RCN position statement on the role and scope of practice of the Nursing Associate

The role and scope of practice of the Nursing Associate. Nursing Associates (NA) have been part of the Nursing and Midwifery Council (NMC) register since 2018 (England only). The role was introduced in response to the Shape of Caring Review to help build the capacity of the nursing workforce and the delivery of high-quality care (Willis, 2015). Since their introduction, NAs have been eligible for RCN membership.

The NA role was introduced to the health and social care workforce in England to provide a bridging role between unregistered healthcare assistants and registered nurses (RNs), filling a perceived skills gap and offering an alternative route into nursing (Willis, 2015). However, the gap the NA was trying to fill was not clearly defined (Hickman and Leary, 2020).

The RCN is aware of work being undertaken across Wales, Scotland and Northern Ireland to review the role of Band 3 and Band 4 ‘Nursing Support Workers’. This statement sets out our position on the role and scope of practice of the NA as it has been implemented in England.

NAs are part of the nursing workforce, who have gained a Foundation Degree, and are accountable for their practice. They are subject to the NMC Code (NMC, 2018a) and once practising can undertake further training and education to achieve additional knowledge and skills, enhancing their competence. They must also undertake revalidation, in line with NMC requirements.

The distinction in the roles and responsibilities of the Registered Nurse (RN) and the Nursing Associate (NA) have been outlined by the NMC (2018b, 2018c) and are illustrated in this table (West, 2019).

The table shows that whilst both are accountable for the care they provide it is the responsibility of the RN to assess care needs, plan, lead and manage care, and evaluate the care provided. The scope of practice of the NA is to provide, monitor and contribute to integrated care.

The NMC has established standards for proficiency for nursing associates which align to the six platforms shown in the table (NMC, 2018c). The NMC code states that all registrants must work within their scope of practice. The RCN position is that Nursing Associates must not work beyond the framework of the six platforms and the associated standards of proficiency.

The NA role was intended to support new care delivery models, particularly based on integrated, generic care. The NA role widens participation in the health and social care workforce by establishing opportunities for those who may be unable to access other routes. For some, it also provides a stepping-stone and route or ‘bridge’ into becoming an RN providing an affordable route into nursing and an opportunity for career development (Coghill, 2018a; Coghill, 2018b; King et al.,2022; Vansen and Bidey, 2019).

The RCN supports and recognises the importance of NAs developing within their role. There is no intention by the RCN to either diminish or negatively challenge the motivation, contribution or commitment of NAs within the Health and Care workforce. However, NAs must be supported to work within their scope of practice by their employers and provision must be offered for those wishing to undertake further education to become a Registered Nurse.

As the NA role evolves, the RCN is increasingly aware of variations between organisations and different settings on the scope of practice being undertaken by the NA workforce. Evaluation of the NA role published in 2021 by Kings College London showed that trusts were developing the role and associated competencies to meet the needs of the services provided, adding to the degrees of variation across employers and settings (Kessler et al, 2021). It also identified that NAs were working to the outer limits of NA practice. In some areas of practice there are active concerns that scope of practice for NAs is being extended inappropriately, with the resulting risk to patient safety.

The lack of clarity and understanding of the scope of the NA role was identified in a study of Trainee Nurse Associates (King et al., 2020) and echoed in a House of Commons Health Committee report (Health Committee, 2018). As well as the risks to patients, the RCN is concerned that there is a risk to NAs, who may act outside of the NMC framework, and the RNs who may delegate inappropriately.

The Professional Standards Authority, in their interim report on the oversight of Nursing Associates, included contributions from consultations with stakeholders who said that NAs ‘should not be pressurised to work beyond their competencies or scope of practice’ (2016). Any extension on NA roles led by the employer must ensure that they adhere to the framework and proficiencies of the NMC as the professional regulator. Where such extended roles fall within the agreed scope of practice, they must be supported by appropriate training and competence assessment. The RCN has produced position statements regarding the scope of the NA role in relation to immunisation, cervical screening, and clinical image requesting (RCN, 2019; RCN, 2021a; RCN, 2021b).

The NMC is clear that the NA role in England is intended to support the work of the Registered Nurse (NMC, 2020). The RCN is aware of evidence from RN posts being advertised as open to NAs, and the accounts of members (both NAs and RNs) that indicate the deployment of NAs into RN roles. Nursing is a graduate entry safety critical profession. The RCN has clearly stated previously and now uses this position statement to affirm that the NA role must have clear boundaries and NAs must not be used as RN substitutes (RCN, 2018).

The lack of clear parameters for the NA role is frequently cited as a concern by our members and whilst we recognise that the Nursing Associate role provides a new route into nursing more work is needed to define its function in the wider nursing workforce.

To safeguard the safety of patients, Nursing Associates and Registered Nurses the RCN’s position calls for NHSE to work with the CNO NHS England, the Chief Nurse for Adult Social Care, the NMC and the RCN to implement an all-England wide employer code which clearly sets out the governance and education assessments of competencies for any health or social care provider introducing extended roles with their NA workforce. This includes establishing a shared understanding of roles, responsibilities and accountability, and compliance with the six platforms identified by the NMC.

The RCN calls for Health Education England (now NHSE) to implement, as a matter of urgency, a formal evaluation of the NA role in England including role definition, scope of practice, career progression, and skill mix to ensure the safe integration and deployment in nursing workforce planning to provide safe and effective patient care. This evaluation should include an analysis of the current funding and deployment of NA posts. Until this is completed the RCN expects this role to remain as an England specific role only.

The RCN reiterates calls for robust structured workforce planning in all of countries of the UK, in line with the RCN’s Nursing Workforce Standards taking into account the nature of the role, patient / service user need, service demand and skill mix.

The RCN also calls for all employers working within health and social care to safeguard and ensure that where a vacancy exists for a registered nurse, recruitment is to registered nurse applicants only.

Approved by RCN Council December 2023

References

Coghill E (2018a) An evaluation of how trainee nursing associates (TNAs) balance being a ‘worker’ and a ‘learner’ in clinical practice: an early experience study. Part 1/2, British Journal of Healthcare Assistants, 12(6), pp. 280–286.

Coghill E (2018b) An evaluation of how trainee nursing associates (TNAs) balance being a ‘worker’ and a ‘learner’ in clinical practice: an early experience study. Part 2/2, British Journal of Healthcare Assistants, 12(7), pp. 356–359.

Hickman S and Leary A (2020) What does the future hold for the nursing associate role? Nursing Times, 116, pp. 18-19.

Health Committee (2018) The nursing workforce (HC353, 2017-19). Available at: https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/353/353.pdf (Accessed 26 May 2023).

Kessler I, Harris J, Manthorpe J, Moriarty J and Steils N (2021) The introduction and development of the nursing associate role: Policymaker and practitioner perspectives. Available at: https://kclpure.kcl.ac.uk/portal/en/publications/the-introduction-and-development-of-the-nursing-associate-role-po (Accessed 20 May 2023).

King R, Ryan T, Wood E, Tod A and Robertson S (2020) Motivations, experiences and aspirations of trainee nursing associates in England: a qualitative study., BMC Health Services Research, 20(1), pp. 1–12.

King R L, Taylor B, Laker S, Wood E, Senek M, Tod A, Ryan T, Snowden S and Robertson S (2022) A tale of two bridges: Factors influencing career choices of trainee nursing associates in England: A longitudinal qualitative study, Nursing Open, 9(5), pp. 2486–2494.

Nursing and Midwifery Council (2018a) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Available at: https://www.nmc.org.uk/standards/code (Accessed 20 May 2023).

Nursing and Midwifery Council (2018b) Future nurse: Standards of proficiency for registered nurses. Available at: https://www.nmc.org.uk/standards/standards-for-nurses/standards-of-proficiency-for-registered-nurses (Accessed 20 May 2023).

Nursing and Midwifery Council (2018c) Standards of proficiency for registered nursing associates. Available at: https://www.nmc.org.uk/standards/standards-for-nursing-associates/standards-of-proficiency-for-nursing-associates (Accessed 20 May 2023).

Nursing and Midwifery Council (2020) We regulate nursing associates. Available at: https://www.nmc.org.uk/about-us/our-role/who-we-regulate/nursing-associates (Accessed 20 May 2023).

Professional Standards Authority (2016) Interim report on oversight of nursing associates. Available at: https://www.professionalstandards.org.uk/interim-report-on-oversight-of-nursing-associates (Accessed 20 May 2023).

Royal College of Nursing (2018) Royal College of Nursing response to the Department of Health’s consultation on the regulation of nursing associates in England. Available at: https://www.rcn.org.uk/About-us/Our-Influencing-work/Policy-briefings/conr-4217 (Accessed 20 May 2023).

Royal College of Nursing (2019) The role of nursing associates in vaccination and immunisation: Position statement (April 2019). Available at: https://www.rcn.org.uk/Professional-Development/publications/pub-007565 (Accessed 20 May 2023).

Royal College of Nursing (2021a) RCN position statement on registered nursing associates (RNAs) training in cervical screening (England only). Available at: https://www.rcn.org.uk/Professional-Development/publications/rcn-rna-cervical-sample-training-uk-pub-009591 (Accessed 20 May 2023).

Royal College of Nursing (2021b) Clinical imaging requests from non-medically qualified professionals. Available at: https://www.rcn.org.uk/Professional-Development/publications/rcn-clinical-imaging-requests-uk-pub-009-108 (Accessed 20 May 2023).

Vansen T and Bidey T (2019) Introduction of nursing associates: Year 2 evaluation report. Available at: https://www.hee.nhs.uk/sites/default/files/documents/15.1%20-%20Trainee%20Nursing%20Associate%20Year%202%20Evaluation%20Report_1.pdf (Accessed 20 May 2023).

West S (2019) Role differences between nursing associates and nurses. Nursing and Midwifery Council, 13 March. Available at: https://www.nmc.org.uk/news/news-and-updates/blog-whats-a-nursing-associate (Accessed 22 May 2023).

Willis, Lord (2015) Raising the bar shape of caring: A review of the future education and training of registered nurses and care assistants. Available at: https://www.hee.nhs.uk/sites/default/files/documents/2348-Shape-of-caring-review-FINAL.pdf (Accessed 9 March 2023)