The registered nursing associate (RNA) role was introduced in 2015 as a response to the Shape of Caring review (Willis, 2015) and, in January 2017, in conjunction with Health Education England (HEE), the first trainee nursing associates commenced training in England (HEE, 2023). Six years on, the role remains misunderstood. There have been multiple job advertisements and role descriptors titled ‘registered nurse (RN)/registered nursing associate’, implying that the roles are interchangeable and that an RNA can be employed in place of an RN. This is the opposite to how the role was intended and potentially compromises patient safety and the safety of the nursing associate. The role of the RNA was never intended to be a replacement for RNs, rather the role was designed to support RNs and other members of the multidisciplinary team to improve patient safety and the patient experience (Nursing and Midwifery Council (NMC), 2020).
There has been a recent example of the role being used inappropriately. During a Care Quality Commission (CQC) (2023) inspection, a trust was found to have failings in patient and safety, which included NAs being left in charge of wards with no RN supervision. This is one of several concerns identified by the CQC at the time of the inspection and resulted in the service being given an overall rating of ‘requires improvement’ (CQC, 2023).
When read in conjunction, the Standards of Proficiency for Registered Nurses (NMC, 2018a) and the Standards of Proficiency for Nursing Associates (NMC, 2018b) demonstrate clear differences between the two roles, which ensures that the patient assessment and planning of care is completed by the RN. The RNA is then able to implement and monitor the care given in partnership with the patient, their family and carers, and to recognise when a reassessment by an RN is necessary (NMC, 2018b).
Because caring for patients in the community is becoming increasingly complex (Chalk and Legg, 2017) the RNA role allows RNs to use the time this frees in direct patient care. In some NHS trusts, the RNA can administer subcutaneous and intramuscular injections, perform male, female and suprapubic catheterisation, provide nephrostomy care, apply compression bandaging, dress complex wounds and provide palliative support.
Skills and outcomes
To enable RNAs to take on these more complex skills, they complete a 2-year foundation degree, which provides them with the underpinning evidence-based theory and opportunity to apply the theory to practice in clinical placements. Unlike RNs, who are field specific, RNAs are experienced and registered to work across all fields, as well as across a variety of care environments. The foundation degree topics include – but are not limited to – human development across the life span, anatomy and physiology, pharmacology, nutrition, bladder and bowel care, supporting those who are dying and their families and the bereaved, teamwork, leadership and supporting the development of others. It is the development and application of this knowledge and the skills required that demonstrates how the RNA role differs from that of the community support worker (CSW) and the healthcare assistant (HCA). Although these team members have a range of skills and knowledge, an RNA has the underpinning knowledge that supports critical thinking and the delivery of care based on the best available evidence (NMC, 2018b).
The Standards of Proficiency for Nursing Associate (NMC, 2018b) ensure that, at the point of registration, the RNA can practise safely and effectively. The standards stipulate outcomes in which the RNA must be competent, which include:
- Monitoring a patient's condition
- Escalating to senior members of the team should deterioration occur
- Venepuncture
- Monitoring glucose levels
- Observing for signs of pain or discomfort
- Assisting with hygiene needs and toileting
- Maintaining skin integrity
- Supporting patients in the use of mobility aids
- Dressing wounds using an aseptic technique
- Identifying individuals at risk of pressure damage and appropriately using pressure-relieving techniques
- Physiological observations
- Monitoring nutrition and hydration
- Identifying continence concerns and being able to appropriately respond to them
- Providing care at the end of a person's life and following death.
This is not an exhaustive list of the skills with which RNAs are equipped following their studies, and these skills can be applied to individuals of any age across a variety of health and care settings. There may be opportunities for RNAs to enhance their knowledge and expand their scope of practice following a period of preceptorship and further education; however, this is something that would be decided at a local level (West, 2019).
Regulation
The RNA role is registered and regulated by the NMC in England and therefore RNAs are required to practise and conduct themselves in line with the standards set out in The Code (NMC, 2018c). Although RNAs can provide more complex care than HCAs and CSWs, they must remain aware of their limitations and work within their scope of practice.
The RNA is professionally accountable to the NMC and, in law, has a duty of care to their patients. As an accountable professional, the RNA must always act in the best interests of the patient, use evidence-based interventions, be responsible for their actions and work within their limits of competence (NMC, 2018b). To be accountable, the RNA must (RCN, 2017):
- Accept responsibility for completing the task
- Have the competence to complete the task, and
- The authority to do so through local policies and delegation.
The RNA can also delegate tasks when appropriate to other members of the team: to do so, the RNA must consider whether the person has the knowledge and the skills to perform the task, whether it is in the best interests of the patient for the task to be delegated, and that any risks are identified prior to the task being completed (NMC, 2023). They must also consider that when accepting delegated tasks, they are assuming responsibility for that task and so must have the confidence to inform a senior member of the team if they are unable to perform the task competently (RCN, 2017).
As NMC registrants, RNAs are also required to revalidate every 3 years. This is to ensure that their knowledge is up to date, promotes good practice and encourage reflection on practice (NMC, 2021). During the original consultation by the Department of Health and Social Care (DHSC) in 2017 on the regulation of RNAs in England, 85% of respondents thought that the role should be regulated in the same way as that of other health professionals to ensure consistency around education and safety standards, with the view that the level of regulation would provide reassurance to the public and patients that RNAs are able to apply high standards of care (DHSC, 2018).
Conclusion
Education around the role must continue for organisations, leaders, colleagues and RNAs themselves to feel secure in the knowledge that these are professionals with the appropriate skills and competencies. RNAs must be able to speak out when they are concerned about patient care and have the sufficient confidence and knowledge of their role to be able to say no when asked to do something outside their sphere of competence.
RNAs must continue to respectfully challenge comments reported anecdotally that they are ‘unqualified’ and ‘untrained’, while being mindful that they are not RNs and they do not have the same skill set as RNs, but that what they do have is the knowledge, skill, and passion to be a valuable, safe and valued member of the team who can provide support to senior colleagues and enable them to have more time for hands-on patient care.
KEY POINTS
- Registered nursing associates (RNAs) are now becoming commonplace in the nursing workforce, but the role remains misunderstood
- To preserve patient safety, it is imperative that employers, colleagues and RNAs understand the scope of practice and have the confidence to speak out when asked to practise outside of this
- As registered professionals, RNAs are accountable for their own practice and the decisions they make, and they have a duty of care to their patients
CPD reflective questions
- If you are a nursing associate, do you feel confident that you understand your scope of practice and are you aware of your limitations?
- If you are a nurse and you have a nursing associate within your team, are there clear differences between what falls within their remit and that of the registered nurse?
- If there is an RNA in your team, has the role improved skill the team's mix?
- If you do not have an RNA in your team, how do you think the role would fit within your team?