Trainee Nursing Associates 

Background

The Nursing Associate (NA) role was developed in England in response to the ‘Shape of Caring’ review (2015). The aim of the role is to bridge the gap between nurses and unregistered healthcare assistants (HCAs) and to provide an alternative route into registered nursing. NAs undertake 2 years of training to prepare them to work across all four fields of nursing. The first NAs qualified in January 2020 and some will go on to undertake further training to become registered nurses. There is little research into this new role, therefore we aim to evaluate some of the policy assumptions that have been made using a range of methods.

This programme of work explored the motivations, experiences and aspirations of nursing associates (NAs) as they went through training and into their first NA posts. In doing so, we aimed to examine some underpinning policy assumptions regarding the introduction of the NA level of practice and identify the challenges and contributions being made by this addition to the healthcare workforce.

Study Design

The approach to this work evolved over the period of the SRA programme as specific issues became apparent. The final design consisted of the following elements:

• An exploratory, qualitative study (in 2018) of 3 focus groups (n=15).

• A national (England) cohort with a longitudinal survey and qualitative sub-cohort. The survey took place in 2019 (n=121) and in 2020 (n=64) and the sub-cohort interviews took place in 2020 (n=14), 2021 (n=17) and 2022 (n=12).

• Annual interviews for 2yrs (in 2020, 2021) with local stakeholders involved in trainee NA programmes (n=9). This included those involved at NHS Trust and Higher Education strategic decision levels (e.g Deputy Director of Education, Head of Department, Director of Apprenticeships) and those involved in NHS Trusts and Higher Education delivery levels (e.g. Learning & Development Facilitators, Clinical Educators, TNA course leaders).

• Cross-sectional interviews (in 2021) with primary care trainee and qualified NAs (n=11) from across England.

• National (England) Cross-sectional interviews (in 2021) with staff involved in trainee NA programme delivery within Higher Education Institutions (HEIs). This involved twenty-seven interviews with staff from five geographically diverse HEIs.

Key Findings

The following represent some of the main cross-cutting findings from this programme presented in theme areas (the detail around these areas is present in the academic and briefing paper output documents noted later in this report):

While NA training created a feasible development opportunity for staff, understanding career pathways beyond NA registration was more complex.

Our findings concur with other research showing that NA training offered affordable, local, career development opportunities that had previously not been present or practically feasible (often due to family or financial commitments). However, we further noted that, following training, some NAs chose to progress into registered nursing (RN) viewing the NA programme as a bridging stage, while others sought the perceived security of registered nursing after becoming frustrated by ambiguity around the new role. Other NAs faced barriers being released into RN training and some preferred to remain as NAs and were keen to promote and embed this role. For employers, having staff train as NAs was recognised as an important way of being able to retain experienced staff with organisational knowledge. We noted how this was the case in both the hospital and the primary care sector. However, both our employer and HEI research highlighted difficulties in workforce planning and in calculating or managing the numbers going through NA training. These numbers could be variable year-on-year and planning for NAs to remain in post, to be present as NAs within a clinical team, could be further complicated by the number wishing to progress to RN.

Support for trainees was variable across clinical settings, influenced by prior understanding of this level of practice, aided by collaborative working relationships and required adaptation in teaching and learning approaches.

All our studies highlighted the importance of support for trainee NAs, though how this was understood varied for the different stakeholders. All studies noted that support varied across different clinical areas and this was often related to how well staff understood what was required of them in supporting trainees and NAs. We noted that this understanding was said to have improved as the role became more embedded, and HEI staff noted they had an advocacy role to play here in improving understanding. Importantly, the ability to provide protected learning time, create opportunities to gain/practice new required skills, and to have these signed off, varied by clinical area and was also heavily impacted by high service demand and limited time (such as during the initial Covid-19 waves). Our data suggests that this issue was compounded in primary care where support systems (such as access to clinical educators, practice-based assessors) were said to be less well established and where the business nature of GP practices created particular employee/trainee tensions for the NAs. Resolving such support issues was recognised in all studies to be improved by developing good partnerships and when required tripartite meeting processes (between employer, HEI and trainee NA) functioned well. When functioning well, we noted that these meetings aided mutual understanding and expectations allowing potential problems, both at process/system level and at individual NA level, to be addressed early. Additional academic support issues were highlighted by the NAs and in the HEI study. Here, our work highlighted how the prior limited experience of study (both level of study and time since previous study) created anxiety and concern for many trainee NAs and required adaptations to be made by HEI staff to provide sufficient academic support. However, staff in the HEI study were keen to point out that these trainees often excelled and that they brought a huge amount of practical experience into the learning environment that could be used to provide practical examples to illustrate points and thereby aid understanding.

Ensuring a safe scope of practice, and a clear work and student identity was complex, strongly influenced by their employee status, and dependent on workforce demands.

A recurring theme within our NA studies was that of uncertainty around the scope of this new level of practice and the ability of NAs to forge a clear identity within the healthcare staffing landscape. It was apparent that there was wide variability of skills at the commencement of training. For some, such as those from primary care, it seemed that while they may already have arguably advanced skills (such as phlebotomy and recording ECGs), some had no experience in certain fundamental nursing competencies such as assisting with personal hygiene needs. This skill variability created a challenge in obtaining the required range of skills and competencies in placements, especially with placements of a short duration. Knowing whether it was safe to practice a familiar skill in a different clinical setting was also highlighted. We noted how the potential to go beyond a safe scope of practice was particularly apparent during the early Covid-19 waves and reflected wider concerns about the potential for boundary blurring and having clear lines of accountability. In line with other research, we demonstrated how some NAs had faced scepticism, occasional hostility, and frequent questioning from staff about what NAs are, and what they can do (though this was noted to have improved as the role became more embedded). One practical difficulty this raised, highlighted in all our studies, was that trainee NAs were sometimes expected to work in healthcare assistant roles, which diminished protected learning time and thereby limited learning opportunities. This reflects a wider identity tension that was seen to exist when NAs are simultaneously employees and trainees. Our studies suggest that NAs were primarily being identified as employees, both by themselves and by their employers. This created a variety of difficulties, most notably, the ability to insist on being released for learning and placement opportunities and to have sufficient (required) protected time and access to the (required) practice-based facilitators. The HEI staff also recognised difficulties in helping trainee NAs develop and maintain a student identity when the academic component was often seen (by employers and sometimes by NAs) as only a small part of gaining the required learning experience and skill development.

Publications

King, R., Ryan, T., Wood, E., Tod, A. Robertson, S. (2020) Motivations, experiences and aspirations of Trainee Nursing Associates in England. A qualitative study. BMC Health Services Research, 20(1): 1-10 https://doi.org/10.1186/s12913-020-05676-7 

Robertson, S. King, R., Taylor, B., Laker, S., Snowden, S., Wood, E., Senek, M., Tod, A., Ryan, T. (2021) Support and career aspirations among trainee nursing associates: a longitudinal cohort study. Nursing Times, 117(12): 18-22

King, R., Robertson, S., Senek, M., Taylor, B., Ryan, T., Wood, E., Tod, A. (2022). Impact of Covid-19 on the work, training and wellbeing experiences of nursing associates in England: a cross sectional survey. Nursing Open 9(3), 1822-1831 https://doi.org/10.1002/nop2.928  

Robertson, S. King, R., Taylor, B., Laker, S., Wood, E., Senek, M., Tod, A., Ryan, T. (2022) Development of the nursing associate role in community and primary care settings across England. Primary Health Care, 32(2)  doi: 10.7748/phc.2022.e1764

Robertson, S. King, R., Taylor, B., Laker, S., Wood, E., Senek, M., Tod, A., Ryan, T. (2022) A local stakeholder perspective on Nursing Associate training. British Journal of Healthcare Assistants, 16(3): 126-133  https://doi.org/10.12968/bjha.2022.16.3.126 

King. R, Taylor. B, Laker. S, Wood. E, Senek. M, Tod. A, Ryan. T, Snowden. S, Robertson. S. (2022) A tale of two bridges: factors influencing career choices of trainee nursing associates in England. A longitudinal qualitative study.  Nursing Open. https://onlinelibrary.wiley.com/doi/10.1002/nop2.1266 

Robertson, S., King, R., Taylor, B., Laker, S., Wood, E., Senek, M., Tod, A., Ryan, T. (2023) Primary Care Trainee Nursing Associates in England: A Qualitative Study of Higher Education Institution Perspectives. Primary Health Care: Research & Development. 24, E3 https://doi.org/10.1017/S146342362200072X 

King, R., Laker, S., Ryan, T., Wood, E., Tod, A., Senek, M., Taylor, B., Robertson, S. (2023) Training and development experiences of nursing associate trainees based in primary care across England: A qualitative study. Primary Health Care: Research & Development, 24, e32  https://doi.org/10.1017/S1463423623000221 

Robertson, S. King, R., Taylor, B., Laker, S., Wood, E., Senek, M., Tod, A., Ryan, T. (2023) Trainee Nursing Associates in England: A qualitative study of Higher Education Institution perspectives. International Nursing Review  https://doi.org/10.1111/inr.12868 

King, R., Laker, S., Ryan, T., Wood, E., Tod, A., Senek, M., Taylor, B., Snowden, S., Robertson, S. (2024) Development of the nursing associate professional identity: a longitudinal qualitative study. Nursing Open https://doi.org/10.1002/nop2.2131