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In December 2015 the government announced plans to create a new role of Nurse Associate within the NHS which would bridge the “gap” between senior health care assistants and registered nurses. There has been a mixed reaction to this announcement over the past 12 months with some greeting the additional support nursing staff may receive from this change positively and some raising concerns about the affect this may have on quality of care. Although this announcement seems like something very new, have we seen something similar in the past and I ask, what lessons can we learn? I will explore this question in this article.

Background


It is important to identify and recognise the motives behind the creation of the Nursing Associate role, a good indication is the principles of the report which recommended its creation, “The Shape of Caring Review” (you can view HEE’s response to this report by clicking here). It set out the following 8 themes:

1. Enhancing the voice of the patient and the public
2. Valuing the care assistant role
3. Widening access for care assistants who wish to enter nursing
4. Developing a flexible model
5. Assuring a high-quality learning environment for pre-registration nurses
6. Assuring high quality, ongoing learning for registered nurses
7. Assuring sustainable research and innovation
8. Assuring high-quality funding and commissioning

This report builds on the recommendations of the Cavendish Review in 2013 which resulted in the creation of the Care Certificate for Healthcare Assistants, this aimed to ensure a high quality of care at all levels of the NHS. The creation of the new Nursing Associate role is being marketed as bridging the gap between Senior Healthcare Assistants and qualified nursing staff and providing an alternative route into nursing from a 3-year University Diploma, it therefore relates to points 2, 3, 4 and 5 of the reports themes.

Some more cynical observers may argue that there is a financial motivation for this change, we have already seen the removal of Nursing Bursaries for student Nurses, is this change just a camouflage for bringing the training of nurses back into the NHS therefore putting an additional strain on already stretched services? It may be unsurprising for some that when the role of a state enrolled nurse was introduced in the 1940’s, it was because of a shortage of fully qualified nursing staff and an unwillingness/inability to pay and wait for staff to gain the requisite qualifications, something which may sound familiar from the many media articles we read and view today.

What are they trying to achieve?


So this leaves a difficult question about what is really trying to be achieved here? Well maybe this is an irrelevant question, if the standards of care can be improved upon whilst saving the NHS money, helping to support already strained wards and increasing the skills and availability of the workforce surely this something which should be embraced? For it to work like this is probably a little idealistic, but can we learn lessons from history to help us achieve as many benefits as possible?

But how do we make it work?....Lessons from history

Comparisons may be drawn between the new Nursing Associate role being introduced in the next two years and the State Enrolled Nurse which was introduced in the 1940’s (this was discontinued in the late 80’s/early 90’s), this is especially true due to the announcement in January 2017 that this new position will be regulated by the NMC. The State Enrolled Nursing (SEN) role required 2 years of training, this course was a simplified version of the SRN (State Registered Nurse) training which took 3 years. It was widely accepted that the SEN training course and indeed job role was a more practical or “hands on” version of the SRN role. So there are clear similarities between the new role and SEN’s, even though the new role stops short of creating a dual layer of nursing registration.
A report conducted by the Institute for Employment Studies (you can read the full report by clicking here) on behalf of the United Kingdom Council for Nursing (UKCC, now the NMC) studied some of the key issues surrounding the role of a State Enrolled Nurse.

“The main issue of concern is that the competencies described in the Rule 18(which set out the competencies of an enrolled nurse at the point of registration), which emphasised the role of second level registered nurses in assisting first level registered nurses in the assessment and delivery of nursing care, are said to be narrowly interpreted and that employers fail to give enrolled nurses recognition for post-registration qualifications and experience.”

Further frustrations were identified in that the there was confusion about what the distinction of a first and secondary grade nurse were, the UKCC themselves identified that it 'imposes no arbitrary boundaries between the role of the first and second level registered practitioner'. This was compounded by the fact that some State Enrolled Nurses found that there was a lack of career progression within this staff group and that the support, funding and willingness to help with the transfer to a State Registered Nurse was lacking.

New roles…new problems


It seems to this observer that any effort to increase the standards of care within the NHS should be welcomed but that the introduction needs to be carefully monitored to ensure that it is used as a support network for the existing nursing staff and not as a replacement or substitute. From the lessons learnt in history it appears there are two main elements which the NHS must get right to make the venture a success:

- It must be clear what duties the Nursing Associate will be expected to perform; confusion on the ward about what people can and can’t do will inevitably lead to frustration and conflict not conducive to high quality care.
- Progression must clear and present; if the role is marketed to people as a new way to access a nursing career, it must be just that. Opportunities to progress to a fully registered nurse must be clear and present with the necessary funding options and university courses in place to satisfy demand.

In addition to this, there should be a clear consideration within the introduction of where this leaves Senior Healthcare Assistants (existing band 3 and 4’s) who may not want to spend 2 years serving an apprenticeship. Does this affect their current role and their career aspirations?
Time will tell how effective the initial pilot programmes have been, and lessons learned from this will help the roll out across the UK, but perhaps a lesson from history could be equally helpful.
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