Words matter. We exist in a culture where what a person or an organisation says matters. Individuals spend hours poring over texts and documents, seeking both overt and hidden meanings. The new Royal College of Nursing (RCN) definition of nursing may be such a document (RCN, 2023a).
Nursing has changed over the past few decades and therefore it seems reasonable that the definition of what it means to be a nurse would also change. Perhaps it is time to move on from Henderson's oft-cited and memorised description:
‘The unique function of the nurse is to assist the individual, sick or well, in performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge and to do this in such a way as to help him gain independence as rapidly as possible.’
Although it could be argued that it is still relevant, this now feels dated. There have been various attempts to define what nursing is since this definition, and the RCN has just presented its first updated definition in 20 years. This is on many levels something to welcome, reflecting as it does the four pillars of nursing and the fact that nursing is both caring and also highly technical.
However, the new definition appears to devalue (or at least fails to recognise) the contribution of one of the fastest growing roles on the Nursing and Midwifery Council (NMC) register, that of the nursing associate. The nursing associate role was accepted on to the NMC register in January 2019 (NMC, 2023a) and there are currently 9339 nursing associates on the register (NMC, 2023b) with the aim set out in the new NHS Workforce Plan to have 64 000 nursing associates working in the NHS by 2036–2037, compared to the 4600 noted in the plan (NHS England, 2023).
The expanded definition is too lengthy to repeat in full here, but the core states:
‘Nursing is a safety-critical profession founded on four pillars: clinical practice, education, research, and leadership.’
‘Registered nurses use evidence-based knowledge, professional and clinical judgement to assess, plan, implement and evaluate high-quality person-centred nursing care.’
The expanded definition then goes on to set out more of the role and function of the registered nurse. Accompanying and underpinning this definition are the eight principles, which apply to all nursing staff. At the end of this is a footnote that tells the reader what is covered by the term nursing staff:
‘The term … includes the nursing support workforce who work with the registered nurse to support the provision of nursing care. This term… encompasses a wide range of roles and titles which may include nursing associate (England only), assistant practitioner, health care assistant, health care support worker, and nursing assistant.’
A point to note is that this definition includes staff with no professional registration, and as such seems to conflate the nursing associate role (which requires a two-year foundation degree) with the role of the healthcare support worker (which generally requires a local care certificate).
If the expectation is that the nursing associate is to step up to the plate and deliver high-quality care within the four pillars set out by the RCN, is it wrong to expect them to at least have the overt and open acknowledgment that they do fall within the definition of what it means to be a nurse, rather than to be tucked away in the footnotes? In all honesty, many will skim over or ignore footnotes. If one considers the use of the term, it tends to be used in the sense ‘X was a footnote in history’, the context being that they are a bit part or of limited or marginal relevance.
The data indicates that in 2022-2023 a total of 756 nursing associates went on to ‘top up’ to registered nurse (NMC, 2023b), meaning the vast majority of nursing associates do not.
If we are looking to have 64000 nursing associates on the register in the 2030s, do we really want them to see themselves as a footnote in nursing, rather than an essential part of the nursing team responsible for the delivery of direct patient care and the development of personal expertise and values? This author would suggest that this is probably not the best way to make both current and future nursing associates believe and feel that they are a critical and vital part of the nursing family.