Nursing Associates in general practice
A collaborative project between ARC-West and local NHS staff to explore the role of the Nursing Associate within general practice to inform education provision, role implementation and staff integration.
Background
The Additional Roles Reimbursement Scheme (ARRS) launched in England in 2019. The scheme supports the recruitment of more staff into general practice, and includes the Nursing Associate (NA) role. NAs are registered healthcare professionals.
Their training sits between a Health Care Support Worker and a Registered Nurse (RN). The role was introduced to build workforce capacity, freeing up time for RNs to undertake more complex work. This role would also increase the number of nurses progressing to graduate-level.
The NHS long-term workforce plan has an ambition to recruit 64,000 NAs across the NHS by 2037. Previous research has investigated this role within secondary care. However, less was known about the experiences of NAs in general practice. This study included a scoping review and semi-structured interviews. The study looked into the experiences of NAs, and other members of staff in the general practice team. This helped to determine the barriers affecting the implementation of the role.
Objectives
The objectives of this project were:
- To identify barriers and facilitators to implementation of the NA role within general practice
- To understand the lived experience of introducing the NA role into general practice.
"Once you're a Nursing Associate, your scope for increased pay is really limited. There are things you can do to increase skills, but for most NAs, many of them will only be used if a nurse isn't available."
Nursing Associate
About the project
Scoping literature review
To begin with, a scoping literature review was undertaken. This included evidence from 21 papers. It provided an overview of current evidence describing the fulfilment of the NA role. The findings highlight four overarching domains:
- Differing routes to practice: The apprenticeship route was consistently preferred. This route allowed trainees to earn money as they train, and stay local to their communities. This route was seen as widening participation and supporting workforce retention.
- Barriers and enablers to implementation: The NA curriculum remains heavily oriented toward secondary care. Trainees in general practice struggled to meet competencies such as medicines management or discharge planning, with some skills gained in hospital settings being “not always relevant" for primary care. However, the presence of ARRS funding was a strong incentive. It reduced financial risk for practices and supported long-term workforce planning.
- Perceptions and impact of the role: NAs were valued for enhancing the skill mix and for their contribution to clinical tasks. They were also valued for their contribution to healthcare monitoring and health education. However, there was widespread confusion amongst other professionals on the identity of the NA role. This included the scope of practice and distinction from Healthcare Assistants.
- Emerging outcome measures: Empirical evidence on the role's impact was not available. Determining the value of the role remains challenging.
Semi-structured interviews
The qualitative study covered experiences and perceptions of NAs in primary care settings. This had a view to understanding their role within multidisciplinary teams. This included the scope of their practice. It also incorporated factors influencing integration and professional development.
The qualitative work comprised semi-structured interviews conducted with 16 participants. These were key partners related to the implementation of the NA role in general practice. NAs, Practice Nurses and workforce system planners took part. The interview was designed to explain further understanding of the NA role in General Practice.
Findings highlighted:
- Practice based barriers: poor understanding of NA role boundaries and a lack of practice manager support were identified. Additionally, there were attempts to integrate the NA role into practice too fast. NAs also cited uncertainty around pay and progression possibilities as challenges.
- Facilitators to implementation: Successful integration relied on support from other staff. This included a university-based educator with understanding of the role in General Practice. Providing clear guidance on role capabilities was necessary. There was support for gradual integration.
Positive outcomes in practice were also recognised and benefits included:
- Increased capacity for Practice Nurses
- Shorter wait times for patients
- Increased continuity of care
- Valuable knowledge exchange between nursing staff.
However, there were some concerns about greater administrative burden.
The NA role has potential to provide a meaningful addition to the practice workforce. However, the role is poorly understood and boundaries ill-defined. This can leave NAs working outside their role description, without realising their potential.
Further exploration into approaches to overcoming implementation barriers and future directions is required. These methods include career development and the support to work across different sectors.
Impact
The findings from this work will inform educators, general practice staff and Nursing Associates of the recognised challenges of implementing the role within general practice. Regional partners involved in the work have engaged with the findings to support education and workforce planning in the future.
Lessons learned and next steps
Working with a highly engaged service level partner is critical to achieve an adequate recruitment sample. They act as an advocate for the study and support staff engagement and involvement.
We intend to apply for further funding from NIHR to undertake an extensive nationwide evaluation of the impact of implementing the NA role within general practice.
