Abstract
In England, nursing education and training is currently undergoing a fundamental change in terms of its delivery and funding. While the debate regarding the loss of the National Health Service (NHS) bursary rages on, albeit with ministers occluding their ears firmly with their fingers, one aspect of government policy that has been off the mainstream agenda for some time is that of the Nurse Associate (NA). However, last month a debate at London Southbank University (LSBU) kicked it back from long grass and into our living rooms – not just figuratively but literally, if you live-streamed the event via Periscope and Twitter. In this paper I will discuss the positions of those involved in the debate from my own perspective – as an undergraduate student nurse currently studying at King’s College London.
The concept of the NA is not a new one. In fact, many NHS trusts currently employ individuals in similar roles but under the guise of different job titles (Cavendish, 2013). This convolutes the debate and leads to confusion as to what will and will not become part of the role nationally, but streamlining and formalising the training of such positions would seemingly be a sensible strategy and is advocated within Health Education England’s (HEE) Shape of Caring Review (HEE, 2015). However, as with many new initiatives, while admirable and well-meaning, it is the unintended consequences that are often overlooked.
Like all nursing students, I have been encouraged to ‘look for the evidence’, ‘question’ and ‘critique’, and LSBU’s debate was very much part of this process for me. Chaired by Professor Warren Turner, the Dean and Pro-Vice Chancellor of LSBU’s School of Health and Social Care, and with Professor Leslie Baillie posing the pro-NA position and Dr Elaine Maxwell opposing, the event finally swayed my allegiance firmly into one camp.
Professor Baillie argued eloquently that the NA role will ‘fill the gap’ left by the abolition of the state-enrolled nurse and the supernumerary status now bestowed upon current student nurses, like myself. It was also argued that its creation will address the concerns highlighted in The Cavendish Review (Cavendish, 2013), namely that healthcare assistants (HCAs) feel undervalued and lack career progression. True as this might be, and having read the work of Kessler et al. (2010), I acknowledge that having career opportunities is integral to maintaining workforce morale and improving retention rates amongst our support workers, but what I feel is missing from this argument is the patient and their safety.
HEE (2016) has assured that the introduction of the NA will not affect the number of registered nurses (RNs). This is welcome, given the wide body of evidence from Aiken et al. (2002) and Kane et al. (2007) demonstrating an association between the numbers of RNs and patient mortality and outcomes. More recent research by Griffiths et al. (2016) has shown that substituting RNs for healthcare support workers is inconsistent with patient safety. Knowing this, should our focus not be on increasing the numbers of RNs within our health system rather than creating a new role which lacks the evidence to support its implementation?
Dr Maxwell further highlighted the lack of clarity with regards to the NA role. Like me, she acknowledges that our current support staff are an integral partner in care delivery and deserve further educational support and development. However, she argues that this does not require a new role to achieve that, and I would have to agree. Recent figures show that there are 377,151 RNs working within the NHS who are supported by 360,402 non-registered support staff (Health and Social Care Information Centre (HSCIC), 2015). The number of NA posts proposed by the Department of Health (DH) is approximately 1000 (Department of Health, 2015). This accounts for 0.1% of the registered and non-registered workforce combined and, as suggested during the debate, it is hard to imagine how such a small number of NAs can have a meaningful impact upon the quality of care delivered and patient outcomes. Although Professor Baillie stated that the role will be piloted, with HEE confirming this in their response to the consultation process (HEE, 2016), the details are not explicit enough. Without an appropriate and well-planned pilot, I am concerned that we may be heading on a trajectory from which we cannot turn back if the perceived benefits do not come into fruition – in much the same way that the government has imposed the changes to the NHS bursary for all future student nurses, midwives and allied health professionals before undertaking their own comprehensive economic analysis. It should be noted that since the LSBU debate, an independent cost analysis by Conlon and Ladher (2016) has suggested that the savings to the Exchequer may not be as large as once thought; but at the time of writing we are yet to hear the DH’s response.
In times of austerity and with NHS budgets under unprecedented pressure, it will be undoubtedly difficult for finance directors to justify spending more on RNs when NAs potentially offer a cheaper alternative. In HEE’s response to the consultation it stated that NAs ‘… will support the health service and workforce by supplementing, augmenting and complementing the care given by Registered Nurses’ (HEE, 2016: 4). Yet supplementing the work of the RN potentially removes them from the bedside and reduces their patient contact time. It also adds another layer of management, with a small number of RNs overseeing the work of larger number of NAs and HCAs, a model described by Dr Maxwell as the ‘Christmas tree model of skill mix’. Furthermore, it adds another job title to the profusion of those already in existence within the NHS, a concern previously highlighted within The Cavendish Review (Cavendish, 2013) and one that should be avoided.
It was also highlighted by members of the audience that rather than create a new nursing support role, we should work with and develop the staff that we already have. One member, a student nurse who was previously a certified and state registered nursing assistant in the US before undertaking her training here in the UK, saw the value in standardising training for support staff, but felt a new role was not necessary to achieve this and that it would in fact undermine the value of the graduate nurse, simply because the current proposal blurs the boundaries of responsibilities between the RN and NA. However, Professor Baillie felt that the NA role will aid the transition from nursing assistant to NA and finally to an RN. While Dr Maxwell was not in complete disagreement, she reiterated that the transition to an RN does not require a new role and that nursing assistants and associate practitioners can already achieve the goal of becoming an RN if they so wish. While only anecdotal I am in somewhat of a minority amongst my peers, in as much as I had no previous experience of care-giving before undertaking my training while they had worked in various settings including as HCAs in care homes and within the hospital environment. Therefore, it would seem that the current system is not broken and requires not a distractive overhaul but support, nurturing and investment.
Dr Maxwell took a far more cynical view of the ongoing situation within nurse education and the state of funding within the healthcare system, but it is important to see this proposal within its financial context. There is no new funding for the government’s proposal and, as suggested by Jane Ball, ‘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’ (Ball, 2016).
However, short-term savings do not always translate into better outcomes for either patient or provider. High-quality care requires an initial investment and the Buurtzorg model of community nursing in the Netherlands is an excellent example of this. Despite having higher costs per hour because the majority of care is delivered by RNs, the Buurtzorg model has resulted in an overall reduction in care costs of between 30% and 40%, yet an increase in both patient satisfaction and the quality of care provided (De Blok, 2015; KPMG International, 2014). Based on these findings and the knowledge that it is the number of RNs that improves patient safety (Krueger et al., 2013), we should be advocating for ourselves and not a cheaper imitation. This is, however, unlikely given that we currently spend less on our healthcare than the Organisation for Economic Co-operation and Development (OECD) average (OECD, 2015), with current projections indicating that funding will further decrease as a proportion of gross domestic product until 2021 (The King’s Fund, 2015). As Dr Peter Carter said on the night, ‘… if you want a world class health service, you have to pay the first class ticket and right now, we are paying third class’. In my view, the introduction of the NA is not going to change that!