Rethinking the role of the non qualified nurse

Contribution to 2020health’s recent report ‘Too posh to wash? Reflections on the future of nursing’

By Gail Beer, Director of Operations, 2020health

We often hear that it was all much better before nurses got degrees, and that if we went back to the way things were, care and standards would be better. Successive governments have come up with gimmicks to try and reassure the public. First, we had modern matrons then hourly patient checks. However, central dictates of this calibre will not do. More qualified nurses are unaffordable and are in short supply and in some circumstances may well be unnecessary. Is it time for us to rethink the role of the unqualified nurse and, more generally, what it means to nurse? Do we really know what we want or need from
the qualified nurse?

In the ‘good old days’ it was simple, but today with so many complex treatments and technologies, and complex packages of care, the role of the qualified nurse has changed beyond recognition. The work that RNs used to do is now undertaken by unqualified staff. Yet the public expects nurses to take on the complex tasks and carry on doing what they always did. We then blame registered nurses for failing to supervise unqualified nurses, blame the unqualified nurse for delivering poor care, and blame managers for trying to get staff on the cheap by using unqualified nurses. Yet there is no real appetite for increasing taxes to pay for more nurses; it is time for a radical rethink.

What is it we really want from nurses and what do we mean by nursing? These are fundamental questions that cannot be answered in this short piece. What we do know is that increasingly, care will be delivered by unregistered staff and it is to their training and supervision, and regulation we must look if we are to assure high standards of care and restore public confidence. Registration in this country will require a first degree; many of those wishing, and with a genuine aptitude, to take on caring roles will not meet the educational entry requirements. If action is not taken, society may be deprived of the skills and compassion of people who are not academically wired, or who are not willing to undertake university training. That is not to say that we should abandon the concept of a first degree for qualified nurses, it is very necessary and right. This is something we need to help the public understand. If we accept this premise, how do we regulate and train those supporting the qualified nurse? Unqualified nurses, or what are really nursing assistants, and carers take on an enormous amount of work. They look after the physical, mental and emotional needs of patients and clients, allowing the qualified nurse to use his or her skills to carry out more complex tasks. Unqualified nurses care in diverse settings; within the NHS, in both acute and primary care, the private sector, and especially in social care settings. They care for patients and clients across a broad spectrum of ages, social backgrounds and physical conditions, all with varying needs. Without them many would be denied even the basic level of care.

The change in the way we deliver healthcare using ever more sophisticated treatments and technology will require the registered nurse to become a different kind of practitioner, highly skilled technically, but also a first class navigator through the complexities of treatment, as well as an informed guide on the choices that patients and clients will need to make. The nurse will become more than a prescriber of care, he or she who will not only evaluate their own practice but supervise and monitor the effectiveness of other nurses and deliverers of care. The debate over the ratio of qualified nurses to non qualified nurses will raise its head when the Francis report is released. There will be stories about needing more qualified nurses and in the case of Mid Staffs this may well be true. Yet the number of qualified or registered nurses per head of population in the UK is comparable with the US, Western Europe and the Antipodes. Yes, we need to ensure that we have the correct ratio and that qualified nurses have sufficient time to carry out the essential tasks they are trained for. Just as importantly, we must ensure that those who are unregistered and caring for people in hospitals, care homes or the clients own home are properly trained, adequately supervised and adequately supported. We must be able to assure the public that the standard of care provided meets the physical mental and emotional needs of the client group, provide confidence that the system can prevent lapses in care and manage poor performance, and in the worst cases prevent re-employment in a caring role, should a nursing assistant or carer prove to be unsafe. There is much in caring that does not require those trained to degree level to undertake, but their supervision and insights are essential to support the work of the registered nurse and vice versa.

Today it is possible to apply for a job in care home with no experience and an offer of ‘on the job’ training. The bulk of the care given outside acute hospitals is to vulnerable, frail and often elderly patients. Interestingly  and quite properly, it is not possible to offer your services to care for a small child with this ‘hit and miss’, variable and sometimes nonexistent level of training. The elderly and frail have as much right to protection as the very young. So what needs to change if we are to become increasingly dependent on the unqualified nurse? How will we assure the public they are being cared for safely, that the unqualified nurse is working safely, is supported in their working environment and is aware of the expectations related to performance?The question is not whether we should have more or less unqualified staff, but how do we train, supervise and regulate nursing assistants and carers. We do not want to create a system that is prohibitive in terms of cost or one that deters those wishing to care from coming forward. On the contrary the system needs to create an environment which encourages those who do not want to become or cannot become registered nurses to work in the care sector.

Some form of registration of unqualified nurses has often been discussed. It has many merits, but to date we are no further forward and naysayers point to the cost and regulatory burden. While the debate goes on we cannot stand by and do nothing, there are some easier wins.

It is time for the introduction of mandatory,  nationally, structured and accredited training for all those working in a care environment. No longer would staff be unqualified, but accredited to work in specific areas, for example in mental health, acute or community care.

Those providing training would be licensed in accordance with a mandatory framework. Licensed training organisations need not be from within the NHS or indeed universities. Here lies an opportunity for the private sector or an entrepreneurial group of nurses who can provide hands on support in clinical situations.

Accreditation for unqualified staff would be achieved through a yearlong assessed and examined course. This is a system that is in place in a number of European countries and is an approach used across the aviation industry. We should develop a structured national training programme that provides a national qualification. A national scheme would restore confidence to patients and carers but to qualified nurses too.

Entrants must demonstrate written, verbal, and numerical skills to a national standard and candidates be assessed as to aptitude and suitability though structured interviews. Sadly today it is possible to be accepted into nurse training without having an interview.

Employers should be charged with a mandatory role to recruit, train, supervise and manage staff according to the highest standards. They must assure themselves that there is no record of poor performance before employment is given. Their licence to provide care should be dependent on demonstrating they have the systems and processes in place that give the utmost assurance that the patients and clients are safe in their hands. Those commissioning health and social care must also assure themselves of the evidence they are presented with, and pay more than lip service to ongoing contract management be that in the NHS or outside. It must become more financially attractive to suppliers of care to provide excellence. If you don’t then you lose the contract.

The question will be asked, isn’t this all too expensive and unnecessary; a sledge hammer to crack a nut? More and more of us will be elderly, and more of us will require care of some kind. Increasingly this will fall to non-registered nurses and carers, not for financial reasons, but for the simple fact that many of us will not need the skills of the  registered nurse.

Elderly and vulnerable members of society deserve a better system that provides them with the comfort of knowing the standards they should expect and that those carers who do not achieve the required level cannot care for others. The outcomes of poor care are often very expensive and it is a false economy not to invest in training our workforce to deliver high quality care.

Finally we should remind ourselves that there are some superb non qualified nurses and carers out there, working now in somebody’s home or by their bedside. They are much loved by their patients and clients and respected by their qualified colleagues. It is time to acknowledge the contribution they provide, demonstrate the value they bring by giving them the training and support they deserve.

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