Over the past few weeks, I have read with interest several posts and questions unfolding on aesthetic forums from practitioners who have been approached to prescribe for nursing associates who wish to, or already do, work in aesthetic practice. I decided to dig a little deeper and examine the role of the nursing associate and where they might fit into this already diverse and underregulated sector.
The nursing associate is a relatively new role. They are members of the nursing team in England and help to bridge the gap between health and care assistants and registered nurses. The role concentrates on the core work of nursing, leaving the registered nurse to focus on more complex clinical care. The programme to train nursing associates started in 2017, and approximately 700 people were eligible to apply to the Nursing and Midwifery Council (NMC) to register in early 2019. Around a further 800 joined the register in 2019. The first cohort did not have a qualification from an NMC-approved programme, but they were assessed against the NMC's standards of proficiency (2018a) under a provision in NMC legislation (article 13A) to allow for specific groups of pre-regulation applicants to apply to register. These included individuals on Health Education England (HEE) pilots or nursing associate apprenticeships who started their courses before July 2019. This cohort was assessed with a competence-based test (CBT) and the observed structured clinical examination (OSCE). There are now several NMC-approved programmes in England, and the role is unique to England and is not operating in other parts of the UK.
The NMC Code was updated in October 2018 to reflect the regulation of nursing associates (NMC, 2018). Nursing associates are a distinct profession with their own part of the register, but they are part of the nursing team. Table 1 outlines two sets of standards, the first for registered nurses and midwives and the second for nursing associates (NMC, 2021a; 2021b).
Table 1. Registered nurses and nursing associates standards
| Future nurse: standards of proficiency for registered nurses (Nursing and Midwifery Council, 2021a) | Standards of proficiency for nursing associates (Nursing and Midwifery Council, 2021b) |
|---|---|
| Being an accountable professional Registered nurses act in the best interests of people, putting them first and providing nursing care that is person-centred, safe and compassionate. They act professionally at all times and use their knowledge and experience to make evidence-based decisions about care. They communicate effectively, are role models for others and are accountable for their actions. Registered nurses continually reflect on their practice and keep abreast of new and emerging developments in nursing, health and care.They demonstrate the knowledge, skills and ability to think critically when applying evidence and drawing on experience to make evidence-informed decisions in all situations. | Being an accountable professional Nursing associates act in the best interests of people, putting them first and providing nursing care that is person-centred, safe and compassionate. They act professionally at all times and use their knowledge and experience to make evidence-based decisions and solve problems. They recognise and work within the limits of their competence and are responsible for their actions.They recognise and report any factors that may adversely impact safe and effective care provision. |
| Promoting health and preventing ill health Registered nurses play a key role in improving and maintaining the mental, physical and behavioural health and wellbeing of people, families, communities and populations. They support and enable people at all stages of life and in all care settings to make informed choices about how to manage health challenges to maximise their quality of life and improve health outcomes. They are actively involved in the prevention of and protection against disease and ill health and engage in public health, community development and global health agendas and in the reduction of health inequalities. | Promoting health and preventing ill health Nursing associates play a role in supporting people to improve and maintain their mental, physical, behavioural health and wellbeing. They are actively involved in the prevention of and protection against disease and ill health and engage in public health, community development and in the reduction of health inequalities. |
| Assessing needs and planning care Registered nurses prioritise the needs of people when assessing and reviewing their mental, physical, cognitive, behavioural, social and spiritual needs. They use information obtained during assessments to identify the priorities and requirements for person-centred and evidence-based nursing interventions and support. They work in partnership with people to develop person-centred care plans that take into account their circumstances, characteristics and preferences. | Provide and monitor care Nursing associates provide compassionate, safe and effective care and support to people in a range of care settings. They monitor the condition and health needs of people within their care on a continual basis in partnership with people, families and carers. They contribute to ongoing assessment and can recognise when it is necessary to refer to others for reassessment. |
| Providing and evaluating care Registered nurses take the lead in providing evidence-based, compassionate and safe nursing interventions. They ensure that the care they provide and delegate is person-centred and of a consistently high standard. They support people of all ages in a range of care settings. They work in partnership with people, families and carers to evaluate whether care is effective and whether the goals of care have been met in line with their wishes, preferences and desired outcomes. | Working in teams Nursing associates play an active role as members of interdisciplinary teams, collaborating and communicating effectively with nurses, a range of other health and care professionals and lay carers. |
| Leading and managing nursing care and working in teams Registered nurses provide leadership by acting as a role model for best practice in the delivery of nursing care. They are responsible for managing nursing care and are accountable for the appropriate delegation and supervision of care provided by others in the team, including lay carers. They play an active and equal role in the interdisciplinary team, collaborating and communicating effectively with a range of colleagues | Improving safety and quality of care Nursing associates improve the quality of care by contributing to the continuous monitoring of people's experience of care. They identify risks to safety or experience and take appropriate action, putting the best interests, needs and preferences of people first. |
| Improving safety and quality of careRegistered nurses make a key contribution to the continuous monitoring and quality improvement of care and treatment to enhance health outcomes and people's experience of nursing and related care. They assess risks to safety or experience and take appropriate action to manage these, putting the best interests, needs and preferences of people first. | Contributing to integrated care Nursing associates contribute to the provision of care for people, including those with complex needs. They understand the roles of a range of professionals and carers from other organisations and settings who may be participating in the care of a person and their family, as well as their responsibilities in relation to communication and collaboration. |
| Coordinating care Registered nurses play a leadership role in coordinating and managing the complex nursing and integrated care needs of people at any stage of their lives, across a range of organisations and settings. They contribute to processes of organisational change through an awareness of local and national policies. | |
Nursing procedures
|
Procedures to be undertaken by the nursing associate
|
In a health service that is currently overstretched, there is definitely a place for the nursing associate. It can be compared to the enrolled nurse, a role that was phased out in the 1990s. Demand for a statutorily recognised second level nursing qualification began in the 1930s, when hospitals were reluctant to recruit ‘expensive’ registered nurses and were making use of various unqualified aides (Brown, 1994). The second level qualification had a much shorter training period of approximately 18 months. Wartime shortages led to legislation giving the UK Nursing Councils (later the United Kingdom Central Council for Nursing, Midwifery and Health Visiting) the power to approve shortened training courses and admission to a new roll of assistant nurses (Seccombe et al, 1997). The two statutory levels, the register and the roll were immediately accepted in England and Wales but much later in Scotland and Northern Ireland (1948 and 1952, respectively). In 1962, the term assistant was removed and given a new title of state enrolled nurse. Entry requirements for nursing were confirmed as two O levels for enrolled nurses and five O levels for registered nurses. It could be said that the shortfall of late and the demise of the bursary payments to nurses undertaking training has created the need to fill the gaps in the workforce. Nursing associates should be able to bridge the void, certainly in traditional areas of nursing: the hospital, the care home and within the community. Yet, I come back to my original question: where do associate nurses fit into aesthetic practice, and do we, as nurses, prescribe for them?
I refer back to the NMC standards (2021a; 2021b) and the code (2018), as well as the need for clinical decision-making, oversight and accountability. In aesthetic practice, many of us employ therapists to administer treatments. As nurses, we delegate tasks, but would you extend this to a therapist not in your employment? For me, the answer is most certainly no. I see extending this delegation as no different to providing clinical oversight for nursing associates and, again, unless they were in my employment, I would not. Ultimately, the accountability and the decision to be made rests with us the registered nurse. Nursing is changing and aesthetics is evolving, but, ultimately, we are patients' custodians and advocates, and we must always put them first.