Consultation on agreeing the parameters of practice for the registered nursing associate role

During 2023, a national project was undertaken by Welsh Government to explore the options and opportunities for the future development of the band 4 nursing role across NHS Wales, noting midwifery was not in the project scope. This has been the most significant review of the nursing workforce since the decision to introduce the graduate nurse in 2004. The project was commissioned in January 2023 by the Minister for Health and Social Services (now referred to as Cabinet Secretary), supported by the Chief Nursing Officer for Wales and the Director of Organisational Development, Welsh Government.

The project aim was to consider whether a nursing associate role, which currently operates in England only, is desirable, appropriate and value adding for NHS Wales. The methodology synthesised Welsh stakeholder opinions with the lived experience of the registered nursing associate in England, fusing views with the literature. There were 20 recommendations made in the project report, all of which were accepted, in full, by the Health Minister in November 2023. Two of the principle and fundamental recommendations are outlined below.

Recommendation 1

Only one band 4 nursing role will exist in NHS Wales, that of the registered nursing associate, with the Nursing and Midwifery Council as the regulator.

Recommendation 2

Enact a centralised, once for Wales, social partnership approach to the development of parameters of practice, which unequivocally distinguish the registered nurse from the registered nursing associate, avoiding role substitution. The parameters of practice will be subject to consultation.

For context, the registered nursing associate is an assistive member of the nursing team, who has gained a Nursing Associate Foundation Degree awarded by a Nursing and Midwifery Council-approved provider, involving the completion of high-level study over 2 years full time (but can be completed part time), enabling nursing associates to perform more significant and complex care activities than a health care support worker but not the scope of a registered nurse.

The pivotal role has been introduced in England to build the capacity of the nursing workforce, supporting delivery of high quality, evidence-based care by assisting the registered nurse, and members of the multidisciplinary team, enabling their focus on more complex and intricate care and activities, embracing prudent health care principles.

The registered nursing associate role can be applied in all health and care settings with people of all ages, and is a role educated across the 4 fields of practice:

• adult
• child
• mental health
• learning disabilities

The introduction of the role in England has enabled advancement of health care support worker careers and expansion of the registered nurse workforce through enabling a pathway for the registered nursing associate to become a registered nurse. The role is a destination, making a valuable contribution to patient care and addition to the nursing workforce, and importantly can also be a stepping-stone to registered nurse.

The aim of the consultation is to agree the post-registration parameters of practice in Wales, which unequivocally distinguishes the registered nurse from the registered nursing associate, ensuring registered nurse role substitution (whether intentional or unintentional) does not occur.

Protection of specific elements of the registered nurse role, that cannot be delegated to a registered nursing associate, will support this aim.

For the purposes of this consultation, it is important to recognise the difference between scope of practice and parameters of practice.

Scope of practice

Scope of practice varies across clinical areas and fields of practice, it is iterative and can be driven by societal change. At the point of registration, the scope of practice is set by the Nursing and Midwifery Council (NMC). Post-registration it is set out within job descriptions and policy, underpinned by the NMC's code of practice. The registered nursing associate scope of practice is not being considered within this consultation but will be a future workstream as part of the registered nursing associate implementation plan for Wales.

Parameters of practice

Parameters of practice set out the boundary limits or ‘red lines’ that cannot be crossed, whilst recognising the unique and distinctive elements of a role that must be protected and acknowledging role overlap will and does occur. Clearly defined parameters of practice cement understanding of clinical roles and responsibilities, ensuring safe patient care, together with role differentiation and distinction. Parameters of practice will be a Wales-specific policy approach, which will not be imposed by the NMC. The NMC professional regulatory framework is common across England and Wales and consists of the code, character checks, proficiencies and revalidation requirements.

Nursing is a safety critical profession founded on 4 pillars:

• clinical practice
• education
• research
• leadership

Registered nurses apply high levels of vigilance and cognition in the application of evidence-based knowledge, professional and clinical judgement to holistically assess, plan, implement and evaluate high-quality, person-centred nursing care.

There are elements of practice relating to the registered nurse that do not apply to the practice of a registered nursing associate. These are set in law or within non-statutory guidance, and, as such, are excluded from discussion within this consultation. These exclusions include:

• the protected title ‘registered nurse’
• being a graduate profession
• field specific NMC registration (whilst noting the ability to be dual-registered)
• non-medical prescribing (independent prescribing)
• administration of medicines against a Patient Group Directive (PGD)
• intrathecal medication administration
• medicines transcribing
• Ionising Radiation (Medical Exposure) Regulations 17(a)
• diagnosis and confirmation of death (life extinct)
• certification and issuance of a fit note
• Mental Health Act (1983) updated in 2007
  • section 5(4) gives registered nurses the ability to detain someone in hospital for up to 6 hours (first level registered nurses can use this holding power within mental health in-patient facilities)
  • section 17 gives registered nurses the ability to conduct a pre-leave risk assessment (registered nursing associates are not currently classified as ‘authorised members of the multidisciplinary team under the Mental Health Act’)
• Mental Capacity Act (MCA) (2005) and Deprivation of Liberty Safeguards (DoLS): Medical Status Examination (MSE) and assessment and decision-making determining mental capacity
• standard and urgent applications, requests and authorisations for DoLS sections 42 and 43 of the act
• best interests assessor (section 4 of the MCA)

There are many elements of regulation and professional practice that apply to both the registered nurse and the registered nursing associate, notably:

• regulation and registration with the Nursing and Midwifery Council
• revalidation
• accountability
• autonomy
• delegation
• providing care
• monitoring care
• prioritising people
• practicing effectively
• preserving safety
• promoting professionalism and trust
• improving safety and quality of care
• working in teams and contributing to integrated care
• promoting health and wellbeing and preventing ill-health
• critical thinking
• applying evidence based practice
• supervision and assessment of students at level 4 and 5 (the registered nursing associate is not able to supervise and assess level 6)
• duty of care, health and safety and position of trust

Parameters of practice is a Wales-specific policy approach, which will not be imposed by the Nursing and Midwifery Council.

The Nursing and Midwifery Council professional framework is common across England and Wales, which consists of the code, character checks, proficiencies and revalidation requirements.

Question 1

Do you think that leading, coordinating, managing care and being ‘in charge’ should be reserved for the registered nurse, with the registered nursing associate contributing to but not leading care?

Question 2

Do you think that holistic^{[footnote 1]} patient assessment should be reserved for the registered nurse, with the registered nursing associate only participating in elements of patient assessment?

Question 3

Do you think that holistic planning of patient care and care plan development should be reserved for the registered nurse?

Question 4

Do you think that holistic evaluation of patient care should be reserved for the registered nurse, with registered nursing associates only participating in elements of patient evaluation?

Question 5

Do you think that leading, responding and supporting safeguarding enquiries into abuse and/or neglect of adults and children should be reserved for the registered nurse?

Question 6

Do you think that complex and sensitive discussions with patients and families (or significant others) about ceilings of treatment (the maximum level of treatment a patient is set to receive) should be reserved for the registered nurse?

Question 7

Do you think that clinical discussion relating to predictable cardiac arrest and do not attempt cardio-pulmonary resuscitation decision-making should be reserved for the registered nurse?

Question 8

Do you think that professional accountability for the decision to discharge a patient should be reserved for the registered nurse, with registered nursing associates only participating in elements of the discharge process?

Question 9

Do you think that the decision to refer a patient to another regulated professional or provider should be reserved for the registered nurse, with registered nursing associates only supporting the referral process?

Question 10

Nine specific questions have been posed. If you consider there are vital aspects for consideration, which are important parameters of practice, which have not been addressed, please use the space below to raise them.

Question 11

We would like to know your views on the effects that an agreed parameters of practice might have on the Welsh language, specifically on:

• opportunities for people to use Welsh
• treating the Welsh language no less favourably than English

Question 12

Please also explain how you believe the parameters of practice could be formulated to have:

• positive effects or increased positive effects on opportunities for people to use the Welsh language and on treating the Welsh language no less favourably than the English language
• no adverse effects on opportunities for people to use the Welsh language and on treating the Welsh language no less favourably than the English language

Question 13

We would like to know your views on the impact that the parameters of practice might have on groups with protected characteristics.

Protected characteristics are: age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex, and sexual orientation.

• Do you think that the contents of this consultation will have any positive impacts on groups with protected characteristics? If so, which and why/why not?
• Do you think that the contents of this consultation will have any negative impacts on groups with protected characteristics? If so, which and why/why not?

Submit your comments by 11 December 2024, in any of the following ways:

• complete our online form
• download, complete our response form and email qualityandnursing@gov.wales
• download, complete our response form and post to:

Quality and Nursing Directorate
Welsh Government
Cathays Park
Cardiff
CF10 3NQ

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Data Protection Officer
Welsh Government
Cathays Park
Cardiff
CF10 3NQ

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SK9 5AF

Telephone: 03031 231 113

Website of the Information Commissioner's Office.

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Number: WG50275.

Large print, Braille and alternative language versions of this document are available on request.

Contact details

For further information:

Quality and Nursing Directorate
Welsh Government
Cathays Park
Cardiff
CF10 3NQ

Email: qualityandnursing@gov.wales 

This document is also available in Welsh.

[1] In this context, "holistic" means an approach which considers multi-dimensional aspects of health and well-being, recognising the whole person from a physical, mental, emotional, psychological, social, intellectual and spiritual perspective.