RCN position on preserving safety and preventing harm - Valuing the role of the registered nurse
The substantial shortfall in the number of registered nurses has been well documented however the latest (May 2021)1 data from the NMC register has grown by around 15,000 in the last year. Most of the growth is generated by registered nurses, however, the rate of growth is slower than the previous year, and the number of people joining the register for the first time is fewer than last year.
International recruitment (outside the EEA) is down, likely due to pandemic travel restrictions. In addition, some of the register growth is driven by recruits who are either nearing or at retirement age and so unlikely they will stay on the register for the long term.
This does not reflect the fact that there are more patients than ever before, and that they are not only living longer but also have more long term and complex health needs There are still more than 36,000 nursing vacancies in the NHS in England, and across the UK in all health and care settings the number is close to 50,000 unfilled posts.
The Royal College of Nursing (RCN) has seen an increase in the number of occasions, where positions requiring a registered nurse are being advertised on NHS and other websites, from Band 5 up to Associate Director of Nursing level with an indication that other registered health care professionals, generally Allied Healthcare Professionals (AHPS) can apply. The only caveat being post holders need to be registered either with the Nursing and Midwifery Council (NMC) or Health and Care Professionals Council (HCPC). As an example a recent advert for Band 5 Staff Nurse required the post holder to be ‘RGN/RN or equivalent Allied Health Professional Qualification’.
The RCN welcomes the NHS Long Term Plan's move towards a more multidisciplinary healthcare team approach to the planning, delivery and evaluation of care. It equally acknowledges the significant role that AHPs play in health prevention and the improvement of health and wellbeing of patients. However, there is minimal research or literature surrounding the impact on patient outcomes of AHPs undertaking registered nursing roles / tasks or in their undertaking of nurse leadership roles.
The RCN challenges the perception that an AHP matron, for example is providing the same clinical nursing supervision and leadership for nursing that a nursing matron would. An AHP matron can provide the management function which is only part of the nursing matron role. Indeed the use of titles such as Matron, or Ward Sister/Charge Nurse by those who are not nurses can be misleading in the attribution of knowledge or skills to the post holder that they do not in fact possess. It is however noted that Matron is not a title protected in law.
Whilst there is merit in a structured workforce review that considers where the specific knowledge, expertise and skills of an AHP might strengthen a multidisciplinary team and may result in restructuring a team to include AHPs working alongside nursing, this should not be in pursuit of a generic workforce where the very specific contribution of nursing becomes diluted. Having non nurses in any nursing role potentially denies patients access to the most appropriate care and could lead to a rise in incidence of missed care which is known to have a negative impact on patient satisfaction and safety.
Many inquiries and reviews have stressed the importance of nursing leadership indeed there is evidence to suggest that nurse leadership has a significant impact in two main areas: patient experience and outcomes, and nurse satisfaction and retention. The Francis Report2 clearly demonstrated the catastrophic risk of having an inadequate number of RNs.
It is not just leadership roles where the RCN is seeing roles which require a registered nurse open to other registered professionals. In England Band 5 roles for registered nurses are now appearing as open to nursing associates as well as those registered with the HCPC. The position of the registered nursing associate (RNA) in England is specifically intended to support the role of the registered nurse and should never be used as a substitute because a registered nurse post cannot be filled. A structured workforce review of a service may suggest the potential for a change in skill mix (and so the role profile and AfC bands within a team) but this should be clearly based on service demand.
Filling registered nurse vacancies with those who are not registered nurses is not filling those vacancies – it is negatively shifting the dynamic of care. Responding in this way to a nursing deficit leads to a (further) deficit in nursing care. Nursing cannot be relegated to a series of tasks to be undertaken by others (if employers decide to do this then they must carry the risk). Patient safety and need must drive the shape of the workforce; a deficit in the nursing workforce can only be met by registered nurses with nursing support workers, when appropriate, who are supervised by RNs. There is currently insufficient attention paid to the risk of reducing the contribution of nursing knowledge and expertise to safe and effective patient care.
The RCN calls for all employers working within health and social care to ensure that where a vacancy exists for a registered nurse, this is open to registered nurse applicants only. Those who require nursing care in whatever setting should have access to nursing staff that provide holistic proactive, continuous care, and coordination across the 24-hour period in all settings.
The RCN expects all employers, regardless of sector, to have developed robust workforce plans, in line with the RCN’s Nursing Workforce Standards, taking into account the nature of the role, patient / service user need, service demand and skill mix. Workforce plans must consider the impact and importance of strong nurse leadership in patient outcomes and developing clinical competencies amongst the nursing workforce. The reasons behind the current workforce crisis are complex and many, but lack of robust workforce planning based on population need is a significant factor. The RCN in its work on staffing for safe and effective care calls for all UK governments to significantly change their approach to workforce planning and base it on population need as a first principle.
