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Practice comment

Different grades of nurses should be reintroduced to improve care


As nursing and healthcare roles have undergone significant change over the last two decades, two grades are needed to reflect levels of care, argues Maggie Nicol.

Keywords: Clinical skills, Education, Training, High-quality care

Clinical skills are the heart of nursing and therefore must be delivered by, or at least supervised by, nurses. Education and training are needed to be able to see beyond the task itself. These are also needed to see the person as an individual and safely deliver holistic care effectively and with compassion.

Lord Darzi’s NHS Next Stage Review (Department of Health, 2008) rightly concluded that compassion, safety and effectiveness of nursing care lie at the heart of quality nursing. Nurses have a big impact on patient safety and well-being as they provide the bulk of patient care - or rather they did.

Now the majority of fundamental care is provided by the increasing number of healthcare assistants (also known as healthcare support workers or nursing assistants) who often have little training apart from mandatory sessions and learning ‘on the job’.

However, nurses should be giving this care; providing a blanket bath is the perfect opportunity to observe the patient’s hydration, nutrition, pressure areas and skin condition, and to respond to their concerns. It is also the perfect opportunity to teach these skills to student nurses and junior staff.

Recent media reports suggested the RCN was dismayed to find that ward managers were spending time delivering fundamental patient care. I would argue that is exactly what they should be doing, working alongside their junior staff, teaching and demonstrating high standards of care.

Until relatively recently there were two levels of nurses; it was recognised that some nurses preferred the ‘hands-on’ aspects of care and a job that stopped at the end of the shift. They did not want (and sometimes did not have the ability) to be leaders of care with responsibility that continued even when not on duty.

Following two years’ training, enrolled nurses (ENs, now known as second-level registered nurses) were well prepared to provide all aspects of fundamental care and were regulated by the UKCC and therefore required to abide by the code of conduct.

The EN grade was phased out in the 1990s and most became first-level registered nurses (RNs), but since then the ratio of nurses to HCAs has changed. In many clinical areas HCAs and student nurses now provide most fundamental care.

Nurses are not ‘too posh to wash’ - they are just busy doing other things. It is HCAs with minimal training and often minimal supervision who are doing the washing.

However, if these practitioners do not have sufficient training to appreciate the consequences of not turning patients regularly, patient care will suffer. If they do not have sufficient training to recognise that observations are abnormal, patient care will suffer.

If HCAs are doing nursing, why don’t we call them nurses? Why don’t we reinstate a second level of nursing called ‘practical nurses’ and provide proper education and training?

But let’s learn from the past. All students should start the same education programme; practical nurses can then ‘step off’ after 18 months unless they choose (and have the ability) to continue to become RNs. This would enable practical nurses to continue their education to become RNs at a later date if they chose to do so.

It would mean that all those providing nursing care would be governed by the NMC’s code of conduct and all would have sufficient education and training to provide compassion and safe and effective nursing care.

Maggie Nicol is professor of clinical skills, School of Community and Health Sciences, City University London


Readers' comments (17)

  • I highly and heartily disagree with your suggestions, firstly beacuse they are not new, therefore one could say that you have achieved nothing at all. On the other hand, blatantly you are covering up that the training is the issue; coverage of the appropriate areas such as life sciences and pharmacology and clinical decision making are lost within hopelessly idealistic, unrealistic and almost over-indulgent focus on the - albeit important yet less useful - emotive supportive philisophical bearing, which is lost on students who need to know HOW THE BODY WORKS!

    To re-create the Enrolled Nursee, when it was mostly done away with because of the obvious skills overlap is unfair to the profession, which weak and defenceless (as always) cannot avoid this. What you think you are doing is having the best nurses as the leaders and the mediocre and worse to perform the tasks (which they are). Again, hopelessly delusional you avoid the fact the not teaching diploma or degree students mostly useable practical knowledge and skills is why it is percieved that this generation of nurses is performing worse than the last.

    I hope this doesn't go through. No good decisions regarding advancing nursing practice have ever been made really. Our career is in ruin because everybody is busy hand wringing about trivial things like this.

    If you want good nurses, at least ask that they have GCSE Biology. You shouldn't be teaching that the heart has four chambers and pumps blood around the body. People should know that already....

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  • As a current student nurse with 6 years of HCA experience, i feel as do many in my cohort with a similar background, that our skills as HCA's are woefully disregarded. i spent about 18 months finishing my NVQ3 in a busy MAU (arent they all?) to show the university i had the ability to study for a degree, i learned all sorts of skills including venepuncture, however, in the trust i am doing placements, simple finger prick blood glucose testing is not allowed to be done by student nurses until the third year! however i CAN prime an iv line and give an im morphine injection?! whats likely to do more damage should i go wrong and what needs more education for. As a mentor HCA, I constantly ran in to training brick walls, either the course was too expensive or it was felt beyond the remit of my job desciption. so even tho registered staff spend less time with patients the keen and able HCAs are not allowed the opportunity to improve (incase they ask for a pay rise) trust directors seem to like the status quo of cheap labour.
    As the article outlines ENs were useful (but isnt that what assistant practitioners are these days with their band 4 status?) and yes there was a skills overlap but surely better than understaffing? it would also mean potentially that HCAs like myself that have undertaken NVQ training leapfrog student brand new to care and reduce the stress they feel. it would also mean the NVQ training would improve to meet the exacting standards of degree level education.
    One huge flaw i feel with the current agenda for change pay scale highlights this. Band 5s are all lumped together irrespective of length of employment or experience and band 8 has four sub sections....mmmmmmmm.

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  • I have been a nurse for thirty years and though I no longer work in the hospital I have recently had a close member of my family in hospital. I have to say the care both the student nurses and HCA's gave my mother was second to none. However a year earlier on a different ward her care was appalling with excrement on the curtains and floor. Staff did not respond to buzzers and their attitude left a lot to be desired and these were staff nurses and ward sisters.

    During my training bed bathing and general care were always used to identify any underlying problems and an opportunity to talk to your patient about any psychological concerns they may have had. While I think HCA's do a very good job if they are not paid proprtionately for enhancing their skills then they will not receive the training to improve their observational and communication skills.

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  • What about Assistant Practitioner's? Disregarded in your discussion - AP's are not HCA's nor are they Nursing Auxilliaries - Who are only qualified to NVQ3 level whereas an AP has a Foundation degree (2 years at University) in Health Studies - Some have ogone on to achieve full Bsc /BA in Health Studies which is more than a lot of registered nurses have achieved. Yes, registration is important but please put things into context!!!!

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  • But we aren't talking about RN's and HCA's. This point is irrelevant. What they are saying is that two tiers of nursing, despite being done away with for good reason ought to be brought back because it appears that a good section of qualified nurses are incompetent or not really capable. Thus an elite sector should rule and direct, much like todays NMC.

    The fact that EN's often excelled against their RGN counterparts is also a major point in why the two tier system was dropped. Talented but less qualified EN's were often held in better regard than the more schooled but often equally able RGN's.
    The two tier system is an ugly left over by product of history that validates class barriers as almost always the middle class nurses were RGN's and below that the EN students were taken from the lower classes of society.

    Little creedence from the government and nursing bodies has been given to the state of education which deems care to be a field outside of other academic health profession by virtue of the lack of focus on comparable sciences.
    The lack of a vast knowledge base in adlult nursing is made all more obvious by the style of teaching and the methods by which nursing education is meant to succeed.

    The classroom material focuses briefly the human body but spends limitless hours examining the role and aspects of nursing and how it is for the patient to be nursed and what hospitalization is like.

    The practical experience plants students in any clinical environment and is expected to immediately ingratiate themselves with the nursing structure whilst observing methods and ways that care is delivered, involving themselves to a limited degree.

    Firstly, the transisition from classroom to clinical practice is made all the more difficult by the lack of a good grounding in the physical sciences. Students enter the environment view the 'taught' stance that the care they provide can occur seperately from the other aspects. Patient care activities such as washing and dressing patients, feeding, bed making and errand running are roles undertaken, not because they truly educational but because it is all students are comptent to do in general.
    The variability of mentors and individual students personalities, working styles and outlooks also means that students experience extremes in what is learned and experienced in the clinical setting. Arbitrary restrictions by nurses themselves can also further hinder the experience.
    Without a genuine knowledge of the human anatomy, other subjects such as pharmacology and biochemistry also have fallen by the wayside and such knowledge is limited to those who deem it relevant for them to know, but not others in lesser positions.

    My thoughts are really, why is nursing education so restrictive and undeveloped when clearly the answer to our prayers is to produce knowledgable and skilled staff.
    Is it right to graduate nurses with no real skills , after all there is no official final comptency for drug administration or phlebotomy or even documentation that gives nurses the righ to do any of those things once the clinical environment is reached and the practical skills of such tasks or not even taught fully during the training itself.
    Isn't the paucity of science in nurse education the reason why nurses appear to have less knowledge and ability compared to previously when there was not much less to know, but the ingratiation of education and practice was complete?

    Nursing doesn't cure patients onits own and it is wrong for the system not to reflect the current realities and provide the relevant educaiton that nurses require. Too many students say to me that their training was a waste of time and that they learnt nothing that could help them in the clinical sphere that is entirely based in the application of classical and academic scientific principles.
    The Roper-Tierrney-Logan model only and others similar only succeeds in ascertaining knowledge about patient care that is more relevant to our assistants that ourselves. It does not allow, comfortably, for the prinicples of haemodynamic or nursing interventions to be incorporated, in fact these areas are omitted altogether and the focus of nursing shifts from maintaining a patients haemodynamic status and intitating, providing and assessing nurse administered therapies or even a comprehensive way of assessing a patient in the plethora of situations and circumstances that patients are in.

    It indeed cannot redress the variety in people or that in many cases the ADL's are irrelevant as there is no issue.

    I argue for a better way to combine the asprational and internalized ideals of nursing with a realistic education in knowledge that genuinely allows us to fully and completely assess a patient rather than attempt to do it via their psyche and behaviour.
    We need to move on from previous ideals and stop romanticizing the past. Our colleagues have a far greater taught knowledge than us that needs to be adressed first and foremost, not trivial pursuits over guff like a return to the unfortunate two tiered past.

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  • Would it not be a whole lot simpler to just employ enough nurses so that they do have enough time to feed, bathe and medicate patients themselves. This way students would truely learn practical skills as their mentor would be able to include them in their daily routine instead of relying on them to pick up the areas of care they simply don't have the time for. Sorry - painfully naive point of view - I do realise there is a thing called a budget but staff retention saves money for a start, not having to spend money on negligence cases.....
    I am a 3rd year student who is not brilliantly skilled yet but is hoping for more fine mentors who will perhaps have the time to continue to develop me into a newly qualified nurse at which point I hope my working environment will be one where I can truely nurse in an holistic way as I have been taught to do.

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  • I can see both sides to the coin. I am a third year student learning disabilities nurse and worked for 5 years as a support worker and sometimes an HCA prior to my nursing education. Unlike many students I was educated to a fairly high level before commencing my nursing education and so had the understanding of biology, chemistry and so on that is so often lacking. The problem, as I see it, is more than just a problem with nursing; it is a problem with perceptions of and attitudes toward nursing too. I have met and worked with many HCAs and HCSWs who are just amazing. I have met just as many who are awful; arrogant, egotistical people on power-trips who cannot and will not even consider that what they are doing may be wrong. The same goes for student nurses and qualified nurses; the difference is though that at least students and nurses know better. If they choose to go against it then that can be dealt with but the attitude of "we've done it this way for 30 years, you're not going to tell me what to do" and "I don't need a care plan, I've been doing this since 1978" is harder to contend with. The reintroduction of something like an Enrolled Nurse - not necessarily the same as before, but giving someone a level of role-specific education before they enter the workplace, beyond moving and handling, would only serve to better the healthcare service. An understanding of medication, illness and wellness, pain management etc can only, surely, be beneficial?! I recently had a discussion with an HCA friend of mine who is doing her NVQ regarding pain relief. According to her, the gentleman for whom she was caring who had cancer and had a urinary catheter should have "shut up and stopped moaning" as he "could see [she] was busy with other patients, and paracetamol's enough for everyone else so he was clearly just exaggerating for attention". I don't believe that it would take a lot to enable someone to understand that pain is subjective...
    I think that a degree of education, getting everyone up to speed with regards anatomy and physiology, pharmacology and perhaps a bit of psychology, alongside things like communication and the standard procedures that are taught in the first year or two of nursing education would help to minimise the "gap" between nurses and HCAs and hopefully do away with some of the anger and resentment on both parts...

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  • To clarify, I meant to say "unlike many students on my course", rather than make a sweeping generalisation about all student nurses ever... I was certainly very surprised to discover how few of my fellow students had no knowledge whatsoever of biology, chemistry or even basic maths... Until recently the pass rate for drug calculations was 40%! And people still managed to fail then... The idea that it might be ok to give incorrect doses of medication 60% of the time is incomprehensible.

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  • I argee with the comment about Assistant Practitioners, you have not got the sitution in context. The AP role is to tackle this issue of hands on knowledge. You raise some good points regarding training and how are the RGN's able to carry out full assements of thier patients. But there are other issue you do not raise that have brought about this sitution.

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  • After reading this article i agree that there should be a re-grading of names for certain nurses. I was a HCA for 4 years and have thoroughly adored my job. I love gaining more knowledge and feel this is vital when working on a busy ward as i do.I therefore applied to do an Associate Practitioners course. I am at the moment a Trainee Associate Practitioner( T.AP)This is a dreadful title, it gets mixed up with Nurse Practitioner to general joe Bloggs. People assume you can do all the roles a Staff NUrse can do and more. Ridiculous in my opinion and i feel is misleading. As it is a new role, even some staff nurses were horrified at what implications APs had regardiong accountability etc. Why cant we revert back to the E.N? They were basic nurses with HCA qualities too. I never want to lose my hands on care and feel an AP is a very rewarding role.Surely then it will be much clearer to visitors and relatives what our role is.

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