In 2017 Health Education England (HEE) launched a pilot programme consisting of 2000 trainee nursing associates. Since 2017 there has been a year-on-year increase in the number of trainee nursing associates who are undertaking their training to become registered nursing associates. Registered nursing associates were admitted to the Nursing and Midwifery Council (NMC) register in January 2019, becoming eligible to join the workforce in England. Registered nursing associates are working in the NHS, in social care, hospices and GP practices, in increasing numbers.
The registered nursing associate offers hands-on, person-centred care working as a part of the nursing team, and a valued member of the wider multidisciplinary team, working with people of all ages in a number of health and social care settings. Registered nursing associates make valuable contributions to the promotion of health, health protection and the prevention of ill health. They are skilled at empowering people and communities to make choices and assume control of their own health decisions and behaviours; where possible, they support people in managing their own care. Registered nursing associates interact on a daily basis with a number of service users, families and carers, as well as with an extensive range of health and care professionals and other agencies, including social services, police and justice systems, probation, prisons, housing, education, language interpreters and third sector/voluntary agencies. They undertake various shift patterns, enabling care to be offered 24 hours a day, 7 days a week for 365 days of the year. The registered nursing associate has become a key part of the team, meeting the integrated health and care needs of patients and service users.
‘Nursing associate’ is a protected title in law. In England, it is an offence for anyone to practice as a registered nursing associate without being registered with the NMC, or to incorrectly claim to be qualified or registered.
Shape of Caring review
The role of registered nursing associate was introduced in response to the Shape of Caring review (https://tinyurl.com/bdcfv5tm), to help build the capacity of the nursing workforce and support the delivery of high-quality care. The registered nursing associate role has been developed to meet the specific needs of the English nursing workforce.
The Shape of Caring review, chaired by Lord Willis, made a number of recommendations to strengthen the capacity and skills of the nursing and caring workforce in England. The review, which reported findings to HEE, identified a skills and knowledge gap between healthcare assistants and registered nurses and the registered nursing associate role was developed to bridge that gap. One of the main recommendations in the review was to explore the need for a defined care role to act as a bridge between the unregulated healthcare assistant workforce and the registered nursing workforce (Willis, 2015).
In December 2015, the Government announced a plan to create a new nursing support role for England (Department of Health and Gummer, 2015). A 6-week consultation on this new role was undertaken by HEE. The NMC was approached to become the regulator for the registered nursing associate and agreed to take on the role, and there was a further consultation regarding changes to the legislation that would allow this to happen (Department of Health and Social Care, 2018).
Nursing and Midwifery Council
The NMC's key function is to regulate. It has a statutory responsibility to maintain the register of nurses and midwives who have demonstrated that they have met the requirements for registration in the UK, and in England, registered nursing associates who have met the conditions for registration. The NMC has set the standards for the professional education that is provided to support those people who have to develop the knowledge, skills and behaviours needed for entry to, or annotation on, the professional register. The NMC influences the practice of those professionals on the register through the development and promotion of standards. The Code (NMC, 2018a) provides the professional standards that all registrants must uphold so as to be registered to practise in the UK. The Code is structured around four themes:
- Prioritise people
- Practise effectively
- Preserve safety
- Promote professionalism and trust.
Lifelong learning is promoted through revalidation. The aim of revalidation is to improve public protection, ensuring that registrants remain fit to practise throughout their career as they develop and reflect on their practice. Registrants are required to revalidate every 3 years.
The NMC will investigate and, if required, will act where there are serious concerns that have been raised regarding a nurse, midwife or nursing associate's fitness to practise. Concerns that may put patients at risk or that could undermine professional standards or public confidence will be investigated. Investigation as part of fitness to practise is vital if the NMC aims to achieve its key objective, which is the protection of the public. The NMC, through its various processes, determines whether a registrant's skills, knowledge, education or behaviour has been deemed to have fallen below the standards necessary to deliver safe, effective and kind care. If those standards have not been maintained, steps are then taken by the NMC to keep the public safe and to prevent something from going wrong again. A range of sanctions can be used to protect the public, this may include, in the most serious of cases, removing people from the register.
The professional register
The number of nurses, midwives and nursing associates on the permanent register on 31 March 2022 was 758 303. This is an increase of 3.6% (26 403 professionals) since March 2021 and makes this the highest number of professionals ever seen on the NMC register (NMC, 2022). There are 6874 registered nursing associates on the register. Table 1 provides an overview of the number of registrants since 2019 when registered nursing associates joined the register.
Table 1. The NMC register 2019–2022
| Year | Registered nursing associates | Registered nurses | Registered midwives | Dual registration (nurse and midwife) |
|---|---|---|---|---|
| 2022 | 6874 | 704 520 | 40 165 | 6744 |
| 2021 | 4353 | 681 527 | 39 070 | 6968 |
| 2020 | 1693 | 669 854 | 37 918 | 7142 |
| 2019 | 489 | 653 544 | 36 916 | 7288 |
Registered nursing associates, nurses and midwives pay their registration fee annually. The fee payable is the same for all registrants, currently this is £120. The annual registration fee allows registered nursing associates to remain on the register. In addition, once in every 3 years they must also demonstrate that they are competent to provide safe and effective practice and this is undertaken through revalidation. Both processes are compulsory in order to maintain registration. In the full year 2021–2022, a total of 205 044 professionals successfully revalidated, included in this number, for the first time since their entry to the register in 2019, were 370 registered nursing associates.
Programme delivery and standards of proficiency for nursing associates
The Standards of Proficiency for Nursing Associates (NMC, 2018b) are the standards that a trainee nursing associate is assessed against. There are six platforms set out with these standards, whereas the Standards of Proficiency for Registered Nurses have seven platforms (NMC, 2018c) (Table 2).
Table 2. Standards of proficiency – platforms
| Registered nursing associate | Registered nurse | |
|---|---|---|
| Shared platforms |
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| Differences |
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Trainee nursing associate programmes are mostly delivered through an apprenticeship model – this is a work-based programme where a student was an employee (existing or new). During the training period the student is working as an apprentice nursing associate. There are compulsory learning days and placements occurring in different areas to meet programme requirements including mandatory protected learning time along with a minimum 460 hours of external practice placements.
Trainee nursing associate programmes are designed to meet local needs and depend on effective partnership working. An alternative full-time pathway is offered by approved education institutions, similar to how pre-registration nursing is delivered. It is important to note that on this kind of pathway the trainee nursing associate is counted as a student of the university, they are not an employee. Being an employee means, for example, that if the trainee nursing associate's ward or unit is short staffed they can be pulled from attending university and have to return to work, or they may be asked to forfeit protected study time and go back to work; service needs come first when employed as opposed to enjoying student status.
The workplace must be conducive to learning as well as having registered staff who are prepared and able to act as supervisors and assessors, in order to effectively support the trainee nursing associate. The NMC's Standards for Student Supervision and Assessment apply (NMC, 2018d).
Scope of practice
Registered nursing associates must be able to care for people in their own home, in the community or hospital or in any care settings where a person requires their services; they work as part of a team, they may be required to work alone when caring for people in their own homes or in the community. The context of care in which they work is in a continual state of flux, involving challenging environments, diverse models of care delivery, and older and more diverse populations, as well as the use of innovation and rapidly evolving technologies. As there is an increasing integration of health and social care services, they are required to negotiate boundaries and play a crucial role in multidisciplinary teams.
The Standards (NMC, 2018b) are the starting point, the baseline, for a registered nursing associate with regard to competency expectations. Registered nursing associates have a range of skills, knowledge and abilities. Their skills and proficiencies should be used to the fullest degree. The registered nursing associate will develop additional skills and competencies that will complement their working environment as they grow into their scope of practice as well as being a part of their career pathway. It is the responsibility of individual organisations to formulate additional competency standards for the registered nursing associate role.
Scope of practice can be defined as the range of roles, functions, responsibilities and activities that the registered nursing associate is educated and authorised to perform. The vision of the scope of practice for the registered nursing associate role should be reflective of workforce development and clinical need, included as a part of the workforce that provides support to the registered nurse in the delivery of care.
The scope of practice should be agreed as part of the workforce plan, there will also be a need to include governance measures, education and training, ensuring that the skill/task is reflected in the person's job description. Processes must be put in place for any concerns or issues to be raised where a registered nursing associate is alleged to be working outside of their scope of practice. There is also a need to have a robust appraisal system.
As registered professionals, including registered nursing associates, are individually accountable for their own professional conduct and practice, they are required to uphold the principles of the NMC Code (NMC, 2018a) and to work within their scope of practice, raising concerns where needed.
Supporting the registered nursing associate in practice
It should be acknowledged that the developing role and scope of practice related to the registered nursing associate is new and, as such, there may not be any local or national definitive list to draw on to guide employers and employees. Effective governance processes must be established and implemented. The overall aim must be to ensure consistency as well as providing the necessary underpinning theory and competence for practice to be safe and for the registered nursing associate to fulfil their role in supporting the registered nurse while acknowledging the role is that of a registered professional in their own right.
As is the case with registered nurses and other health professionals, registered nursing associates can expand their scope of practice through further education, experience and support. Usually, expanding scope of practice takes place after a period of consolidation and preceptorship that supports the transition from trainee nursing associate to registered professional. Proficiencies and skills will require further education as well as competency assessment and to be supported through the individual's job description, policies and guidelines.
Moving forward
As the evidence base develops around the role of the registered nursing associate, it could be that they will be undertaking other activities, these activities should be monitored and where needed changes made to standards and education provision (pre and post registration). It is essential that data are gathered, collated and examined as the evidence underpinning the role increases and the role itself matures and gathers momentum.
The expectation is that the role of registered nursing associate, regardless of care setting, is clearly related to the needs of patients, aligning patient needs with the skills and competencies of the practitioner – this would be the case with any healthcare practitioner. See Table 3 for an overview of the expectations for safe, sustainable and productive staffing.
Table 3. Expectations for safe, sustainable and productive staffing
| Expectation 1 | Expectation 2 | Expectation 3 |
|---|---|---|
| Right staff | Right skills | Right place and time |
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Lucas et al (2021) conducted a qualitative study in order to explore the views of a number of stakeholders regarding their experiences concerning (what was then) the newly implemented nursing associate role in England as well as the potential the role had to contribute to the care of patients. Their results suggested that the role was ‘broadly adaptable to different healthcare settings and provided a positive professional development mechanism for healthcare support workers’. There were limitations noted with the role, especially when it came to medicines and intravenous medicine management. Some of the respondents commented on the speed at which the role was implemented, suggesting that poor communication and insufficient time for planning could have been factors resulting in role misunderstanding.
Lucas et al's (2021) work was undertaken in an acute care setting, limitations associated with the role in this care setting were noted. The results discussed in this study should not be generalised to other care settings. As the numbers of registered nursing associates increase and deployment to various health and care areas increases, further and ongoing evaluation is required to explore how the role is embedding.
It was noted by Lucas et al (2021) that the registered nursing associate role has to be communicated clearly, ‘championed and supervised and its scope demarcated to build a clear identity within healthcare organisations’. They added a further caution: the role should not be seen as a stepping stone only into registered nursing positions, it needs to be valued in its own right. Reflecting these views, British Journal of Nursing is starting a series of articles that are directed primarily at the registered nursing associate.
Conclusion
The needs of the patient must always dominate when determining what level of practitioner is required to care for them. The registered nursing associate provides care to people in health and social care settings, this role has only been implemented in England. The role has been developed to bridge the skills gap between care assistants and registered nurses, contributing to the core work of nursing, and as such can enable the registered nurse to work at the upper limits of their registration as they focus on more complex care needs and leadership.
The registered nursing associate is educated to foundation degree level. When the trainee nursing associate has successfully completed their programme of study they may apply to the NMC for entry to the professional register thus becoming an accountable practitioner. All registered nursing associates must undertake continuous professional development and demonstrate through revalidation that their practice is up to date.
KEY POINTS
- The role and function of the registered nursing associate is dynamic and subject to change
- There has been a year-on-year increase in the number of trainee nursing associates undertaking training to become registered nursing associates
- The Nursing and Midwifery Council is the regulator for the registered nursing associate (in England)
- Trainee nursing associate programmes are mainly delivered through an apprenticeship model
- Registered nursing associates are accountable for their actions or omissions
CPD reflective questions
- Consider the role of the registered nurse and the registered nursing associate. What are the differences and similarities between these two roles?
- How does the Nursing and Midwifery Council hold the registered nursing associate to account?
- What do you understand by the term ‘appropriate delegation’?
- Describe the preparation of the trainee nursing associate in order to achieve registered nursing associate status