15 / 02 / 2021
Watch the recording of this webinar and hear how health and social care organisations are using the nursing associate role across different healthcare settings.
This is an opportunity to hear employers share their successes of using the role and celebrate how nursing associates have contributed to the NHS workforce supply.
- Nicola Brockie and Beverley Allingham from University Hospitals Plymouth NHS Trust, an acute trust, spoke about how they've challenged thinking and deployed nursing associates in areas where there was scepticism about the role and whether it would work in that environment.
- Tracey Jones from Livewell South West, a community trust, talked about how nursing associates have been deployed in a variety of community settings.
- Nicola Wright and Maureen Holman from Devon County Council shared how they have implemented the nursing associate role locally in social care.
Download a copy of the slides and access the webinar recording below. We have also included answers to questions asked during the webinar.
This webinar took place in collaboration with Health Education England and NHS England and Improvement.
Answers to questions during the webinar
Q: How are organisations applying safe staffing practices in relation to qualified NAs? Are they included in registered numbers?
A: Unfortunately, I do not have the answer to this for all our services in Livewell that have NAs. I am aware for a ward environment, they are rostered into both registered and unregistered numbers depending on patient numbers. When in unregistered numbers it has been commented that this does help with freeing up the RNs' time to do other work around the unit. This is an area that we need to have clear guidelines about. But individual managers and matrons who know their service best are leading on this.
Q: I thought their role was NAP and not QNA, as they are a band 4 until they do their training. Is this the case?
A: All our trainee NAs and our trainee assistant practitioners are band 3 while training and they move into a band 4 position once qualified and the higher apprenticeship is completed.
Q: RNAs cannot make changes to plans of care. You mentioned that yours update care plans in the community. Do they need to get this signed off by an RN?
A: NAs complete ongoing assessments as part of monitoring and providing care, and in doing that, within the community setting, will update for example a wound care plan if changes were needed after assessing that patient. These patients are not new to the caseload but are seen by HCAs, NAs and RNs on a regular basis. If a change in care was recommended by the NA, this would be discussed with the RN during the visit via telephone or at handover. As part of being a registered practitioner NAs are responsible for understanding if they are not competent at performing an element of care and will refer to RNs to review the patient if needed. All community visits completed by a NA are delegated to them by the RN and all visits are then reviewed by the RN and caseload at handover.
Q: Fabulous to hear of the scope of practice and how this differs dependent on team/needs. Can Tracy explain how oversight from the RN works on a day to day basis, particularly where NAs are lone working as in the community?
A: Thank you for recognising the difficulties with a NA's scope of practice in different services, it is something I hope to work on with the matrons and managers so it becomes clearer. In any community setting, HCAs and support workers work on their own as well as NAs and RNs. We have a robust competency package that compliments the training received on the undergraduate programmes. So all members of the community team will have to be assessed as competent using a competency framework on a skill before providing that care autonomously. Also the RN is responsible for delegating patients to NAs and the visits/patient care is reviewed with a RN at handover on a daily basis.
Q: The NMC platform for the difference between NAs and RNs state that assessment and care planning remains the responsibility of the RN, how has your organisation supported initial assessments as part of the NAs scope of practice?
A: From my understanding NAs can provide ongoing assessment because they monitor and provide care, and in order to do that they have to assess. So in the community we have supported NAs completing initial/first visits by the RN triaging the referral first. We have a delegation and accountability policy that gives guidance to the RN on what is applicable to delegate. Now we know that any person working on their own in the community including HCAs may go to a patient’s home and see a different scenario than first thought. But the NA is a responsible registered practitioner who is able to identify when care is outside of their remit and refer the patient to a RN. A first visit will include assessments including a nutritional and skin assessment, taking clinical observations and an environmental assessment for example. A TNA during their training will practice completing these assessments under the direct guidance of a RN and Livewell have a comprehensive competency package that all NAs will complete before providing any care autonomously. NAs are not responsible for an admission to a ward but can be delegated parts of that admission. I think it is overall about delegating appropriately and making sure the RN remains the leader and co-ordinator of care.
Q: Could you please talk about the role limitations of NAs in comparison to a mental RN?
A: Unfortunately I am an adult nurse by background so cannot give you a full answer. However, NAs in any setting won’t be the lead person for an admission but can be delegated parts of the admission. The RN will always be the leader and co-ordinator of care. NAs cannot administer IV medication. An RN in any setting will always oversee the care a NA gives and it’s about the RN delegating appropriately to the NA. There are obvious theory knowledge gaps between a degree RN and a NA, which will reflect on care decisions. As I said in my presentation, having a clear distinction between a band 4 and a band 5 is needed and will be different depending on what branch of nursing and service, but hopefully as the role becomes more widespread we will see those clear distinctions in action in the clinical areas. I don’t think we are there yet.
Q: Tracy - is it possible to get a copy of your handbook? I am part of a working group producing a handbook for those TNAs making the transition to NAs.
A: Yes, it will be available soon on our web pages and it will be updated here with the link. We are just making final revisions.
But I have shared the current copy with NHS Employers, if you would like a copy of that document, please send a request to email@example.com.
Q: How are organisations funding/supporting the NA trainees? e.g. central funding via vacancies or within services' workforce planning?
A: Currently funding comes from HEE / apprenticeship levy and if the trainee successfully completes the bridging programme, Devon County Council will also support with funding.
Q: Have you introduced the TNA into residential homes or to domiciliary care?
A: Inaugural cohort in care homes with nursing and one residential care. Domiciliary care is definitely in the workforce plan, for the future.
Q: How do you organise nurse supervision (practice supervisor/practice assessor role during learning) where the home has not got nurse staff?
A: Only one setting (residential care home) did not employ registered nurses. The practice assessor was from a different healthcare setting and supervision was led by community nurses who delegated nursing duties. There are other health professionals who are able to support supervision and setting up a collaborative supervision model is central to progressing supervision of learners in residential (and ultimately) domiciliary care.
Q: For the care home that does not have a nurse, what is the plans for their TNA once qualified? How will they operate under the umbrella of a nurse once registered NA?
A: Care homes without nursing can employ nursing associates, but they cannot carry out nursing activity unless delegated by a healthcare professional from the CQC Treatment of Disease, Disorder or Injury (TDDI) list, for example a district nurse. This would be similar for domiciliary care agencies (DCAs). If a DCA provider wants to provide TDDI, they must employ a registered nurse (or other from the HCP list), otherwise nursing associates cannot carry out nursing care.
Q: How did secure back fill for the role?
A: Individual providers organised backfill as required. Some had arranged for extra staff during the first lockdown period so that they did not need to bring in bank / agency staff so had their own staff to call upon if necessary. External placements were delayed so the areas only ‘lost’ their TNA(s) for one day per week whilst they attended their University study day. This year will be different as the TNAs begin the external placements so managers may need to arrange backfill.
Q: We are working on the basis of 36-40% in learning, whereas the nurse degree is 60%. Can we have a link for the NMC guidance that says up to 60% for the nursing associate apprentice learning please?
A: Info can be found on: nursing-associates-protected-learning-time-supporting-information.pdf (nmc.org.uk)
Q: There is also the HEE/Skills for Health developed bridging programme (level 3 study skills) - is this the same thing?
A: The bridging programme is level four, aimed at preparing candidates for higher education, in this case the focus is the foundation degree.
Q: We would be really interested to hear about the outcome of discussions with CQC and scope of practice for your NA once they qualify within the care home that does not have a nurse. We are also piloting this so would be good to exchange info. Would you be happy to share your contact details?
A: Yes, of course, please do get in touch: Maureen.firstname.lastname@example.org and Nicola.email@example.com
Q: How is the bridging course funded?
A: Devon County Council funds the programme currently. In our strategic plan for the coming years we may have to look to other avenues for funding.
Q: Can we get involved in the Kings College research? We have 8 apprentice nursing associates in social care in North East London and would be keen to contribute to the research. Is it possible to connect me with the relevant person?
A: The lead is Professor Ian Kessler and is the ideal person to contact for information about the study: https://www.kcl.ac.uk/people/ian-kessler
Q: Has anyone managed to clearly define and articulate the difference in practice between registered nurses and nursing associates within your trust?
A: We currently provide the attached NMC guidance (word doc) for the comparison between RN and NA. As stated there are guiding principles for the NA role but additional CPD can be adjusted to the individual environment.
Q: What questionnaires were used at UHP? Can this be shared/emailed to us?
A: We have completed evaluations as follows: The TNA final evaluation (word doc), and NA managers (word doc) understanding and impact of role. Other work has been interview or focus groups.
Q: Would really like to know more about how the role works for you in paediatrics?
A: We are currently working with paediatrics to identify workforce opportunities to employ NAs in this area.
Q: Can UHP share what terms and conditions they offer staff on their career pathways? e.g. do you pay external young people on 4year pathway less than existing staff recruited to NA etc?
A: The four year registered nurse degree apprentices are employed in their current position on application. This will be band 2 HCSW. They continue to be employed by their current manager, working two days in their current employment, one day academic study and two days either working in practice placements or if on a theory module they will remain in their current employment for the majority of these days. For those stepping on to year two of their RNDA due to holding FD/Level 5 they will be paid at band 3, again completing two days per week as an employee, with one day study and two days either practice placement or continued employment.
Q: Do your registered nursing associates give IV medicines?
A: UHP does not currently advise that NAs administer IVs. At this present time it is considered that the NA is the registered professional at the patient’s bedside, freeing the RN to undertake more complex tasks. Administering IVs will require the NA to be away from the patient’s bedside. Recommendation 6 of the HEE medicines management guidance for NAs identifies process to follow should IVs be considered. Neither NMC or HEE state that IVs cannot be administered by NAs, but it is not initial recommendations.
Q: Great presentation. Thank you. My problem are some line managers. How can I win them over?
A: We have worked with matrons and managers talking through the benefits of the NA and helping them to review their workforce, identifying the benefits of employing an NA by releasing RNs. The Matrons/managers questionnaire responses, feedback from the Test of Change wards and review of Metrics has also provided positive feedback about the role and benefits. We have run workshops, sent leaflets, handbooks, posters to increase understanding, but have found that the personal approach has had the best impact.