The nursing associate (NA) qualification has been a standalone qualification in England since 2018 (Health Education England (HEE), 2017). Publication of the Standards of Proficiency by the Nursing and Midwifery Council (NMC) in 2018, just as the first cohort of trainee NAs associates were due to complete their educational programme, provided a basis for regulation for NAs alongside registered nurses (NMC, 2018; 2024). The role was envisaged to primarily support and develop the nursing workforce of healthcare assistants and support workers across the health and social care sector (HEE, 2017), predominantly as a result of recommendations made in the Shape of Caring review (Willis, 2015). The role provides the basis for lifelong learning and a pathway for an experienced group of staff who were often unable to access higher education and a bachelor's degree programme leading to registered nurse status (HEE, 2024).
The NA role, at the outset, was widely recognised as a stepping stone for healthcare staff to ultimately progress into the registered nurse workforce (Vanson and Bidey, 2019; King et al, 2020; Kessler et al, 2021; King et al, 2022), while at the same time building capacity within the nursing workforce (NHS Employers, 2023). The role has facilitated the delivery of high-quality patient care by individuals who are driven for personal development and seek additional job satisfaction thorough increased responsibility. There is currently no available evidence pertaining to the development needs of this staff group once registration with the NMC is achieved. In December 2023, the Royal College of Nursing (RCN), asked NHS England to formally review the role of the NA in England (RCN, 2023).
Revalidation
NAs are required to meet the revalidation requirements set out by the NMC (2021), including 35 hours of continuous professional development (CPD), 20 of which must be participatory learning. It is essential that, as registrants on the NMC register, NAs understand the importance of demonstrating ongoing competence in all areas of proficiency necessary for revalidation. Therefore, employers have a duty to ensure training and education is readily available.
Role background
Various evaluations of the role and research studies (King et al, 2020; Kessler et al, 2021; King et al, 2022) have identified the main benefits of the NA role include affording students who would not normally be able to complete a nursing degree – due to either financial or personal commitments – the opportunity to embark on the pathway to qualification as a registered nurse. The role is now also considered to be central to many organisational ‘grow your own workforce’ plans (HEE, 2020; King et al, 2023). King et al (2022) and Kessler et al (2021), identified that approximately 73% of trainee NAs and registered NAs intend to continue education and complete a programme leading to registered nurse status. However, although this is acknowledged to be one of the key aims of the role – improving recruitment to the registered nursing workforce (HEE, 2024) – it also hinders the opportunity for a large NA workforce to be embedded in clinical teams.
The NHS Long Term Workforce Plan (NHS England, 2024) identifies the importance of the role of the NA across the health and social care sector, setting out ambitious plans to train 5000 NAs in 2024/25 and then increase to 7000 a year before the target of 10500 training places by 2031/32. Given the relatively low numbers of NA roles available and various degrees of endorsement of the role across individual organisations, there is a need to review how retention for this professional group can be enhanced. Available training places are not always filled despite there being funding. The opportunity for employment in a band 4 role following completion of the course is limited in some organisations and dependent on local workforce planning.
In order for the NHS Long Term Workforce Plan target to be met, the value of the NA role within the workforce needs to be well established, supported and promoted. This is a consistent finding in research regarding the role of NAs (King et al, 2020; Kessler et al, 2021; Lucas et al, 2021; King et al, 2022; Topping, 2023). Other recurrent themes in research findings are the staff group not feeling consistently recognised by colleagues, and organisational constraints that directly impact on staff wellbeing, retention and development (Vanson and Bidey, 2019; Kessler et al, 2021; Lucas et al, 2021; Hedayioglu et al, 2023; Rixon, 2023; Topping, 2023). NAs do not appear to move between band 4 opportunities and career development can often be hindered as many band 5 roles require bachelor degree-level education.
At the outset of role implementation, NA positions were predominantly available in secondary care. However, there has been a large increase in the number of NAs working in primary care (NHS England, 2016; Robertson et al, 2022; King et al, 2023) and within my local ICB footprint (North East and North Cumbria) there are significantly more NAs employed in primary care than in secondary care. However, findings from a study by Topping (2023) criticised trainee NA educational programmes, stating they are not always considered suitable for entry into autonomous working in general practice without preceptorship and extensive support, being heavily focused on the hospital care element of the NA curriculum.
Across the North East region and North Cumbria the role of the NA has been embedded with varying degrees of success. Local evidence suggests the role ranges from being an essential component of the local workforce plan, to not being included at all. The diversity of healthcare provision across the region requires individual organisations to adapt local workforce planning to meet the needs of the population. Some organisations cover a large geographical area and require a number of staff hubs away from the main site, whereas others predominantly provide care across a small number of larger sites. Feedback from local organisations, in informal scoping conversations regarding NA numbers and development, indicates that within mental health and learning disability services, NAs work across inpatient and community teams. Across adult services as a whole the allocation of NAs within the workforce was vast but the areas where they were employed varied from trust to trust. Areas included theatres, occupational health, sexual health, community teams (district nursing), across medical and surgical directorates and within paediatrics. This picture appears to support previous research, which outlined the diversity of role implementation in organisations (King et al, 2020; Kessler et al, 2021; Lucas et al, 2021). The diversity of contexts in which some organisations are employing NAs also supports the argument made by Morgan (2022) that NAs bring a broader, more holistic approach and complement the existing workforce.
Data from primary care suggested this appears to be an area where the NA role has been endorsed and fits well into the clinical team (Robertson et al, 2022); however, recent research by Topping (2023) disagreed with this to some extent. Healthcare assistants (HCAs) in some primary care practices already perform extended tasks in comparison with the kinds of roles HCAs undertake in secondary care – many HCAs provide diabetes prevention programmes, or deliver health education regarding cardiovascular risk factors. NAs can perform more tasks and take more responsibility than an HCA, so take on some of the workload that has traditionally been the role of the practice nurse (Robertson et al, 2022).
Challenges and progression
A common challenge for workforce planning teams is associated with retaining NAs following qualification in the long term. Information gathered from organisations in my local area revealed that over twothirds of NAs have gone on to ‘top up’ to registered nurse, either via an apprenticeship route or through leaving an organisation completely to undertake training due to lack of available places/funding. Again, although this is reflective of the national picture identified in published research (King et al, 2020; Kessler at al, 2021; Lucas et al, 2021), and a key ambition for the role and purpose of NAs, this poses a significant challenge in enhancing the role and reputation for NAs who do not wish to pursue the career path towards registration. Robertson et al (2022) found that NAs working within primary care indicated they were less likely to complete further training to become a registered nurse, with 47% of respondents, compared with 63% from secondary care, indicating this to be their intention.Therefore, this further highlights the need to develop CPD offerings, allowing these professionals within the nursing workforce opportunities for personal and professional development. It is worth noting that research by King et al (2023) highlighted a common driver for NAs to pursue registration was experiencing role ambiguity and interprofessional conflict.
Several research studies also identified that the value of the NA role as perceived by the ward manager/matron/practice manager was a big influence on the acceptance and development of the role of the NA across the local workforce (King et al, 2020; Kessler et al, 2021; Lucas et al, 2021). For many NAs, the opportunity to undertake NA training at the outset was dependent on there being a band 4 vacancy within a team – this was frequently the main method of facilitating recruitment to a trainee NA course, and was also a key factor in retention within local clinical teams.
Scope of practice
The scope of practice for the NA role is intentionally vast to allow flexibility within the role and to facilitate management of the health needs of a changing population (Robertson et al, 2022). Participants from a study by Lucas et al (2021) said the role of the NA needed to be flexible to fit the needs of the service, ultimately ‘moulding’ the role for the clinical area. However, literature published since establishing the NA role has emphasised the need for communication and education regarding the scope of practice. This was highlighted by HEE in 2015 and remains a theme in more recent research (Lucas et al, 2021; King et al, 2023; Hedayioglu, 2023; Topping, 2023). With no clear career development opportunities, limited understanding of clinical abilities and organisational need, a robust framework of development opportunities would overcome many of the documented barriers NAs currently experience.
Within primary care, the development of HCAs to facilitate delivery of care requiring higher levels of critical thinking has supported primary care service provision during times of staffing crisis and low morale through upskilling the workforce, although the national challenge to recruit remains a problem. Unfortunately the specific tasks undertaken and skills used by a NA continue to differ among individual general practice providers and there is some debate within the research (King et al, 2023; Topping, 2023) regarding the skills that can be completed as a newly registered NA without further training, resulting in further costs for practices.
Actions
A search of the literature found no sources regarding CPD for NAs, revealing this as an important area for future research. Local data identified NAs seeking CPD, who were limited to accessing current available CPD for registered nurses. This poses multiple risks: NAs are at risk of working outside their scope of practice (NMC, 2024) which ultimately puts patient safety at risk, as well as personal NMC registration. Expansion of CPD provision for NAs, aligned to the six platforms of proficiency (NMC, 2024), in conjunction with stakeholder demand is a new development within the School of Nursing at the University of Sunderland. The RCN (2023) has emphasised its position regarding NA working beyond the framework in the NMC's six platforms of proficiency.
On social media platforms and in emerging evidence, concerns remain evident regarding the scope of practice of NAs and how this impacts on the wider professional nursing workforce, with posts being openly advertised to both NAs and registered nurses, which ties into concern regarding deployment of skills and working beyond role limitations. Robertson et al (2022) highlighted the importance of wider research in the context of identifying roles within the NA workforce with clear boundaries and expectations, which they suggested would ultimately help consolidate the sense of professional identity, preventing a barrier that is currently experienced by many. A finding of the work by Topping (2023) that could cause some significant concern was that some participants said that they envisaged NAs would replace practice nurses over time in their clinical area.
The breadth of competence of the role of an NA across the health and social care sector means it is difficult to regulate CPD access, as the requirement in one clinical area for role development can be very different from another clinical area in the same organisation, let alone across different organisations. This means personal development is guided by individual line management. Ultimately, access to NA-specific CPD, encompassing the Standards of Proficiency (NMC, 2024) will allow the workforce to thrive, transferable skills to be used across the wider nursing provision, quality assurance of nursing care delivered and revalidation requirements to be achieved.
Professional development of NAs does not appear to be an area that has been previously researched, therefore I am in the process of a longitudinal research project seeking the views and opinions of the NA workforce and local stakeholders to improve CPD provision for this group of nursing professionals. Consideration will also be given to the national picture of training needs.
KEY THEMES
- Research into career development for nursing associates is not available and this needs to be addressed
- Not every nursing associate wishes to ‘top up’ to a bachelor's degree and registered nurse status, therefore this valuable staff group need to be offered CPD to inform their clinical practice and personal development
- Strategies to retain nursing associates need to be considered to prevent them leaving a career in health care due to role ambiguity, feeling unvalued within the team and repetitive explanations of the role
- Clear boundaries need to be evident and publicised setting out the scope of practice for a nursing associate and how this differs from the registered nurse workforce
- Establishing clear professional boundaries, scope of practice and career pathways will help in achieving the NHS Long Term Workforce Plan recruitment target for Nursing Associates by 2031/32