Who Cares? Nursing Associates and safe staffing

We have a shortage of registered nurses, hence nursing is once again on the occupational shortage list. With insufficient ‘home-grown’ registered nurses (RN) available, Trusts have had to resort to other measures: use bank and agency, recruit ‘ready-made’ RNs from other countries, run services with a high vacancy rate and try and ‘stretch’ the existing resource to cover the gaps.

By Jane Ball, Principal Research Fellow, NIHR CLAHRC Wessex

The solutions are far from perfect – each bearing a financial cost and increasing pressure on existing staff, to manage temporary staff, accommodate staff from other countries, or bear the brunt of staffing shortages themselves. Increased pressure leads to sickness, absence, higher burnout, and staff leaving. This leads to more vacancies and more pressure – a downward spiral fuelled by too few RNs.

In December 2015 Health Education England published the national workforce investment plan. Confusingly, given the context of too few RNs, just 300 additional adult general nurse training places are to be funded, despite an assessment that suggested more than 3,000 more RNs were needed. In the same month came the announcement of a new role: the ‘nursing associate’. So will introducing a nursing associate role help with the shortage on RNs? 

In my view it cannot. The ensuing consultation stated that the proposed role is not intended to substitute for RNs, but to complement them. But consider how the introduction of the new role might work in practice.

Clover Ward, a 30-bed acute medical ward, has an agreed establishment of 30 RNs and 15 healthcare support workers (HCSW) that has been arrived at using the Safer Nursing Care Tool (SNCT) and professional judgement. All the HCSWs posts are currently filled – easy to do so as no training needed and ample supply in the local labour market. Ten per cent of RN posts are currently vacant.

Then comes the plan to introduce nursing associates. So how does the establishment change?

a) New money is provided for Clover Ward to allow them to have two nursing associates on top of the funded establishment, to support RNs and existing HCSWs, and free up RN time? Unlikely. There is no new money.

b) HCSWs are funded to become nursing associate’s? What many of us were hoping for. HCSWs have typically had no more than two weeks preparation for their roles, frequently working beyond their pay grade and their skill-set. But HEE says funding for education will have to be found by providers/employers.

c) Or, does the finance director and HR manager and nursing director look at the empty RN posts and say – let’s not wait to find more RNs to recruit, we should switch those vacancies into nursing associate posts. It’s the nationally proposed and endorsed solution to increase capability and capacity of the nursing workforce. It will provide some much needed extra pairs of hands on the ward, and meanwhile save us money. And according to the Health Education England (HEE) it will stop “RNs being dragged down by fundamental care”.

Which of these is likely to happen? There is only one option that in the current context can happen. The last one.

If we introduce the nursing associate role within the existing budget, it can only be as a replacement for RN posts, as anything else costs money. And so the nursing associate role will sometimes, as the CNO of NHS England acknowledged at the Deputy Director congress, be used as a substitute for RNs. Question 12 of HEE’s FAQ’s asks: ‘Will the new nurse role be introduced across the UK?’ Note the term already in use: the new nurse role.

The result is that patients will receive a higher proportion of their care from staff who are less well-equipped to do so: less knowledge, less training. A 30-bedded ward that rosters five RNs plus three HCSWs, becomes a ward that only has enough RNs for four RNs plus four HCSWs. Each RN has one more patient to care for, plus more staff to support and supervise.

So who cares about who delivers care? We all should.

This isn’t a nursing issue. This is a fundamental issue about the level and quality of care we as a society want to be available to patients when they receive care in the NHS.

Insufficient investment in training enough RNs got us into this mess. Investment in the workforce is needed to get us out of it. Having established the number of RNs needed, we need to train and employ them, without compromise.

But can we afford to do that? Should we not accept that safe staffing levels is not a feasible objective in the current financial climate, and focus instead on “sustainable” staffing levels?

In my view, we cannot afford not to fund the level of RNs needed to provide care safely and effectively. Low RN staffing levels cause patients too die in hospital when they should have recovered and gone home. Eighty-six per cent of RNs on acute wards are leaving necessary care undone because they haven’t enough time. We cannot undo our knowledge of these things.

We can’t keep accepting compromises that patients ultimately pay the price for. When we ‘make do and mend’ it’s care quality and patient lives that suffer. These aren’t our compromises to make.

If there isn’t the money in the system to run this number of beds or to provide that range of services, then close some beds. Cut some services. Reduce what is covered by the NHS. Charge for some elements of it. Put a penny on taxes of higher paid for a health fund. Change the balance of resources so that a slightly higher percentage goes into nursing workforce rather than medicine.

I don’t know which of these are the right choices. I’m not a policy maker. I’m not a health economist. Nor am I a politician. But I do know that these are choices that need making. If we want a health care system that provides care safely, and that meets the first principle of medicine and nursing: do the patient no harm. Or else we need to be honest with ourselves, with the public and with patients, about the compromise we are making, and the risks we are being asked to take.