Design

A qualitative multiple case study design with an interpretive approach was used. According to Yin (2017), such an approach enables researchers to investigate ‘how’ and ‘why’ questions in situations where participants’ behaviours are not under their control. A multiple case study design is generally more compelling and robust than a single case study design (Yin 2017).

Participants

Purposive sampling was used to recruit general practices in north east England. Because there are few nursing associates in primary care, all practices in the region who employed nursing associates were invited to take part. Recruitment was carried out through the nursing directors of the seven local clinical commissioning groups (CCGs) and supported by the Health Education England senior nursing workforce regional lead and research engagement leads. Five general practices in five out of the seven CCGs were recruited. Table 1 shows the demographics of the participating general practices.

Data collection

Data were collected between October 2021 and October 2022, at least six months after the nursing associates employed by the practices had registered, so that they would have had time to settle in their new role. NHS England (2022) recommends a minimum length for preceptorship programmes of four months, so six months was considered a reasonable time period.

Semi-structured interviews were used. Different members of staff were interviewed in each practice: GPs, managers (nurse managers or practice managers), nurses and nursing associates. A different semi-structured interview schedule was used for each participant group, with questions covering three broad areas:

Nursing associates were also asked about their relationships with members of the practice team and patients.

In three of the five practices, focus group discussions were held with various members of the nursing team – nurses, trainee nursing associates and/or healthcare assistants.

All interviews and focus groups discussions were audio-recorded and transcribed verbatim. The transcripts were anonymised and the data transferred to NVivo (version 12) software.

Data analysis

Template analysis, a form of thematic analysis (King and Brooks 2017), was used to identify and organise themes from the interviews and focus group discussions. A priori themes generated by a review of the literature on the implementation of new work roles were used as the basis for template analysis – in particular Kessler et al’s (2017) work on the institutionalisation of new support roles in healthcare, which had expanded the model proposed by Reay et al (2006). The focus was on identifying overarching organisational and operational factors affecting the implementation of the nursing associate role and the early effects of its implementation. Data were first analysed at the level of each practice and then across practices.

Ethical considerations

Ethical approval had been obtained from Northumbria University, Newcastle upon Tyne, and from the Health Research Authority. Informed consent was obtained from the GP practices and all the participants. Pseudonymisation of personal data was carried out to ensure the confidentiality of personal data.

Motivations for introducing the new role

Initially the author had hypothesised that the COVID-19 pandemic and its effects on staff numbers and service needs would have been one of the main factors motivating general practices to introduce the nursing associate role. However, this hypothesis was not borne out by the study.

In all five practices, workforce-related factors were identified as the first motivation for introducing the new role. Reasons for introducing the role included the shortage of nurses, an ageing workforce, the difficulty attracting younger people to general practice, issues with retaining staff, succession planning and workforce development. In all practices there was a strong desire to develop the experienced healthcare assistant workforce.

The second motivation for introducing the new role was service needs, both short-term and longer-term, articulated at strategic and operational levels. In practice 2, a multidisciplinary model had been envisaged to address the shortages of GPs and nurses.

Participants in practices 2, 3 and 4 mentioned cost savings as a motivation for introducing the new role. Those in practice 3 also recognised and welcomed cost savings as a secondary benefit of the change. Participants in practice 4 thought that the initial cost of introducing the role would be set offset by long-term gains. In practices 2 and 3, the additional funding via the ARRS was explicitly discussed as an incentive:

‘So it wasn’t really something that we had to consider as strongly as we would have done for other roles, because of the fact that it wasn’t coming out of our core funding.’ (GP, practice 2)

In practice 2, one nurse expressed scepticism regarding the official reason given for introducing the role, believing the change to be financially driven:

‘They’re going to be doing [a practice nurse’s] job for a fraction of the price, really.’ (Nurse, practice 2, focus group discussion)

Role purpose, scope and remit

For the most part, the nursing associates had continued to carry out the tasks they had been undertaking as healthcare assistants. The number of enhanced or additional duties allocated to them was limited. One registered nurse interviewed in practice 1 explained that there were not enough tasks in the week to fill a full-time nursing associate post.

Table 3 outlines the tasks carried out by nursing associates in the five participating practices.

Table 3.

Tasks carried out by nursing associates in the five participating practices

Despite having similar job descriptions, the nursing associates had taken on varying responsibilities (Table 3). Their role was described in all practices as being on a continuum from healthcare assistant to nurse. The manager in practice 1 described the duties of a nursing associate as:

‘The higher level of healthcare assistant work… coming from a different mindset because of the training.’ (Manager, practice 1)

In practice 2, participants highlighted the overlapping of the roles between healthcare assistant and nursing associate. In practice 3 it was considered that involvement in clinical decision-making was an important difference between nursing associates and healthcare assistants. Members of the nursing team in practice 5 considered that the nursing associate would stand out from their previous healthcare assistant role by gaining new skills.

In practices 1, 2 and 3 some participants expressed the view that nursing associates and newly registered practice nurses had comparable responsibilities and that this should be reflected by pay equity:

‘The only issue I have with this is, I think, the need to be banded in a band 5 across the board instead of a 4. I really do because [nursing associates are] actually doing band 5 work.’ (Nurse, practice 1, interview)

In all practices except practice 4, participants compared the role of nursing associate to the role of state enrolled nurse, which was abolished in the 1990s. In practices 2 and 4, members of the nursing team considered that the nursing associate role was of less use than that of healthcare assistant and was not needed in general practice.

A lack of clarity about the role of nursing associate was highlighted in all practices and participants had expected more guidance from the NMC on that aspect. Scope, remit, accountability, boundaries and professional identity were all cited as areas that lacked clarity. At times the practices appeared to struggle to determine the place and purpose of nursing associates and to decide what responsibilities could be allocated to them. Nurses in particular were unsure where accountability for some delegated tasks would lie. The nurse interviewed in practice 4 described ‘huge grey areas’ in that respect.

Accountability is integral to delegation and crucial when developing a new professional role. There was a perception that although NMC registration instilled confidence it could not automatically be interpreted as enabling delegation. Participants in practices 3 and 4 considered that having confidence in the person was more important than the fact that they were registered. Participants’ views on the role of nursing associate and their perceptions of the individuals taking up the new role in their practice appeared intertwined.

Based on the author’s professional experience and knowledge, the introduction of the nursing associate role was further complicated by a lack of robust service and workforce planning and the higher skill set of healthcare assistants working in general practices compared with healthcare assistants working in the hospital setting. This was confirmed by the findings of this study, for example one trainee nursing associate from practice 2 indicated that she could already carry out some of the duties of the nursing associate role as a healthcare assistant. As a result, the practices proceeded cautiously, with the contents of the role being a matter for local interpretation and its development slower than expected.

Future development opportunities envisaged for nursing associates included practical ‘treatment room’ duties such as ear syringing, dressings, vaccinations and blood pressure monitoring. Some practices envisaged that nursing associates would replace practice nurses over time.

Professional identity

Developing a professional identity was something all nursing associates found challenging, with one of them stating:

‘It’s been very hard to shake the fact that I’m no longer a healthcare assistant with other members of staff… and I do feel like I have struggled to get out of the [healthcare assistant] box since I’ve qualified. It is an ongoing thing.’ (Nursing associate, practice 5)

In practice 5, the new role created tensions in the nursing team. According to the nursing associate in that practice, their promotion to a higher role and their alignment with other registered healthcare professionals had caused ‘a bit of a backlash’ from the team. The nurse interviewed in practice 4 explained that some healthcare assistants had ‘difficulties in sort of accepting [the nursing associate’s] new role and also for the team in general [it’s] taken a little bit of getting used to’.

All nursing associates had continued their previous duties and, overall, practices had maintained their old ways of working. This compounded the challenges for nursing associates to establish a distinctive professional identity. Furthermore, nursing associates described a severe lack of support from the university for trainee nursing associates in primary care, with one of them describing their experience as:

‘Like hitting a brick wall every single step of the way.’ (Nursing associate, practice 5)

In some cases, the new role had been – or was going to be – advertised on the practice’s website. In practices 1, 2, 3 and 5, participants thought that patients had shown little or no awareness of the new role; however, according to participants, some patients had noted the change in uniform or the different tasks taken on by nursing associates and some patients had compared it to the role of state enrolled nurse.

Barriers to implementing the new role

Table 4 summarises the barriers to implementing the new role identified by participants.

Table 4.

Barriers to implementing the new role

One barrier mentioned by participants was that practices have to organise aspects of the training programme beyond the time trainee nursing associates spend at the practice. For example, according to participants, practices have to contact relevant organisations to arrange external placements for trainees, secure honorary contracts and negotiate access to clinical areas, particularly in hospital settings.

Another barrier was that the contents of the education provided by universities was not always relevant to general practice. Some participants questioned whether the training programme was fit for purpose for primary care settings. In practices 4 and 5, participants criticised the level of support from the university for trainees and for the practice. In practice 4, participants wondered whether their nursing associate might have stayed if better support had been available during training and after registration. At the time of the study, there was no peer support network for nursing associates in primary care nor any preceptorship programme for newly registered nursing associates working in general practice.

In line with the NMC (2023b) standards for student supervision and assessment, trainee nursing associates must be supported by a practice supervisor, who has to be a nurse and undergo specific training for their supervisor role. Practices found it challenging to provide supervision, notably because of limited physical space. The capacity of practices to train and supervise trainees was further hampered by nurses’ workload and the shortage of nurses, in general and especially during the COVID-19 pandemic. Some practices also lacked the physical space to set up additional clinics that nursing associates could take on once they had registered.

Additional subject-based training was considered necessary before newly registered nursing associates could take on certain responsibilities, for example cervical screening, which practices would have to pay for. Another barrier cited by participants was that nursing associates were not allowed to administer medicines under a patient group directive.

Early effects of the new role

Participants in practices 1, 2, 3 and 5 reported an increase in the capacity for patient appointments. In practices 1, 3 and 5, nurses had more time to focus on patients with complex long-term conditions. Releasing GPs’ time was mentioned in practice 3, while in practice 5 the early effects of the new role were described as ‘keeping services running’. Early effects included a higher quality of service resulting from the nursing associate’s enhanced knowledge (practice 1), continuity of care (practice 5), resilience of the nursing team (practices 3 and 5), additional skills leading to better patient access and choice (practice 2) and having more time with patients (practice 2). Other staff had benefited from the presence and support of a nursing associate: in practice 1 the nursing associate had mentored a phlebotomist; in practice 2 the nursing associate had supported trainee nursing associates; and in practice 5 the nursing associate had supported a new practice nurse.

Limitations

The number of participants was relatively small, which was partly due to the fact that the study took place during the COVID-19 pandemic. The findings would have had further weight with a larger sample size, wider regional coverage, the inclusion of other sources of evidence and a mixed-method study design.