way (Reid, 2008). If the new role could pose a risk to patients, registration and regulation must be considered (Thurgate et al, 2010).
Consultation and engagement
Consultation with a wide range of health professionals to define and design the new role is fundamental to its acceptance. Eklund (2010) reported that, where roles have been introduced without engaging with the wider team, they have not been accepted and were discontinued shortly afterwards.
Thurgate et al (2010) identified that stakeholder engagement at every stage is important to gain buy-in and allow the role to be embedded in service delivery. Co-designing the new role – as well as the supporting education programme – is best practice. Collaborating with stakeholders to design the new role not only helps understand need, but also prevents professional boundaries being encroached upon (Thurgate et al, 2010).
Including service users in service development is established best practice in the NHS. The articles included in the literature review recognise that there is value in engaging with patients in the process of identifying need, including gaps in service provision (South et al, 2007; James et al, 2006) – however, they fall short of outlining a role for patients in the design of new healthcare roles.
Strong leadership is pivotal to the process of introducing a new role. James et al (2006) identified senior management support as the most important factor in the success of role redesign and initiatives that support new ways of working. Embedding a new role in an existing workforce is challenging. Leaders who use quality improvement and change methodology have found these to be positive enablers (Fletcher et al, 2008).
There are reports in the literature of a lack of senior leadership, lack of planning and lack of change models to steer the introduction of new roles. New roles are not always systematically implemented, but instead may be left to the enthusiasm and skills of individual clinical departments (Stewart-Lord et al, 2011). The engagement of leaders is required throughout the organisation – and at a national level if the new role is to be implemented on a national scale – to ensure the necessary governance and lines of accountability are in place (Gill et al, 2014).
Designing an education programme for the new role is paramount. Health professionals’ education is synonymous with work-based learning, which provides real-life work experience in parallel with gaining knowledge through academic channels (Thurgate, 2018; Manley et al, 2009).
Work-based learning in healthcare is well established and adopted in many countries. The workplace is acknowledged as a site of learning where the learner, supported by a supervisor, can bring the curriculum to life (Morris and Blaney, 2013). In work-based learning, two worlds are merging – that of an educational institution and that of healthcare settings – to provide valuable learning opportunities. Education providers help learners to translate theory into practice (Thurgate et al, 2010; Chow et al, 2008).
The education programme for a new role needs to:
- Mirror the needs of patients;
- Reflect the scope of practice that must be delivered by future practitioners;
- Provide learners with the knowledge and skills they need to deliver excellent patient care.
There must be synergy between patient need and educational content (Tranter et al, 2011; Bennet et al, 2007). In the case of nursing associates, one of the educational challenges is that the scope of practice is still emerging.
Collaboration between clinicians, leaders, policy makers, regulators and higher educational institutions in the design of the curriculum is instrumental in ensuring that both the curriculum and the approach to delivery meet service need. Including patients at all stages of healthcare education design and delivery can be regarded as best practice, as people who have real-life experience of care provide an essential insight into what it is that they need. However, the literature included in the review falls short of identifying this as best practice.
Work-based learning brings with it some inherent problems, including potential pressure on the clinical environment and, ultimately, on patient care. Where resources are constrained, the challenge of educating the future workforce while ensuring patient care is delivered to the highest standard is a significant one. There is a dichotomy between trying to build capacity through training and having a reduced workforce to deliver care. If work-based learning is to be successful, it needs to be adequately resourced, otherwise it could place an additional strain on the system (Price et al, 2015).
Constructivist educational theories are premised on the belief that learning is a socially active process in which participation and engagement with others are essential. Learning occurs when there is not solely an acquisition of know-ledge, but also an understanding of how to apply it (Fuller and Unwin, 2003; Lave and Wenger, 1991). When these theories are applied to a work-based learning model in healthcare, the role of the clinical educator appears to be key to creating a positive learning environment.
Learners need to be supported, encouraged and given the opportunity to perform new tasks – initially under direct supervision. As their confidence and knowledge grow, the skill of the clinical educator is to transition from direct to indirect supervision while ensuring patient safety is maintained (Manley et al, 2009). In the UK, the importance of the clinical educator, who needs to be both an expert clinician and a skilled educator, has been recognised (Whitehead, 2010).
A learner’s sense of belonging to the clinical team has a significant impact on the quality and volume of learning that occurs, and results in more learning opportunities being made available (Brown et al, 2008). This becomes more challenging when a new role is introduced. Clinical educators need to have a good understanding of the new role and its scope of practice to know how to support learners in practice. Lack of awareness of these elements may result in poor supervision. A robust plan needs to be in place to ensure that supervision is adequate and learning is facilitated, while time resources need to be invested in the preparation and ongoing support of clinical educators as well as learners (Wood et al, 2011).
Introducing a new role needs to be a well thought-out process. The review has highlighted key factors that leaders and workforce planners need to consider; these are summarised in Box 3.
Box 3. Introducing new roles: key factors
Leaders and workforce planners should ensure the following:
- Workforce planning is robust, taking into consideration how the new role will fit in with existing services and workforce
- Scope of practice is well defined and the education programme mirrors patient need
- Leadership is strong and uses change management methodology
- Time and money are adequate, and resources include provision of a clinical educator
This literature review has established that the introduction of new clinical roles in the NHS is challenging, with significant implications for patient care. It can also have consequences for existing staff and, while we need to embrace new roles and innovations, this should not be at the expense of the existing workforce. Collaborative partnership working with all stakeholders is fundamental, and patient need must be at the heart of the project and remain central in the change process.
- The nurse associate role is being introduced to improve the capacity and capability of the NHS to care for patients
- Introducing a new role in a healthcare system that is subject to policy change, demographic pressure and financial constraints is challenging
- Workforce planners need to consider how the new role will fit in
- The new role must be based on patient need and have a well-defined scope of practice
- The role of clinical educator is pivotal to ensure the success of work-based learning
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