Registered nurses’ perceptions of nursing associates’ professional identity

The nursing associate (NA) role in England was announced in 2016, with the pilot programme for trainees starting in 2017, as a measure intended to address a workforce gap in the NHS, by developing an alternative educated and skilled workforce group. The gap existed because of a loss of older nurses reaching retirement and attrition of younger nurses. There are also increased demands on health services due to greater demands from patients living longer and those with complex care needs. The role allows progression beyond a foundation degree to become a registered NA regulated by the Nursing and Midwifery Council (NMC).

The NHS Long-Term Workforce Plan (NHS England, 2024) sets out an aim to recruit 64000 NAs by 2036/37 and so signals a change in frontline nursing teams to accommodate this. Being a new role, the identity of the NA group has yet to be fully established and accepted. It is important, therefore, to know how the role of NAs and their professional identity are understood by registered nurses (RNs).

Although the role is still in its infancy, Vanson and Beckett (2018) considered that the speed with which the NA role was implemented has significantly affected organisational readiness to respond, suggesting that this could affect the implementation of the role. Furthermore, Currie et al (2010) noted that diversification of nursing roles and levels of practice could be unsupported by the nursing profession because of cultural conservatism. Similarly, NAs working in non-traditional roles may be mistrusted and could experience a negative professional identity.

Professional identity refers to the values, beliefs and attitudes shaping and legitimising behaviours of individuals or groups belonging to a profession (Wilson et al, 2013). It is important to note that professional identity is dynamic rather than static and develops through enculturation, workplace participation, knowledge and promotion (Rasmussen et al, 2021). How nurses perceive their role has links to job satisfaction and retention (Horton et al, 2007).

It is important to move beyond anecdotes and generate evidence about how the role is viewed by RNs. The aim of this article is to report on findings from a survey undertaken as part of a professional doctorate that examined both the NA and the RN perceptions of the NA role. In the broader study, a sample of trainee NAs and registered NAs were interviewed. In addition, perspectives were sought from a sample of RNs on the role of the NA because of their close work with trainee/registered NAs, and in the context of some resistance reported in relation to this new role. It was thought to offer a valuable insight into a factor that influences the identity of NAs. This article reports only on the findings of the RNs’ perspectives when working alongside NAs. These findings represented an initial stage of enquiry that informed a protocol design for a later interview stage to examine the professional identity of the NA.

Methods

Survey design

An exploratory qualitative survey was designed to explore RNs’ perspectives about the NA role. A university subscribed JISC survey tool was used to obtain free-text responses to 8 open questions about RNs’ understanding of professional identity of the NA role, including views on its scope, implementation, positive and negative aspects of the role, and views on any proposed change to it. Box 1 lists the survey questions.

Box 1.

Survey questions

• What is your understanding of the role of a nursing associate?
• What is your understanding of the scope of practice of a nursing associate?
• What are your thoughts as a registered nurse with regard to implementation of the nursing associate role?
• What do you think are the positive aspects of the NA role? Please provide examples
• Are there any drawbacks to the nursing associate role? if so, please can you provide example(s)?
• Please explain what professional identity means to you. In what ways is professional identity important? What is your explanation of the professional Identity of a nursing associate?
• If you could make changes to the role of a nursing associate what would the change be? (N/A if no comment)
• Any further comments regarding the role of a nursing associate?

Ethics

Ethical clearance was approved via University of Bolton Research Ethics Committee (MANUAP0043) as part of a larger qualitative doctoral study.

Sample and recruitment

Participants were a self-selecting convenience sample aligning to an inclusion criterion of being an RN who had worked with a registered NA in England.

Recruitment was via social media (Twitter/X) to give prospective participants an information sheet outlining the study aims and actions requested if they chose to be involved. A JISC online survey tool containing a consent form was used to obtain data. The survey was made available on Twitter/X between 23 May and 13 June 2022. During this period prompts were sent to encourage participation. A total of 23 responses were obtained.

Analysis

The survey generated free-text data which were extracted and thematically analysed adopting the Braun and Clarke (2006) approach. The sex-step process involved the researcher (AK) becoming familiar with the data, generating initial codes, searching for subthemes, then themes, and reviewing and naming themes prior to writing up the findings. A second coder check was undertaken (RG) to discuss convergence on the emergent analysis.

Findings

Table 1 shows the themes that were identified.

Theme 1: NMC standards and scope of practice

This theme had three categories:‘limited’, and ‘NMC’, and ‘role confusion’. NAs were thought to be limited in their scope of practice. This included contrasting views on what an NA could do compared with an RN and differed according to ‘each trust [organisation] that they will work in’, also noting that there were geographical and employer differences described as ‘per organisation [and] job description’. This led into views on the work that NAs either could or could not undertake: ‘overall an NA can monitor, whereas [an] RN can evaluate care’. This variation from setting to setting was attributed to ‘local clinical frameworks, and … national guidance’. Given that the NA role is employer led, the note about national guidance might have referred to NMC statements (see Table 2), but this remains unclear.

Overall, it was thought that ‘the NA scope [of practice] is to work with the RNs implementing care’ and limitations were in place: ‘to care which does not require active assessment or nursing evaluation’. They are also ‘unable to perform certain high-risk procedures, although these rules are often ignored’ and ‘so tasks such as ‘giving IVs [intravenous drugs] [were] not allowed in some areas’, as were other tasks, such as ‘NAs not [being allowed] to admit or complete initial assessments’. The deciding factor was that nursing care was undertaken ‘in accordance with the NMC scope of practice’ and ‘expanded by individual trusts and organisations’ as necessary. Thus, the role was described by some RNs as ‘not quite at the level of RN, broadly similar, can do procedures but some funny restrictions’. However, the restrictions remained imprecise.

Views differed over scope of practice around tasks undertaken, for example: ‘…if NAs do IVs then what is the difference in the role? I need to know what an RN can do that an NA can't.’ Some took the moral high ground regarding patient care and claimed that ‘the role confuses patients’, as well as the ‘non-nursing AHP [allied health professional] who don't properly understand the role’. When countering a rise of the ‘cheap nurse’, the distinction was asserted again about scope of practice:‘Many NAs do not know their own scope of practice, [indeed] there is no need for NAs.’

Being registered gave NAs ‘a responsibility’ to uphold the ‘Code of Practice from the NMC’, meaning they were held accountable. This translated into ’clearly defined roles and they exactly know what is expected of them [with] no grey areas’. However, this was complicated by the local employment arrangements that introduced anomalies in practice within and across organisations. Some practice was ‘safely delegated’ through the oversight of an RN.

In relation to being a registered professional, RNs viewed NAs as having a sense of a professional identity, which was important, as ‘we are professionals together’, viewing the registered NA as a professional with ‘self-respect … team spirit and values’. The values encompassed ‘who I am and what I am viewed as’. Furthermore, in being regarded as professionals NAs had an identity that encompassed ‘the attitudes, values and beliefs of a professional group such as nursing’.

Overall, the scope of NA work was seen as being within the bounds of the NMC code and yet the specifics of practice were locally determined with either restrictions or extensions to their scope of practice.

There was some role confusion, even when seen as ‘a great role’, with some RNs wanting ‘further clarity’ – specifically,‘more understanding of their roles [was] needed’. The scope of practice was at the heart of this, with education and clarity being cited as key because without this the ‘responsibilities and scope of practice become too grey and lack clarity’. A consequence of the role was ‘a lot of confusion in the wards’, which was attributed to the role being in its infancy and one that was not ‘embedded’ because of this. Some confusion was attributed to NAs who ‘don't know their full scope of their role’. Others perceived an RN understanding and acceptance issue:‘…some staff are unable to see how the role fits and still don't fully understand the role’, seeing it classed as ‘the old State Enrolled Nurse [SEN]’ being re-established. It was ‘fairly new and some don't like change’. One challenge raised was over a view that there were ‘too many roles [and] nursing [being] watered down’ resulting in confusion or blurring over knowing ‘who is who and what they stand for’. In parallel with other professions,‘like the physician's associate, it's a funny role in terms of scope and also in terms of career progression’ and one RN didn't know whether the NA as a registrant had an NMC registration number.

Solutions offered were: ‘standardising across a service’ and some ‘HR [human resources] work to be done’ so there might be ‘more acceptance in the workplace’, which suggested that ‘the full benefit was as yet unrealised’ and some RNs were ‘worried about the skills and knowledge that NAs have with the role being generic’. Clear definitions were required ‘over scope of practice’. Image was important too, with a recommendation to ‘change the colour of the TNA [trainee NA] uniform’. There was a perceived need for clarity in terms of public understanding to ‘know [the] role of nurse’, with a view that ’patients and public [were] not aware’ and ‘staff and patients … need to know exactly what they should be [and] not do’. This was seen to start with a clear job description and ‘clear role abbreviation [for the registered nursing associate] as some say “NAR” and others “RNA”’. An outcome of such steps would be to ‘raise awareness of the role [for the] public, patients, and organisations’.

Theme 2: The ‘cheap nurse’

This theme contained categories of ‘tribalism’ and ‘substitute nurse’. The perception of the NA as a cheap substitute nurse introduced the prospect of tribalism in the workplace. The idea of an RN nursing ‘tribe’ was evident when RNs wrote that ‘being a nurse should carry respect’ and that they ‘hated’ it ‘when HCAs are considered [as] nurses’, asserting that this identity was ‘who we are’. Here, the RN expressed that the NA was not anything more than an HCA. Indeed, an RN reported that: ‘the public call me a nurse but can the public call an NA a nurse?’

The idea of a cheap substitute for an RN featured strongly in the responses: ‘nursing associates are being used as cheap labour.’ Some saw a direct threat, as ‘registered nurse positions [were] being replaced by nursing associates’ and represented a ‘substitute taking the place of an RGN ‘on the grounds that ‘they are cheaper than registered nurses’. This was acknowledged as ‘an opportunity to exploit cheaper alternatives to registered nurses’.

A case example of the role being seen as a threat to RNs was cited as the role being ‘used to supplement [the work of] RNs,’ but in reality, in a ‘previous area of work, instead of being used to replace HCAs, it was used as a replacement for RNs’. A consequence in the workforce was a that patients would receive care similar to that given by an RN, ‘but with less training and knowledge’. This might have an association with a focus that later emerged about NA performance of tasks as being synonymous with an RN role. The sense of threat was described by some as the NA role being ‘an unnecessary and potentially damaging role’ that ‘degraded’ and ‘confused’ what a registered ‘nurse is and what they do’. One RN participant held the view that, through being an NA, those in the role were colluding in their own oppression because it helped to ‘perpetuate the culture of willing exploitation of cheap nursing professionals’.

Paradoxically, cheap was valuable too. The value of the NA role was supported as being ‘important and a good idea … to support qualified nurses’, but with the caveat that ‘they should not be taken as a qualified nurse or taken to compromise a qualified nurse's requirement.’ Others, however made the case that, if they were working in an area as an RN,‘for example in ICU [intensive care unit], and therefore looking after complex patients… why should they not be RNs?’. A consequence of this was thought to be a threat, given that there may be less need for nurses if an NA can do most nursing jobs.

In addition, some thought the NA represented an extra workload commitment for RNs: ‘They create an additional burden to registrants who need to manage them and their practice.’ This introduced a comment about the value for money to redirect the funding that was ‘spent on NA and NA training to [be used to] train more RNs through the established graduate route’ or to dispense with the NA role and ‘upskill HCAs and not to replace RNs’.

Rivalry emerged in comments such as ‘they [NAs] don't feel as valued as nurses and lack respect for RGNs’.

Theme 3: Skills development and progression

The two categories in theme 3, ‘skills’ and ‘workforce development’, illustrate how the NA was seen as a means of workforce development and progression, especially around clinical skills. These took on a symbolic characteristic that reduced the gap between an NA and RN, whereas distance was maintained by focusing on what the NA could not do.

The NA skill set represented a route ‘allowing HCA to progress’ into a different role, but these skills were typically reported in terms of their limitations. These included a position with a ‘wider range of skills than HCA, but not as many as [an] RN’. The problem that existed was of variance between and across healthcare providers, with a respondent noting that ‘some elements they don't do and it varied to [different] areas’. For some, the NA ‘should perform the nursing care which has been planned by a registered nurse’, whereas others, who had been ‘trained in IVs, on the ward, they have same role as a registered nurse without the ability to change a patient's care plan’. Thus, the skill tasks became a defining feature of alignment with the RN role. Therefore, many participants noted medication administration – ‘they can administer medication like registered nurses’ – but others contradicted this, stating that ‘they have the same role, however they can't hand out medications on their own’.

So, when seen purely in terms of actions performed, some RNs saw that NAs ‘are working and doing the job of RNs minus IVs’, questioning ‘…why [is there] a banding difference for this?’. This led some to see that there was a common ground around professional identity, because NAs were ‘trained [and] are registered professionals on the NMC register’. Overall, skills development and progression offered a career step between the HCA and a higher paid role, which is one reason why the NA mirrored some aspects of an RN's work.

Theme 4: A supportive bridging role

Positive aspects of the NA role emerged in which 13 out of 23 respondents described it as a ‘bridging and supportive role’, with NAs having skills ‘in their own right’ so that RNs could be free to deal with ‘more complex cases’ and ‘deal with more complex patients/service users’. This sense of being able to ‘release RNs to undertake more complex duties’ was valued. However, although it has been several years since the establishment of the role in 2017 only 56% of participants were aware of the scope of practice of NAs. The gap between the HCA role and the RN was grounded in acquired skills, where undertaking the role was synonymous with overseeing and directing patient care. This was aligned with what a nurse ‘used to do and should be doing’. Others linked back to a historical secondary nature of the role ‘like the former SEN’ and ‘under the supervision of registered nurses’.

However, as noted earlier, NAs were not able to fulfil the full scope of practice that the RN was permitted to do because the secondary nature of the role was to be ‘there to support a fully qualified nurse and make decisions, but not allowed to do medication.’ Other NA duties included ‘ward reviews, medication administration, meetings’, and ‘support to band 5 nurses running the wards’. In summary, it was ‘like there is an extra nurse on the shift’. The respondents’ differing views about the value of the NA were recognised in part but, even then, only in a secondary capacity.

Discussion

The four themes depicted the NA existing in a position of ambiguity where statements about clarifying the role placed it within the bounds of the NMC Code, but were again confused over locally determined specifics of practice. The respondents’ differing views about the value of the NA role were recognised in part but, even then, only in a secondary capacity. Some resisted the role, and tribalism featured in terms of rejecting it as a substitute for an RN and one that ‘cheapened’ the service.

The themes depict a workforce group caught between conflicting views that makes it difficult to find acceptance as a registered professional. Clearly, there is a threat to an existing workforce configuration and there is suspicion that economic agendas are driving a change to ‘cheapen’ the professional nursing workforce. It could be argued that the political agenda to stem a growing workforce shortage enrols NAs in their own oppression, accepting similar work to an RN but for lower pay.

There are pragmatics in play here because the role was established as an opportunity for some HCAs to advance in knowledge, skill and pay, to address a workforce gap. There were some advantages for NAs via this progression as a career step. In addition, the role offers a potential route to eventually becoming an RN, although that was not the original intention when seeking to establish a stable workforce to meet the demands of care provision. In this way, however, the role can be rewarding.

Although the role mirrored some aspects of an RN's work, this introduced further ambiguity because a focus was often placed on tasks undertaken by the NA and RN and less attention given to distinguishing between the knowledge and legal responsibilities of RNs and NAs. Indeed, some attention was repeatedly turned to whether or not an NA could perform IV drug administration for patients, as did the RN. In this way task performance became the NAs’ embodiment of being an RN when undertaking certain visible roles and, where this occurred locally, it played into the hands of those arguing that NAs were merely a cheap alternative.

Some participants did recognise that there was a knowledge difference and implied that it could have consequences for patient care, but did not expand greatly on this beyond concerns about the (unspecified) quality of care a patient would receive from staff with lesser knowledge. The challenge here is that workers performing similar tasks (the visible) does not reveal the thinking that goes on around this (the invisible), and it can be argued that copying what a nurse does, as in the former apprenticeship learning by the side of registered staff, is not the same as being an RN. When RNs’ work is reduced to merely task, then it is easy to argue for cheapening of a service. This overlooks the decision-making around the assessment, planning, delivery and evaluation of care that characterises some of the role of an RN. This was not hugely articulated by the respondents, but their concerns touched on it. The findings also draw attention, through role clarification, to the need to protect the title of ‘nurse’, which is the subject of a campaign (Leary, 2021) to legally protect it.

Attention therefore returns to the role of the NA and attempts that are necessary to remove ambiguity and confusion via clarification about what ‘a nurse’ is. That continues an evolving debate about the role of the nurse that has changed in part since Florence Nightingale wrote a description in her Notes on Nursing in 1860 and yet still retains some familiar features (such as managing the environment of care, observation, carrying out treatment plans and reporting information to doctors). Education, skills, registration and scope of practice has developed since then and the evidence-based movement has seen nurses contribute original knowledge to a growing body of ‘nursing’ as opposed to other discipline-based knowledge.

Role clarification in terms of knowledge, skills and scope of practice would contribute to a better public and provider awareness of the role, ensuring NAs are able to work safely within their scope of practice. Clarification in terms of the differences between RNs and NAs (Table 2) requires development and collaborative working with employers to ensure clear roles and distinctions.

Conclusion

This article has reported a survey of RN views about the NA role and identified four themes. The findings must be contextualised in the era in which the study occurred, namely the early years of the implementation of this new role, and associated diverse ways in which it has been locally interpreted and implemented. None of that has served to consolidate and clarify the role and it has generated a degree of confusion.

When the role of a nurse is judged according to what it appears to involve via observable actions, the work of the NA might look similar in some settings, and when it does it can seem to be a threat to the more expensive RN role. A way forward lies in bringing clarity to stem confusion and a role description consistency that is broad enough to accommodate the pragmatics of local care delivery. In this way both professional and public have an opportunity to understand what and where the role fits within a modern healthcare team and have confidence in the quality of work of those who provide care.

KEY POINTS

• The nursing associate (NA) professional identity occupies a place of ambiguity and inconsistency in professional practice giving rise to confusion about what NAs can and cannot do
• Acceptance of the NA role in the workplace encountered resistance and it has been perceived as a threat to the registered nurse (RN) role
• An NA's performance of tasks also undertaken by an RN served to align the professional identity with that of an RN and introduced a focus on the technical competence of an NA
• The NA may be seen as a ‘cheap substitute’ for the RN
• The NA was, on the one hand, valued and seen as a useful bridging role between the healthcare assistant (HCA) and RN, while, on the other, seen as colluding in efforts to ‘cheapen’ the workforce.

CPD reflective questions

• What is your understanding of the nurse associate (NA) professional identity?
• To what extent do the NA and registered nurse roles have a shared professional identity?
• What factors influenced the development of your professional identity?
• What are your perceptions of the NA role?