nursing associate essay example

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Writing a personal statement for a Nursing Associate application

This is your chance to set yourself apart from the competition - sell yourself..

Your personal statement is your chance to set yourself apart from the competition.

First of all, remember your personal statement should be  personal . This is your chance to sell yourself and explain to the university why you are a potential nursing associate.

You should avoid plagiarising content from another applicant’s personal statement – even if you have their permission. Similarity detection software can be used to highlight any duplication and it could lead to your application being rejected.

Treat it like an essay. Before you start writing, take the time to make bullet points of everything you want to include and order them in terms of importance.

Make sure you have done your research – look at the admissions criteria and read through the professional standards that are set out by the Nursing and Midwifery Council.

Your personal statement should flow and have a clear introduction and ending.

Be honest! Exaggerating or including fictional situations in your application could catch you out at a later point.

Play to your strengths.

Tell them who you are.

Discuss the personal values and qualities you hold that are needed to become a good nursing associate and show evidence of these.

There is likely to be some emphasis on a values-based selection process that demonstrate how your own values and behaviors align with the seven core values of the  NHS Constitution .

Only mention interests or hobbies that reveal something relevant about you.

Avoid being too generic – “I am a caring person” or “I like caring for people” doesn’t offer the interviewer any insight.

Why do you want to be a Nursing Associate?

Speak with passion but try to avoid clichés.

There is so much more to being a nursing associate than giving our medications – show you understand the reality of being a registered healthcare professional in the twenty-first century.

Demonstrate you understand the demands the course will have – placements with a mixture of shifts alongside academic writing and pracitcal learning.

Speak about any existing care experience you might have that gives you an insight into the role.

If you have attended an open day or recruitment event – mention it.

Relevant interests, skill and experience.

Don’t simply list things you have done – you need to relate it to the role.

Transferable skills are key. Take any relevant interests, skills and experience you have and demonstrate how they are transferable to your chosen career.

Discuss and evidence your communication, organisational and time management skills.

Mention key professional issues.

Taking a look at one of the many nursing or midwifery professional magazines or speaking to somebody already on the course can help you identify any current professional issues – but try to stay away from politics.

Ensure you relate any relevant content to the Nursing and Midwifery Code of Conduct alongside professional values such as  the ‘Six C’s’ .

Understand the limitations of the role and how the role came about.

Talk about your ambitions.

The competition for the nursing associate courses is fierce, and consequently, they want to ensure only candidates who genuinely want to become a nursing associate are successful.

You don’t have to have a dedicated ‘five-year plan’ but having an idea of what interests you about the profession is a good start.

Make it clear you would strike to provide good quality and evidence-based care.

Avoid getting caught up in the moment and submitting your application without checking it.

Correct spelling and grammar is absolutely vital and demonstrates you have taken care and attention on your application.

Try to include in-line citations if you refer to a study, document, policy or procedure.

Follow CustomWritings.com can help you write your nursing school personal statement.

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Nursing Essay Examples

Nursing Essay Examples That Will Help You Write a Stellar Paper

Published on: May 6, 2023

Last updated on: Jan 29, 2024

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Many nursing students struggle with writing effective nursing essays, which are an essential part of their education and professional development.

Poor essay writing skills can lead to low grades and an inability to effectively communicate important information.

This blog provides a comprehensive guide to writing nursing essays with examples and tips for effective writing. Whether you are a nursing student or a professional looking to improve your writing skills, this blog has something for you. 

By following the tips and examples provided, you can write compelling nursing essays that showcase your dedication to the field.

Let’s get started.

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What is a Nursing Essay?

A nursing essay is a type of academic writing that aims to explore a particular topic related to nursing. It also presents a clear and concise argument or viewpoint supported by evidence. 

Nursing essays can take many forms, including:

• Descriptive essays
• Reflective essays
• Analytical essays
• Persuasive essays

What is the Importance of the Nursing Essay?

Nursing essays are important for several reasons. First, they help nursing students develop critical thinking skills by requiring them to analyze and evaluate information.

Second, they help students develop research skills by requiring them to locate and use credible sources to support their arguments. 

Third, nursing essays help students develop communication skills by requiring them to present their ideas clearly and concisely in writing. Finally, nursing essays are important for nursing education because they prepare students for the types of writing.

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To help students better understand how to write nursing essays, it can be helpful to review examples.

Below are some examples of nursing essays.

Nursing School Essay Examples

College Nursing Essay Examples

Graduate Nursing Essay Examples

Nursing Scholarship Essay Examples

Nursing Essay Conclusion Examples

Nursing Essay Examples of Different Fields

Nursing is a diverse field with many different specialties and areas of focus. As a result, nursing essays can take many different forms and cover a wide range of topics. 

Given below are some examples of different types of nursing essays:

Personal Philosophy Of Nursing - Essay Examples

Cal State Fullerton Nursing Essay Examples

Evidence Based Practice Nursing In Medical Field - Essay Examples

Leadership In Nursing And Healthcare Professionals - Essay Examples

Principles Of Professional Practice Of Nursing Professionals And Pharmacists

If you're seeking additional examples of nursing essays, you're in luck! 

Below are some more examples that can help you gain a better understanding of nursing essays:

Health Care And Reflective Models For Nursing - Essay Examples

History Of Nursing Essay Examples

Ethical Dilemma In Nurses Work - Essay Examples

Mental Health Nursing Essay Examples

Why I Want To Be A Nurse Essay

Working In A Team And Collaboration In Nursing

How to Write a Nursing Essay

Writing a nursing essay can seem daunting, but with the right approach, it can be a rewarding experience.

Here are the key steps involved in writing a nursing essay:

Understanding the Topic and Question

The first step in writing a nursing essay is to carefully read and understand the topic and question. 

This will help you determine what information you need to research and include in your essay. Make sure you understand any key terms or concepts related to the topic. Consider different perspectives or viewpoints that may be relevant.

Researching the Topic

Once you have a clear understanding of the topic and question, it's time to research. 

Start by gathering information from credible sources such as academic journals, textbooks, and government websites. 

Consider both primary and secondary sources, and make sure to take detailed notes as you read.

Organizing and Outlining the Essay

Once you have completed your research, it's time to organize your ideas and create an outline for your essay. 

Start by identifying the main points or arguments you want to make, and then organize them into a logical order that flows well. 

Your outline should include an introduction, body paragraphs, and a conclusion.

Writing the Essay

With your outline in place, it's time to start writing your essay. Make sure to follow your outline closely, and use clear and concise language that effectively communicates your ideas. 

Use evidence from your research to support your arguments, and cite your sources appropriately.

Editing and Revising the Essay

Once you have completed a first draft of your essay, take some time to edit and revise it. Look for any errors in grammar, spelling, or punctuation, and make sure your essay is well-organized and flows well. 

Consider asking a peer or instructor to review your essay and provide feedback.

What To Include In Your Nursing Essay

When writing a nursing essay, there are several key elements that you should include. Here are some important things to keep in mind:

• Introduction

Your introduction should provide a brief overview of the topic and purpose of your essay. It should also include a clear thesis statement that presents your main argument or point of view.

• Background Information

Provide some background information on the topic to help the reader better understand the context of your essay. This can include relevant statistics, historical information, or other contextual details.

• Evidence and Examples

Use evidence and examples from your research to support your arguments and demonstrate your knowledge of the topic. Make sure to cite your sources appropriately and use a variety of sources to strengthen your argument.

• Analysis and Evaluation

Provide analysis and evaluation of the evidence and examples you've presented. This can include discussing strengths and weaknesses, comparing and contrasting different viewpoints, or offering your own perspective on the topic.

Your conclusion should summarize the main points of your essay and restate your thesis statement. It should also offer some final thoughts or suggestions for further research or action.

Nursing Essay Topic Ideas

Choosing a topic for your nursing essay can be challenging, but there are many areas in the field that you can explore. Here are some nursing essay topic ideas to consider:

• The role of technology in nursing practice
• The impact of cultural diversity on healthcare delivery
• Nursing leadership and management in healthcare organizations
• Ethical issues in nursing practice
• The importance of patient-centered care in nursing practice
• The impact of evidence-based practice on nursing care
• The role of nursing in promoting public health
• Nursing education and the importance of lifelong learning
• The impact of nursing shortages on healthcare delivery
• The importance of communication in nursing practice

These are just a few ideas to get you started. You can also explore other topics related to nursing that interest you or align with your academic or professional goals. 

Remember to choose a topic that is relevant, interesting, and feasible to research and write about.

Tips for Writing an Effective Nursing Essay

Writing a successful nursing essay requires careful planning, research, and attention to detail. Here are some tips to help you write an effective nursing essay:

• Writing Concisely and Clearly

Nursing essays should be written in clear and concise language, avoiding unnecessary jargon or technical terms. Use simple language and short sentences to help ensure that your ideas are communicated clearly and effectively.

• Stating a Clear Thesis Statement

Your thesis statement should clearly state your main argument and provide a roadmap for the rest of your essay. It should be clear, concise, and located at the end of your introduction.

• Using Proper Citation and Referencing

Citing and referencing your sources is crucial in any academic writing, including nursing essays. Make sure to use proper citation and referencing styles, such as APA or MLA. Include a reference list or bibliography at the end of your essay.

• Seeking Feedback and Revising

Before submitting your nursing essay, seek feedback from peers, professors, or writing tutors. Use their feedback to revise and improve your essay. Make sure that it is well-structured, coherent, and effectively communicates your point of view.

By following these tips, you can write a nursing essay that demonstrates your knowledge and skills in the field.

In conclusion, writing a successful nursing essay requires careful planning, research, and attention to detail. 

To showcase your knowledge in the field of nursing, it is important to have a clear understanding of the topic at hand. When writing your nursing essay, be sure to include relevant examples, incorporate current research, and use proper citation and referencing. 

And remember , seeking feedback and revising your essay is key to ensuring that it effectively communicates your ideas and arguments.

If you need help with your nursing essay or any other type of academic writing, consider using our AI essay writer . 

Our nursing essay writing service can provide personalized support to help you succeed in your academic goals.

So, why wait? Contact us to get college essay writing help today! 

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• Research article
• Open access
• Published: 26 August 2020

Motivations, experiences and aspirations of trainee nursing associates in England: a qualitative study

• Rachel King   ORCID: orcid.org/0000-0003-4012-0202 1 ,
• Tony Ryan 1 ,
• Emily Wood 1 ,
• Angela Tod 1 &
• Steve Robertson 1  

BMC Health Services Research volume  20 , Article number:  802 ( 2020 ) Cite this article

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The nursing associate role was developed in England in response to the ‘Shape of Caring’ review. It has been implemented to fulfil two aims; to bridge the gap between registered nurses and healthcare assistants, and to provide an alternative route into registered nursing in light of workforce shortages.

Other high income countries deploy second level nurses within their healthcare systems, however the UK has a turbulent history with such roles. The previous state enrolled nurse was phased out in the 1990s, and more recently the assistant practitioner (AP) role has faced wide variation in titles, scope and pay. Little is known about those who have embarked on the new nursing associate training course and their experiences of the role.

An exploratory qualitative study was undertaken using focus groups of trainee nursing associates to generate in-depth discussion about their motivations, experiences of training, and career aspirations.

Three focus groups ( n  = 15) took place in December 2018 using a purposive sample of trainee nursing associates registered at a University in the North of England. Two researchers facilitated each group discussion at a time and place convenient for participants. The discussions were audio recorded, transcribed and data was analysed thematically.

This study found that trainee nursing associates are motivated by affordable, local, career development. During training they face challenges relating to clinical support, academic workload and uncertainty about future career opportunities. They experience role ambiguity both individually and across the wider organisation. Trainee nursing associates rely on broad support networks to build their occupational identity.

Conclusions

The barriers and facilitators of trainee nursing associate personal development have implications for policy and practice relating to recruitment and retention. The results increase our understanding of this emerging role, and have informed the development of a larger longitudinal cohort study. Further research is required to evaluate the impact of this new role.

Peer Review reports

The nursing associate (NA) role has been introduced in England in response to recommendations set out in the ‘Shape of Caring’ review [ 1 ]. The aim of the role is twofold; to bridge the gap between healthcare assistants (HCAs) and registered nurses (RNs), while simultaneously offering an alternative route into nursing. This is particularly important in the current context, as the UK health service is under increasing pressure due to an aging population and workforce shortages [ 2 ].

Little is known about the new NA role as the first students only qualified in January 2019, however lessons can be learned from previous research on similar roles such as the state enrolled nurse (SEN) and assistant practitioner (AP).

NA training combines academic and work-based learning, incorporating all four fields of nursing [ 3 ]. A service evaluation of 39 trainee nursing associates (TNAs) in the Northeast of England raised a number of important issues related to TNAs, including role clarity, placement models, mentorship and protected learning time [ 3 , 4 ]. A larger internal evaluation of the TNA pilot programme has recently been commissioned by Health Education England [ 5 ]. The current study builds on these previous evaluations, exploring the motivations, experiences and aspirations of trainee nurse associates (TNAs) in one particular Higher Educational Institute (HEI), and makes suggestions for future research on this emerging role.

The healthcare workforce in the UK has experienced a significant shift from traditional role boundaries over recent years. Nurses have taken on more medical tasks and, consequently, HCAs have adopted more advanced skills in patient care [ 6 ]. The introduction of NA training has offered HCAs the opportunity of formal career development [ 1 ]. Two pilot cohorts of TNAs, with around 1000 trainees each, were funded across 35 sites in England in January 2017 and April 2017 [ 7 ], with the first student qualifying in January 2019. Since then an apprenticeship model has been introduced with an additional 5000 trainees recruited in 2018, and plans for a further 7500 by 2020 across England [ 8 ].

Globally HCAs and similar support roles have lacked formal training and opportunities for career progression [ 1 , 9 , 10 ]. One US study, found that despite high aspirations to become RNs, few support workers progressed their careers within the healthcare setting [ 10 ]. However, career development, further education, and increased wages are all motivators for progression if given the opportunity [ 10 , 11 , 12 ].

Nursing workforce shortages of more than 40,000 are a growing concern [ 13 ]. There are currently 100,000 vacancies across the NHS in England, with a predicted rise to 350,000 by 2030 [ 2 ]. In the UK, applications to study nursing, particularly among mature students, have fallen since the removal of the student bursary and many nurses are leaving the profession due to difficult working conditions, exacerbated by poor staffing levels [ 14 ]. There has been a 30% increase in support staff (compared to 10% increase in nurses), since 2013, as organisations attempt to meet increasing patient need [ 15 ]. In this context, some have raised concerns that substitution of RNs with less well trained staff is unlikely to provide an effective solution to the nursing workforce crisis [ 16 ]. One policy assumption is that 50% of NAs will go on to become RNs, with the transition to RN being smoother and with lower attrition rates than other student nurses [ 1 , 7 , 17 ].

Several other high income countries such as the USA, Australia and New Zealand deploy second level nurses with varying titles such as enrolled nurses, licenced vocational nurses, or licenced practical nurses [ 18 ]. In the UK, the new NA role has been compared to both state enrolled nurses (SENs) and assistant practitioners (APs) [ 19 , 20 ]. The SEN role was phased out in the 1990s after the restructuring of nurse education following criticism of its lack of career progression and the limitations imposed by employers in narrow interpretations of role competencies [ 19 , 20 ]. More recently the assistant practitioner (AP) role was introduced [ 6 ], however it has experienced wide variation in titles, scope of practice and pay due to a lack of national regulation [ 21 , 22 ].

TNAs gain a Foundation Degree over 2 years and, unlike APs, are required to register with the NMC, gain clinical exposure and experience in all fields of nursing, and adhere to the standards of proficiency for nursing associates [ 23 ]. Griffiths and Robinson [ 24 ] argue that national regulation of such bridging roles would improve patient safety by ensuring mandatory, standardised training, controlling access to employment, and clarifying the scope of practice.

New roles in healthcare are associated with widespread ambiguity [ 9 ]. One mechanism by which healthcare workers can support each other is through a community of practice. These occur either formally or informally, with the common aims of improving practice and exchanging knowledge. Characteristics of communities of practice include social interaction, knowledge sharing, knowledge creation, and identity building [ 25 ]. Naturally occurring communities of practice can be exploited by formally developing them for the purpose of translating knowledge into action [ 26 ]. The current study contributes to the emerging evidence base on an under-researched area of workforce development.

The aims of this study were to explore TNA motivations, experiences, and career aspirations, and to generate data that will inform future research, including the development of a larger longitudinal cohort study.

This exploratory study used qualitative research approaches including focus group discussions with TNAs and thematic analysis techniques [ 27 ]. Focus groups are commonly used in exploratory research [ 28 ], and are particularly useful in generating data through group interaction which progresses back and forwards, producing deeper levels of response than can be gained from individual interviews [ 29 ]. The questions used to guide the focus group discussions are presented in Table  1 .

Purposive sampling was used to select TNA participants. The sampling frame included all TNAs registered on two cohorts at a University in the North of England. The first group were from the April 2017 pilot cohort and the second group were from the June 2018 apprenticeship cohort. Sampling aimed to achieve maximum diversity in terms of age, gender, and previous health care work experience. Table  2 shows that this was only partially achieved and that the groups were very homogenous in terms of ethnicity, relatively homogenous in terms of prior working background, but more heterogeneous in relation to gender and age.

Recruitment

All TNAs on the two programmes were sent information sheets via email and those interested in taking part were requested to contact the research team directly. A £10 gift voucher was offered to each participant, not as a payment incentive to participate but as a small token of recognition for the time they had given as is common in qualitative studies. Fifteen TNAs agreed to take part in the study out of a total of 70 students. Three focus groups were undertaken, one from the first cohort and two from the second cohort (to ensure convenience for students at different sites). In line with suggested guidelines for qualitative research, the numbers in studies focusing on experiences should be big enough to demonstrate patterns across a data set but small enough to retain a focus on individual experiences ([ 30 ] p.45). We believe a group of 15 TNA’s provides this balance and data analysis suggests the same in terms of reaching saturation of themes. These same guidelines recommend between 2 and 4 focus groups for studies using a thematic analysis design ([ 30 ] p.50).

Data collection

Focus groups took place in December 2018, at times and academic settings convenient for participants. They were led by two facilitators, one male and one female, using a topic guide (see Table 1 ). The topic guide covered TNAs’ reasons for applying to the course, experiences of the role (whether it met expectations, differences compared to previous roles, learning in practice), and future career aspirations. The topic guide was piloted with a TNA lecturer and a TNA.

Three focus groups were undertaken, one from the first cohort and two from the second cohort, as this second cohort was split geographically across health care education sites. The focus group discussions lasted between 42 and 60 min and were audio-recorded [ 28 ]. Each group contained 3 to 9 individuals (see Table 2 ), which is within acceptable parameters for focus groups [ 28 ].

Quieter participants were prompted to ensure that each member had the opportunity to contribute to discussions. The stages of the focus groups followed those set out by Ritchie et al. [ 29 ], including introducing ourselves and setting ground rules, participant introductions, conducting the discussion, and ending the discussion, with opportunities to add anything else.

Data analysis

The focus groups ran sequentially and preliminary analysis was undertaken in between the three sessions. By the third focus group, no new categories or themes were emerging and data saturation was therefore reached [ 29 ]. Quirkos v1.5.2 software was used to manage the data. Data was analysed thematically using the six steps outlined by Braun and Clarke [ 27 ]. Coding and categorising were completed independently by one researcher. A sub-sample was analysed independently by another researcher, then all authors assisted in finalising the themes. This process helps ensure that the quotes provided are not the idiosyncratic views of individuals but are illustrative of points and themes developed across the dataset. The analysis consisted of both semantic (descriptive) and latent (inferential) levels. Descriptive level analysis took the data at face value and reflected it directly in the results; such as those presented in results section 1.1. Latent analysis provided a further level of interpretation such as that noted in results section 3.1 where the tensions and conflict reported can be understood as representing a wider issue of role ambiguity for the TNAs.

Rigour has been enhanced in this study by undertaking systematic and recognised methods of data collection and analysis, providing a detailed description of the study design, and using researcher triangulation [ 29 ]. The focus group topic schedule was developed following consultation with 10 key stakeholders involved in TNA commissioning, training and deployment, including NHS managers ( n  = 2), university lecturers ( n  = 2), Health Education England commissioners ( n  = 3) and senior members of the Royal College of Nursing ( n  = 3). Two researchers analysed the transcripts and all authors contributed to the development of themes.

Three overarching themes were identified following thematic analysis; facilitators of TNA personal growth; factors restricting TNA development; and TNA role ambiguity. Anonymised data extracts have been used to illustrate the themes.

Facilitators of TNA personal growth

TNAs in this study demonstrated personal growth through affordable career progression by developing new knowledge and embracing wider career opportunities.

Affordable career development

Participants had previously worked as healthcare assistants (HCAs) or support workers in diverse fields such as learning disabilities, mental health, surgery, emergency care, orthopaedics, and haematology. Most felt that, prior to undertaking the TNA course, they lacked opportunities for career progression:

“I’d been working as a support worker for years before doing this course … I wanted to develop a bit more, ‘cause as a Band 3 support worker, there aren’t many opportunities to develop or to move into other things.” (Focus group 1 Scott)

As unregistered HCAs and support workers, despite extensive experience, participants lacked investment in their roles, both financially and academically. Linked to this, financial responsibilities such as student loans and dependence on a regular income, had previously limited participants from accessing further training:

“I’ve got a young family so I couldn’t afford to go and get a loan as it is now. I couldn’t even live on a bursary, let alone a loan. So this was the only way of developing for me.” (Focus group 1 Carl)

For many, especially those with family responsibilities, training close to home was important. It was not convenient to move away to advance their careers, therefore they valued the opportunity for progression within their local hospitals:

“I think it’s really good that local hospitals … are willing to train their own staff. I think that’s really positive, rather than having to go where the training is, but they’re investing in their own staff, because healthcare assistants, they do want to progress, don’t they, and, a lot of them, felt like they couldn’t.” (Focus group 2 Jane)

In addition to this desire for career development, some participants viewed the NA role as a mechanism to gain deserved, formal recognition. In this way, the training was important in providing clear justification for increased remuneration:

“I’m quite happy to admit that finances was a massive thing for me, you know, when you’ve been ten years at the top of your band and you’ve been in a pay freeze in the NHS … I think it’s perfectly understandable when you’ve got a young family to think, I want a bit more money for what I’m doing.” (Focus group 1 Carl)

TNAs who were well established in their previous roles were not in a position to reduce their income, take on debt, or move locality, so NA training provided an option for progression that many felt they would never experience.

New knowledge and opportunities

In addition to the opportunity for career promotion, TNAs also valued the development of new knowledge. They talked about having experienced personal growth through developing new knowledge, skills and opportunities. There was clearly frustration with the constraints of their previous roles and many desired to develop skills to more effectively support registered nurses in improving patient care:

“I think you sort of get stuck in a bit of a rut when you’ve worked on a ward for so long and then you’re just doing your normal everyday jobs in your little role. I got a bit fed up of just doing my bit and then seeing the nurses struggle and I wanted to be able to do more to support them better, so really excited when this course came up.” (Focus group 2 Julie)

Several participants reflected on how their increased knowledge led to greater confidence in providing patient care. For example, one TNA explained how she is better placed to provide relevant information to patients and their relatives:

“If there were phone calls before I’d have to go and find a nurse to discuss with whoever was on the other end of the phone, whereas now I can take responsibility for that call. Or if somebody asks for pain relief, I can look at the drug chart and I can understand what they’ve had, what medication they’ve got left to have. I don’t have to go and find a nurse.” (Focus group 2 Julie)

In addition to developing new knowledge, TNAs experienced a range of new opportunities during their training, from the wide variety of clinical placements to travelling to conferences.

These experiences not only helped build confidence in delivery of patient care, but also influenced future career aspirations. Some TNAs were content to work in a role that bridged the gap between healthcare assistant and registered nurse, planning to return to their previous workplace.

“I’m quite happy there. And at the moment, I don’t really have any, sort of … any thoughts of leaving ‘cause I enjoy it. Yeah.” (Focus group 1 Scott)

Others also planned to continue to work as NAs but in new settings, and some aspired to undertake further training to transition to RNs. Through undertaking a range of placements, TNAs gained insights into a variety of healthcare settings, providing greater possibilities for future career choices:

“I’ve been to endoscopy and I absolutely loved endoscopy, and I wouldn’t have seen that if I’d just been a HCA on my ward. Whereas district nursing I love that and just going and doing all the different things. It was very interesting. It gives you a wider scope of where you might want to go in the future.” (Focus group 3 Sally)

Around two-thirds of the TNAs in this study expressed an interest in becoming registered nurses:

“Yeah, I do want to do my nursing. So as soon as the opportunity comes up I’m probably going to take it, but for the time being … I really want to just get into a job, work for a little bit... So yeah, that’s what I’m thinking.” (Focus group 2 James)

There was a clear passion for career development among TNA participants, driven by a lack of developmental opportunities in their previous roles and made available through training that was funded and offered locally.

Factors restricting TNA development

These TNAs were pioneers in their workplaces, lacking role models to emulate or embedded systems of support. Therefore they faced novel challenges relating to their development, such as placement concerns, academic pressures, and unclear career progression.

Placement variations and academic pressures

Participants raised several concerns relating to clinical placements, including how they were organised. Those based at a single site, with short ‘alternative’ placements throughout the 2 years described being settled in their role compared to those who moved base placements every 6 months and experienced associated anxiety:

“It was terrifying moving away from places you’ve been, well, for ages and then to go into a different place, meet new people, then lose those people, off again, start again in six months’ time.” (Focus group 2 James)

The experience of mentorship and general support during placements was also a concern for some. For example, one TNA identified that her mentors did not have the required qualifications to legitimately support their practice:

“I was given two mentors but then I got onto the ward and found out that they’ve not actually passed their mentorship course, so I ended up with nobody. For six months I’ve not had anybody.” (Focus group 3 Hannah)

Others expressed a general feeling of being ‘in the way’ during their clinical placements. Workplaces lacked experience of supporting TNAs, therefore they felt burdened by the task.

“They all run the other way when they say, “oh will you work with so and so”, they reply “oh no, I’m not doing that!”” (Focus group 3 Kim)

TNAs experienced variations in supernumerary status and protected learning time during their placements, which, they felt, impacted on their development:

“Because we’re counted in the numbers, I don’t think we get as much opportunity as we’d like. I think that’s the biggest issue for me.” (Focus group 2 Julie)

A lack of protected learning time was viewed by some as a barrier to learning. Several participants had limited experience of university and associated academic pressures. Such pressures were highlighted as significant in terms of the level of study but also in terms of the time commitment, alongside their clinical work:

“You’ll be doing assignments, you’ve got exam revision. And there’s not enough hours. A lot of people naively came into it not expecting that, and I think that’s where a lot of upset was caused: well, how am I going to do this, why am I not having a day to do it.” (Focus group 3 Hannah)

It is clear that TNAs were enthusiastic about the opportunities to develop their role but faced disappointments in their placement and academic pressures.

Unclear career progression

Despite high aspirations to transition to RNs, all participants expressed a lack of clarity about how to access the training. They were unsure whether a transition course would be university-based or distance learning.

“I asked last week and somebody said that they [tutors] would potentially be writing something while we’re doing this class for a top up. If not it could be like a home learning thing where you stay on your base placement.” (Focus group 3 Anna)

There was also uncertainty about job opportunities. Participants described competition for jobs and a lack of choice with options governed by areas of high nursing staff shortages:

“You’re under the impression that basically you can pick where you’re going to go. In reality, the NAs that are due to qualify at [town] have been given jobs in cardio and respiratory where they’re short staffed.” (Focus group 3 Claire)

It is clearly important for TNAs to have confidence of job security on completion of the course, and clarity around the process of converting their training to becoming registered nurses, however neither are certain.

TNA role ambiguity

TNAs experienced widespread role ambiguity, both personally and within their organisations. However, in mitigating the adverse effects of this lack of role clarity, they value broad support networks, which functioned as naturally occurring communities of practice.

Lack of role clarity

Participants experienced both personal and departmental lack of role clarity. They were often asked to define their role by patients and colleagues.

“Personally the first question nearly everybody asks you when you see them on placement is “what actually is a TNA?”” (Focus group 1 Scott)

“It’s quite stress inducing that though, isn’t it, when you’re trying to explain something you’re not really fully understanding what you’re doing yourself.” (Focus group 1 Carl)

The inability to explain their role highlights a lack of clear occupational identity. One group explained that the difficulty in describing the role to others was compounded by the late introduction of the NA scope of practice, mid-way through their training [ 23 ]. A consequence of this role ambiguity, and perhaps also the lack of supernumerary status, was that TNAs were often expected to work as HCAs during their clinical placements. Their scope of practice sometimes varied throughout the day, and was dependent on the expectations of their managers:

“On some of the placements, it’s like you’ve been sent to learn how to be a healthcare assistant in another setting.” (Focus group 1 Rob)

This illustrates the tension between being a ‘trainee’, with associated learning needs, yet also being counted as part of the workforce and expected to deliver care. The lack of experienced NA role models contributed to role ambiguity:

“You’ve got nobody to follow on from, like I say if you’re … a student nurse, you know what the course is or you know pretty much what it’s going to entail. There’re thousands [of student nurses] everywhere and everybody knows what you’re going to be doing afterwards. For us there isn’t any of that at all.” (Focus group 2 Jane)

In addition to these tensions in role expectations and lack of role models, TNAs perceived that some RN colleagues felt their jobs were under threat by the emergence of the NA role:

“Other people have been saying, like, nurses have felt threatened... I think some RNs on wards are maybe seeing us a cheaper replacement.” (Focus group 1 Rob)

This suggests a lack of consultation and education across organisations regarding workforce changes prior to implementation of the NA role. Participants also found that more experienced RNs compared the NA role to the previous SEN, generating concerns about the potential transience of the NA role:

“And I think probably more so from like your old school type nurses, older generation, because there was obviously the enrolled nurse, so they like to make sure that it’s not going to be the same as that and it’s just going to phase out again and, well, what’s the point.” (Focus group 2 Jane)

There was a perception that RNs were reluctant to invest their time and effort in mentoring TNAs if the permanence of the role was in doubt. A lack of role clarity by colleagues was clearly a challenge to TNAs, particularly as they were not entirely sure of their scope of practice themselves. This affected both the supervision and expectation of TNAs, and consequently the experience of TNAs. Despite this role ambiguity and associated role conflict, participants viewed the role as a valuable opportunity for career progression and sought out others to legitimise their position in the healthcare team.

Broad support networks

Due to the infancy of the NA role, and subsequent challenges, TNAs relied on broad support networks. These included line managers, academic tutors, and other TNAs (both locally and nationally via social media). Despite some of the problems associated with mentorship, several TNAs received good support from clinical colleagues:

“I’ve had support from all staff, they’ve been going through this journey with us and they’re in the same boat. They’ve had no clue what’s been happening but they’ve all been accommodating.” (Focus group 2 James)

This highlights the value of organisational consensus in choosing to make the role a success, striving to facilitate the career development of HCAs, despite widespread ambiguity. In addition to clinical support, several TNAs talked about the support they gained from good relationships with academic tutors.

They valued a TNA ‘community of practice’ in which to share knowledge, experiences and to support each other. This was particularly important considering the lack of qualified NA role models in their workplaces. Although face-to-face support was important to participants, they also gained a wider perspective of other TNAs nationally through a social media group:

“So we’re part of this Facebook group that’s got all the TNAs in and they were all putting that they were doing all these medications and stuff and we still weren’t allowed to do it.” (Focus group 2 Julie)

This provided insight into how TNAs across England managed a range of challenges related to the new role, for example, regarding medication administration. It is clear that these TNAs were keen for the role to succeed and be recognised as legitimate members of the healthcare team.

England has introduced a new second-level nursing role, similar to many other high income countries [ 18 ]. This study has revealed some of the drivers and challenges faced by student TNAs. TNA personal growth is achieved through affordable local career progression, the acquisition of knowledge and varied workplace opportunities. For some, NA training is seen as the only viable route into nursing in light of the lack of student nurse bursary [ 14 ]. The motivation to increase knowledge and skills is consistent with previous studies which identify a lack of career development opportunities for HCAs and support workers [ 1 , 9 , 10 ].

TNAs face a number of challenges including; lack of mentors, academic pressures and unclear career pathways. The inadequate provision of mentors should not be a problem in the future as changes to the NMC standards will ensure that all new nurses and NAs will qualify with the skills to supervise students [ 23 , 31 ]. The move from ‘supernumerary’ to ‘protected learning time’ time was also raised as an issue by TNAs. This is an inevitable consequence of apprenticeship funding as made clear by the NMC; “The NMC does not require nursing associate students to be supernumerary while learning in practice, but the student must have protected learning time p2” [ 32 ]. It may be that TNAs need to develop negotiating skills to ensure their learning needs are met. A role evaluation has highlighted the need for TNAs to be assertive when seeking learning experiences [ 3 ]. It is important for future studies to explore how ‘protected learning time’ is played out in clinical practice given current contextual pressures.

Furthermore, pathways for career progression were unclear for TNAs. It has been suggested that TNAs could transition to become RNs via an 18-month nursing degree, or two and a half year nursing apprenticeship [ 19 ]. However, TNAs in this study were unsure of where and how to apply for such training. It will be important for further research to explore whether this ambiguity around career progression is a widespread problem for TNAs, and whether development opportunities arise.

Some TNAs experienced a lack of clarity concerning their scope of practice relating to drug administration. Due to the late publication of national guidelines for NA practice [ 23 ], this was particularly problematic for the pilot cohort who were nearing completion of their course. Role ambiguity is clearly an obstacle for TNAs which is consistent with previous research on the similar assistant practitioner (AP) role. Wakefield et al. [ 9 ] identified role ambiguity as a consequence of the lack of regulation and clarity of scope of practice in the AP role. APs have been described as sitting between two occupational spaces; as neither professional staff, due to the lack of regulation, nor support staff, due to the extra responsibilities expected [ 9 ]. Although TNAs also blur boundaries with nursing, they differ from APs as they are regulated with clear standards of practice developed by the Nursing and Midwifery Council, the national professional body for nurses [ 23 ].

Some TNAs perceived that their nurse colleagues felt threatened by the new NA role. Similarly, Traynor et al. [ 6 ] found that the AP role challenged the unique skills previously owned by nursing. The Nursing and Midwifery Council outlines that NAs can undertake many traditional nursing tasks, therefore blurring the boundaries between the roles, but cannot make autonomous decisions about care planning [ 23 ]. Traynor et al. [ 6 ] argue that nursing has retained professional power over APs through a hierarchy of organisational accountability. This is achieved, firstly, by the aspiration of APs to becoming RNs and secondly by the configuration of paraprofessional groups, largely trained by nurses. In the present study, TNAs are similarly trained by nurses, and most aspire to transition to becoming RNs. Therefore, it might be argued that they should not pose a threat to the professional identity of nursing [ 6 ].

TNAs made use of a range of social networks (face-to-face and via social media) forming a community of practice to mitigate the consequences of role ambiguity, and other factors that hindered their development, inevitable in the implementation of new roles [ 33 ]. Previous new roles in healthcare have benefitted from forming communities of practice, which have been found useful in identity building [ 4 , 25 ].

It will be important for future research to explore the impact of academic preparedness and pressures raised in this study and to evaluate the clinical impact of TNAs in terms of inter-professional working, patient satisfaction, and adverse events. The impact on the skill mix change should also be explored.

Limitations

Data collection was limited to three focus groups of TNAs based at one University. TNAs all had backgrounds working as HCAs which may not represent TNAs of the future. Future studies, including the planned longitudinal cohort study, should therefore explore experiences of TNAs from a wider range of organisations and occupational backgrounds.

Affordable local career progression is an important driver for undertaking NA training. TNAs face placement and academic challenges in addition to role ambiguity, finding face-to-face and online support networks crucial to managing these issues.

The growth in numbers of nursing associates (NAs) will undoubtedly impact on the very similar, but unregistered assistant practitioner (AP) role, leading to role confusion. Policy makers should be aware of the factors that promote and hinder TNA development when considering recruitment and retention strategies. Educators and employers should ensure role clarity to improve occupational identity for TNAs, patients and wider healthcare teams. The results from this study will contribute to the global evidence relating to the development of new nursing roles under development in similar healthcare systems.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Assistant Practitioner

Healthcare assistant

Nursing Associate

Nursing and Midwifery Council

Registered Nurse

State Enrolled Nurse

Trainee Nursing Associate

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This project was funded by the Royal College of Nursing (RCN) as part of the Strategic Research Alliance between the RCN and the University of Sheffield. The views expressed are those of the author(s), and not necessarily those of the RCN or University of Sheffield.

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RK, EW, TR, AT and SR planned the study and contributed the background literature. RK, SR, and TR facilitated the focus group discussions. RK and SR analysed the data. TR checked the analysis. All authors read and approved the final manuscript.

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King, R., Ryan, T., Wood, E. et al. Motivations, experiences and aspirations of trainee nursing associates in England: a qualitative study. BMC Health Serv Res 20 , 802 (2020). https://doi.org/10.1186/s12913-020-05676-7

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Writing an Outstanding Application Nursing Essay

Embarking on the path to a nursing career involves navigating through various challenges and significant moments, with the nursing application essay standing out as a key component. This essential part of your application transcends mere formality; it presents a special chance for you to highlight your character, commitment, and aptitude for the nursing profession. In this detailed guide, we aim to explore the intricacies of creating a standout nursing application essay. Whether you’re just starting to explore the nursing field or are ready to submit your application, this article is your roadmap to success.

Understanding the Purpose of the Essay

What do nursing schools seek in your essay.

Nursing schools are looking for candidates with the academic qualifications and personal qualities essential for nursing. Your essay should reflect your compassion, empathy, commitment to the profession, and understanding of the nursing role.

The Essay’s Role in Your Application

Your application essay is your voice in the admission process. It’s where you can speak directly to the admissions committee, tell your story, and explain why you are drawn to the nursing field. This essay can be the deciding factor in your application, setting you apart from other candidates.

Preparing to Write

• Research: Aligning with the School’s Values

Prior to beginning your essay, it’s essential to familiarize yourself with the fundamental ideals and beliefs of the nursing school you’re applying to. Spend time browsing their website, absorbing their mission statement, and comprehending their perspective on nursing education. This crucial insight will help you tailor your essay to resonate with the school’s philosophy. This research will help you tailor your essay to resonate with their ethos.

• Self-reflection: Your Nursing Journey

Reflect on your experiences and why you chose nursing. Think about moments in your life that led you to pursue this career. These reflections will help you create an authentic and personal narrative.

• Brainstorming: Crafting Your Story

Take time to brainstorm ideas for your essay. Think about your strengths, experiences, and what aspects of nursing excite you. Make sure to note down these key points; they will be the essential framework for your essay.

Structuring Your Essay

• Introduction: Making a Strong First Impression

The introduction of your essay is your first chance to capture the reader’s attention. Begin with an engaging story, a meaningful personal experience, or a statement that makes the reader think. This approach will offer a window into your personality and highlight your enthusiasm for nursing.

• Body: Building Your Narrative

Organize the body of your essay around a few key experiences or ideas. Each paragraph should focus on a specific aspect of your journey or a particular quality you possess. Use examples from your life to demonstrate your commitment, compassion, and ability to overcome challenges.

• Conclusion: Leaving a Lasting Impression

Your conclusion should wrap up your essay by summarizing the key points and reaffirming your interest and readiness for a nursing career. This is your final chance to remind the admissions committee why you are a suitable candidate.

Writing Tips and Best Practices

• Clarity and Conciseness

Keep your writing clear and concise. Avoid unnecessary jargon and be direct in your storytelling. Remember, the admissions committee reads many essays, so getting your point across quickly is crucial.

• Authenticity: Be Yourself

Your essay should reflect your true self. Don’t try to be someone you’re not. Honesty and sincerity will resonate more than trying to fit a certain mold you think the school wants.

• Using Specific Examples

Provide specific life examples rather than general statements about your passion for nursing. This might include volunteering, personal experiences with healthcare, or moments of inspiration from other nurses.

• Attention to Technical Details

Proofread your essay multiple times for grammar, spelling, and punctuation errors. Also, adhere to the nursing school’s formatting guidelines, such as word count and font size.

Common Mistakes to Avoid

• Steering Clear of Clichés and Generalities

Clichés and overused phrases can make your essay sound generic. Instead, focus on providing unique insights and personal experiences that highlight individuality.

• Directly Answering the Essay Prompt

It’s crucial to stay on topic and answer the essay prompt directly. Deviating from the prompt can lead the admissions committee to question your attention to detail and ability to follow instructions.

• Avoiding Excessive Jargon

Revising and Refining Your Essay

• The Importance of Drafts and Revisions

Your first draft is just the beginning. Be prepared to revise and refine your essay several times. This process helps fine-tune your message and improve the overall flow and clarity.

• Seeking Feedback

Get feedback on your essay from mentors, teachers, or peers. They can provide valuable insights and suggest improvements you might not have considered.

• Final Proofreading

Before submitting your essay, do a thorough proofreading. Check for grammatical errors or typos, and ensure your essay adheres to the specified word limit and formatting requirements.

Crafting your nursing application essay is an opportunity for self-reflection and a chance to convey your zeal for nursing. It’s important to remain authentic, be truthful in your narrative, and allow your sincere passion for nursing to be evident. With careful preparation, thoughtful structure, and attention to detail, your essay can prove your readiness for a nursing career.

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Open access exploring the implementation of the nursing associate role in general practice, annie topping director of nursing, nursing and quality directorate, north east and north cumbria integrated care board, england.

• To refresh your knowledge of the nursing associate role and the reasons why it was introduced

• To recognise the barriers and challenges in implementing the nursing associate role in general practice

• To consider how the nursing associate role could be better supported and more widely accepted in general practice

Background The nursing associate role was introduced to help reduce staff shortages in the NHS by bridging the gap between healthcare assistants and nurses. However, there is evidence that its implementation in general practice has been limited.

Aim To understand why, how and to what extent the nursing associate role has been implemented in general practice and what the barriers and enablers have been.

Method Semi-structured interviews and focus group discussions were conducted with a purposive sample of general practice staff in north east England. Template analysis based on a priori themes drawn from the literature was used to analyse the data.

Findings A total of 17 interviews and three focus group discussions were conducted with 29 GPs, managers, nurses, nursing associates, trainee nursing associates and healthcare assistants from five general practices. The barriers to the implementation of the new role included a lack of clarity about the place and purpose of nursing associates, a mismatch between nursing associate training and practices’ needs, tensions around professional boundaries, and challenges in developing a professional identity.

Conclusion In general practice settings, the role of nursing associate is not yet fulfilling its original purpose and it needs to be better supported, accepted and implemented.

Primary Health Care . doi: 10.7748/phc.2023.e1817

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@nursetopping

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Topping A (2023) Exploring the implementation of the nursing associate role in general practice. Primary Health Care. doi: 10.7748/phc.2023.e1817

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence (see https://creativecommons.org/licenses/by-nc/4.0/ ) which permits others to copy and redistribute in any medium or format, remix, transform and build on this work non-commercially, provided appropriate credit is given and any changes made indicated.

Published online: 29 November 2023

career pathways - community - general practice - nursing associates - primary care - professional - skill mix - support staff - workforce - workforce planning

Workforce shortages in the NHS are frequently under the spotlight, often due to their negative effects on service delivery and patient safety ( Buchan et al 2020 , Rolewicz et al 2022 ). The coronavirus disease 2019 (COVID-19) pandemic has increased the demand on healthcare services and the pressures on the NHS ( Shembavnekar et al 2022 ) but the underlying chronic workforce shortages remain and are an area of concern for policymakers and healthcare service managers.

Despite medical and technological advances, delivering healthcare services remains highly labour-intensive. The government has committed to an expansion of the NHS workforce with more GPs and additional resources for professionals including nurses, physician associates, pharmacists and mental health workers, together with an increase in funding ( NHS 2019 , NHS England 2014 , 2016 ).

The workforce continues to be a significant component of the NHS budget and one of the main factors in the increase of healthcare costs ( Addicott et al 2015 ). In 2019/2020, the total expenditure on NHS staff was £56.1 billion, almost 47% of the NHS budget ( King’s Fund 2023 ). Making the most effective use of this resource is critical.

In recent years, acute workforce issues in nursing and general practice have been reported, and continuing staff shortages and high workloads have caused significant strain ( Buchan et al 2019 , Shembavnekar et al 2022 , King’s Fund 2022 ). These issues have been exacerbated by the COVID-19 pandemic and by the subsequent period of recovery ( King’s Fund 2022 ). A Health Foundation report predicted persistent shortages of practice nurses and GPs amid wider workforce concerns ( Shembavnekar et al 2022 ). To help address GP shortages, a change in skill mix in primary care has emerged as one practical response ( Nelson et al 2018 ).

In 2019, as part of the introduction of primary care networks, it was announced that 26,000 additional non-medical clinical staff would be recruited in primary care by 2023/2024 through the Additional Roles Reimbursement Scheme (ARRS) ( Baird et al 2022 ). The nursing associate role is one of 13 roles eligible for that financial support ( Baird et al 2022 , Francetic et al 2022 ). While some primary care networks have been quick to take up the offer of financial support and recruit new staff, there is evidence of ineffective implementation of the ARRS ( Baird et al 2022 ).

The role of nursing associate was created in response to the Shape of Caring review ( Willis 2015 ), with the intention of bridging the gap between healthcare assistants and nurses ( Nursing and Midwifery Council (NMC) 2023a ). Nursing associates are regulated by the NMC (2023a) and the role only exists in England.

This article describes a study conducted to explore the implementation of the role of nursing associate in general practice. To the author’s knowledge it is the first of its kind. It is intended to inform the future planning and implementation of the nursing associate role and other non-medical roles in primary care and beyond.

Implications for practice

• Skill-mix changes in general practice need to be underpinned by robust workforce planning

• Preceptorship and peer support are needed to facilitate the integration of newly registered nursing associates in general practices

• Integrated care boards, primary care networks and general practices need to work together to clarify the role of nursing associate

• The possibility for nursing associates to administer medicines under a patient group directive needs to be explored

• The structure and contents of nursing associate training programmes must better reflect the needs of general practice

• Public and professional awareness of the nursing associate role could be raised through a media campaign

To understand why, how and to what extent the nursing associate role has been implemented in general practice and what the barriers and enablers have been.

The associated research questions were:

• In establishing (or institutionalising) the nursing associate role, what processes are followed?

• What effect does professional role identity have on the legitimisation process?

• What are the early effects of implementing the nursing associate role?

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.

Table 1.

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:

• General views on the nursing associate role.

• Use of the nursing associate role in daily practice.

• Effects of the implementation of the new role.

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.

In total, 17 interviews and three focus group discussions were conducted with 29 members of staff. Table 2 shows participants’ role and the data collection methods used. All nursing associates had previously been employed by their respective practice as healthcare assistants.

Table 2.

Participants’ role and the data collection methods used.

Five themes emerged from the analysis of the data:

• Motivations for introducing the new role.

• Role purpose, scope and remit.

• Professional identity.

• Barriers to implementing the new role.

• Early effects of the new role.

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.

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.

Studies on the implementation of new roles in healthcare are scarce ( Kessler et al 2017 ) and evidence regarding primary care is generally lacking ( Nelson et al 2018 , Spooner et al 2022 ). This study adds to the evidence in these under-researched areas and to the emerging evidence on the implementation of the nursing associate role in settings other than general practice ( Kessler et al 2020 , 2022 ).

Contrary to the findings of Gibson et al (2023) , the primary reason to implement the role of nursing associate was to address workforce issues, not to increase appointments. In that respect the findings of the present study reflect the rationale given by chief nurses for introducing the role ( Kessler et al 2020 ) and other evidence on introducing new roles in healthcare ( Bungay et al 2013 , Drennan et al 2014 , 2019 , Evans et al 2020 ).

Payment systems can enable skill-mix changes ( Sibbald et al 2004 ) and are used often to encourage the uptake of new roles ( Drennan et al 2019 , Gibson et al 2023 ). However, in the present study financial incentives did not appear to be one of the main motivating factors, which reflects the findings of Gibson et al (2023) . Data from NHS Digital (2022) showed that despite a 41.7% increase in direct patient care staff employed in England under ARRS between March 2019 and March 2022, the numbers of nursing associates and trainee nursing associates remained low overall in March 2022. The actual increase between this period was 0.07% for nursing associates and 0.88% for trainee nursing associates. Furthermore, the author of this article has access to evidence to confirm that many practices have not been taking advantage of the ARRS to introduce trainee nursing associates and nursing associates. This suggests that the financial support may need to be more targeted at specific staff groups to be effective.

Skill mix can be changed in many ways. The findings of the present study support previous research that emphasised the importance of paying attention to the process of implementing skill-mix changes ( Sibbald et al 2004 , Nelson et al 2019 , Maier et al 2022 , Spooner et al 2022 ). They also illustrate how important it is to clarify the scope of new roles, as emphasised by various authors ( Drennan et al 2014 , van der Biezen et al 2017 , Halse et al 2018 , Nelson et al 2018 , Drennan et al 2019 , Maier et al 2022 ).

Professional identity has been described as highly resistant to change ( Chreim et al 2007 ). The relationship between role and professional identity needs to be recognised so that the development of a new role is accompanied by the construction of a professional identity ( Chreim et al 2007 , Goretzki et al 2013 ). In the present study, challenges in the construction of a professional identity included the existence of the well-established role of healthcare assistant, recollections of the defunct role of state enrolled nurse and the absence of a strong narrative for the new role of nursing associate. The lack of peer support networks and preceptorship programmes and the absence of role models for nursing associates in primary care at this early stage compounded the challenges.

A major revision of people’s skills and competencies is necessary before they can adopt a new role ( Sibbald et al 2004 ) and various authors have highlighted that this requires adequate resources ( Halse et al 2018 , Drennan et al 2019 , Kilpatrick et al 2019 , Greenhalgh et al 2020 ). The findings of the present study suggest that current nursing associate training programmes do not meet all the needs of general practices nor those of nursing associates working in general practice. Some participants felt that nursing associates were not ‘practice ready’ on registration and it is possible that nursing associate training programmes are more targeted at the hospital setting. If the nursing associate role is to be expanded in general practice, it is essential that training programmes are tailored to that setting. For example, all nursing associates appear to need additional subject-based training after registration, such as cervical screening, so this needs to be included in their preregistration training.

Some practices seemed unconvinced of the benefits of the nursing associate role, considering the efforts and investment required. The main factor that will determine the scale and pace of any future roll-out of this role in general practice is the presence of demonstrable benefits and added value. Kessler et al (2017 , 2021) similarly concluded that the decision to implement the role would depend on there being evidence of a distinct contribution and improved quality of care.

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.

There is limited evidence regarding the implementation of the nursing associate role, particularly in general practice settings. This study, believed to be the first of its kind, provides insights into why, how and to what extent the nursing associate role has been implemented in general practice. Barriers to its implementation appear to include a lack of clarity about the role, a mismatch between nursing associates’ training and the needs of general practices, the lack of a strong narrative for the role, and the challenges encountered by nursing associates in developing a professional identity.

The author suggests that in general practice the nursing associate role is not yet fulfilling its original policy purpose, and that it needs to be better supported and more widely accepted and implemented.

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Health Foundation. A critical moment: NHS staffing trends, retention and attrition. 2019. https://tinyurl.com/y4gfrwlm (accessed 6 June 2019)

NHS England. NHS Long Term Plan. 2019. https://tinyurl.com/ydh7y999 (accessed 6 June 2019)

NHS Pay Review Body. Thirty-first report. 2018. https://tinyurl.com/ycdkkn9z (accessed 6 June 2019)

Nursing and Midwifery Council. The Code: professional standards of practice and behaviour for nurses, midwives and nursing associates. 2018a. https://tinyurl.com/gozgmtm (accessed 6 June 2019)

Nursing and Midwifery Council. The standards of proficiency for nursing associates. 2018b. https://tinyurl.com/yc4zj8em (accessed 6 June 2019)

The vital role of nursing associates

Patricia Robinson

Senior Lecturer, Community Health Team, Brighton University

View articles

The dangers of a diminishing community nursing workforce have been highlighted in many reports ( NHS Pay Review Body, 2018 ; Health Foundation, 2019 ). Since 2009, there have been significant falls in the numbers of nurses working within community health services, with increased pressure to provide more complex care closer to home. There is now a major drive to implement a new role to support the nursing workforce—that of nursing associates. The number of new nursing associates is projected to increase by 50% in 2019, with 7500 new nursing associates starting on a programme over the year ( NHS England, 2019 ).

The nursing associate role is designed to stand alone alongside the registered nurse workforce; it aims to support but not substitute the registered nurse. Trainee nursing associates (TNAs) undertake a 2-year apprenticeship and, on successful completion, they will join the Nursing and Midwifery Council (NMC) as registrants regulated by a professional code of practice that was updated in 2018 to include this new role ( NMC, 2018a ).

The TNA's journey starts at the work place with their employer prior to application. They apply to the university after completing an internal process with the employer that identifies their role development from a personal development plan and the need for nursing associates from the employer's workforce development plan. The role of the course team in this 2-year foundation degree programme is to nurture the TNA by providing an enriched curriculum to enhance their skills, abilities and professional and personal responsibilities and potential. One of the strengths of the course is that all TNAs are employed, promoting partnership working between the university and employer to support them to complete the course with a recorded qualification with the NMC.

TNAs have a wide range of backgrounds, with a significant number working within community teams, where they work under the leadership of a registered nurse. They work within all aspects of the nursing process, providing high-quality holistic and person-centred care to individuals. They will also support the RN in the assessment, planning and evaluation of care. Additionally, TNAs will be expected to undertake medicines management and develop transferable skills by having external practice.

For those NAs who wish to progress into registered practice, the apprenticeship can provide credits into some higher education programmes and makes them eligible to enter year 2 of BSc Hons Nursing. TNAs will have a registered nurse/nursing associate identified as their practice supervisor throughout practice and a registered nurse/nursing associate practice assessor who can undertake the assessment of skills in practice. A learning agreement will be developed between the TNA and the practice supervisor with support from the university and a personal tutor.

TNAs attend university 1 day a week during term time and have 1 day per week off-the-job training when not attending university. In addition, TNAs must achieve 675 hours of protected learning time in external placements in each of the following areas: in-hospital, close-to-home and at-home care. During the remaining time in their homebase (the primary site where the TNA is employed to work), TNAs receive a minimum of 7.5 hours per week of protected learning time for practice learning (this is in addition to the 7.5 hours of on-the-job-training received each week). The skills outlined in the NMC standards are completed in all the work-based learning settings ( NMC, 2018b ). Struggling community nursing teams should consider supporting the recruitment and development of their own nursing associates as soon as possible.

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Development of the nursing associate professional identity: A longitudinal qualitative study

Rachel king.

1 The School of Allied Health Professions, Nursing and Midwifery, The University of Sheffield, Sheffield UK

2 Winona State University ‐ College of Nursing and Health Sciences, Winona Minnesota, USA

Bethany Taylor

3 Sheffield Centre for Health and Related Research (SCHARR), School of Medicine and Population Health, The University of Sheffield, Sheffield UK

Michaela Senek

Sally snowden, steve robertson, associated data.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

The aim of this study was to understand the factors that contribute to the development of the nursing associate professional identity.

A 3‐year longitudinal qualitative study of trainee nursing associates.

Trainee nursing associates in England were interviewed remotely annually in February 2020, March 2021 and March 2022. They also provided diary entries. Data were anonymised, transcribed and analysed thematically.

Nursing associate professional identity was developed through: increased knowledge, skills and responsibility; and self‐perceptions of identity alongside responses to the role by colleagues. Tensions arose when the scope of practice expected by organisations differed from that expected by the nursing associates. Frustrations occurred when nursing associates were perceived as substitutes for Registered Nurses in the context of nursing workforce shortages.

Nursing associates in this study clearly valued their new knowledge, skills and responsibility, enabling them to provide enhanced patient care. Increased clarity of role boundaries is necessary in enhancing the professional identity of nursing associates and reducing inter‐professional tensions arising from role ambiguity within health and social care organisations.

Implications for the Profession

National guidance and employers should provide clarity on the boundaries of the nursing associate role which will strengthen their professional identity and mitigate role ambiguity within health and social care organisations.

Reporting Method

The Consolidated Criteria for Reporting Qualitative Research has been used to guide reporting.

Patient of Public Contribution

A patient and public involvement group was consulted during the initial study design stage.

• This study aimed to understand the factors which contribute to the development of a nursing associate professional identity.
• Nursing associate professional identity is developed through increased knowledge, skills and responsibility, and the perceptions of identity by participants themselves and their colleagues.
• The findings should inform the implementation of initiatives to clarify nursing associate role boundaries and the development of similar roles internationally.

1. INTRODUCTION

The nursing associate (NA) role has recently been introduced in England as a bridge between the Registered Nurse (RN) and healthcare assistant (HCA) roles. When similar roles have been implemented in other parts of the world, both NAs themselves and their colleagues have experienced confusion around the boundaries of their scope of practice. This study aims to understand how the professional identity of NAs is developed, using a longitudinal qualitative design.

2. BACKGROUND

The Shape of Caring review (HEE,  2015 ) of healthcare assistant (HCA) and Registered Nurse (RN) work and training identified a perceived gap between these two well‐established roles. It recommended the introduction of a second‐level nursing role, the nursing associate (NA), as a bridge between the two roles. This follows the phasing out of a previous second‐level nursing role in the United Kingdom, the Enrolled Nurse, in the 1990s as part of a move to an all‐graduate‐level nursing profession (Glasper,  2016 ). Important in this move was a transfer of nurse education and training in the United Kingdom away from hospital settings and into Higher Education Institution settings. This shifted the dynamics of the vocational nature of training. Nurse students were no longer included in staffing numbers in clinical settings and became seen as more removed from the practical aspects of learning even though placement hours remained nationally mandated (NMC,  2018a ). The move to reinstate a second‐level nursing role in England aligns with similar workforce models found in other high‐income countries such as Australia, New Zealand and North America (Lucas et al.,  2021 ; The Health Foundation et al.,  2018 ). In general, second‐level nurses undertake a 2‐year diploma‐level programme and work under the supervision of RNs (who study for a 3‐year degree), and this approach was replicated in the implementation of the NA programme (Lucas et al.,  2021 ). In the United Kingdom, theory and clinical skills training are delivered through universities and clinical settings. However, the training of NAs differs from that of RNs. NA trainees are primarily full‐time health service employees based in a clinical area, with limited time release for university study and alternative placements. Conversely, RN trainees are primarily university students who are provided with clinical placements. As mentioned previously, the standards of proficiency and programme content emphasis for NAs is on generic skills that can enable them to meet the needs of anyone they encounter regardless of life stage or health conditions (Nursing and Midwifery Council,  2018b ).

One of the drivers for the development of the NA role was to provide career development for HCAs, a group who otherwise lacked such opportunities (HEE,  2015 ; King et al.,  2020 ). It also provided a new route into RN training, at a time when the profession was, and still is experiencing significant workforce shortages with difficulties in recruitment and retention (WHO,  2022 ).

Health Education England ( 2017 ) has set out a framework for the knowledge and skills that NAs will develop over their programme of study. NAs are trained to undertake clinical skills similar to RNs, for example, cannulation, ECGs, catheterisation and administration of medication including intramuscular and subcutaneous injection (NMC,  2018b ). On qualification, NAs can undertake additional training to administer intravenous drugs and immunisations and undertake cervical screening (RCN,  2023 ). Although there is some overlap with RN competencies, attempts to define role boundaries have been made by the Nursing and Midwifery Council ( 2019 ) (Box  1 ). Both are accountable professionals, responsible for promoting health, providing care, working in teams and improving the safety and quality of patient care. The key differences (in bold italics) are that RNs hold a leadership role and are responsible for assessing needs, coordinating, planning and evaluating care.

Main differences between the NA and RN roles

(Nursing and Midwifery Council,  2019 ).

Although NAs work alongside members of the nursing profession, they do not hold the title of ‘registered nurse’, creating challenges in relation to the formation and maintenance of ‘registered nursing associates’ identity. Professions are constructed by identifying problems, devising strategies to solve them and adopting that work as their own (Abbott,  2010 ). They are defined as having ownership of particular areas of knowledge, expertise and decision‐making (Traynor et al.,  2010 ).

In distinguishing one profession from another, professional identity is formed through professional socialisation in both academic and clinical settings (Maginnis,  2018 ). Maginnis ( 2018 ) emphasises the importance of role modelling in building a nursing professional identity. Similarly, in a study of student nurses, clinical experience, role modelling, critical thinking and reflection were identified as important factors in building professional identity (Fitzgerald & Clukey,  2021 ).

In a concept analysis of professional identity, Fitzgerald ( 2020 ) identified the following key attributes: skills, knowledge, values and ethics; personal identity; group identity; and the influence of the context of care. All of these elements of professional identity begin to develop during the training process (Fitzgerald,  2020 ) and are important to consider in workforce retention strategies as a lack of professional identity may result in insecurity and a feeling of dislocation from the profession (Maginnis,  2018 ).

Workforce boundaries can blur when work is taken on by another profession through substitution (Nancarrow & Borthwick,  2005 ). Boundary blurring and subsequent knowledge sharing can enable less powerful or emerging professions to advance their positions (Currie & White,  2012 ). Much research on boundary blurring has explored the interface between nursing and medicine (Allen,  1997 ; Johannessen,  2018 ; Nancarrow & Borthwick,  2005 ; Schober et al.,  2016 ) and more recently between the physicians' associate role and medicine (Halter et al.,  2018 ). In the case of the new NA role, it is important to explore whether role distinctions set out by the regulator are clear in practice, or whether boundary blurring occurs with RN‐specific competencies and roles. It is also important to consider the role that the more vocationally embedded nature of NA training plays in its identity construction. In countries where second‐level nursing roles have had more time to become embedded into healthcare teams, studies have identified role confusion, with blurring between the scope of practice of RNs and LPNs, for example, in Finland (Lavander et al.,  2017 ) and Canada (Lankshear et al.,  2016 ).

Threats to professional identity can be fuelled by discrepancies between the ideals and realities of the scope of practice (Fitzgerald,  2020 ). An international review of the perspectives of healthcare professionals on second‐level nurses found that some are devalued, while others are given increased responsibility, leading to boundary confusion (Lucas et al.,  2021 ). A culture shift in valuing the care provided by second‐level nursing is recommended, along with a system‐level increase in role clarity within healthcare teams (Lucas et al.,  2021 ).

Previous studies on NAs have focused on the experiences of trainees (King et al.,  2020 ; Robertson et al.,  2021 ) and the integration of newly qualified NAs into the workplace (Kessler et al.,  2020 ). This paper explores the issues associated with forming a distinct professional identity in the NA role as they occupy the space between HCAs and RNs.

3. THE STUDY

The aim of this study was to understand the factors that contribute to the development of the nursing associate's professional identity.

4.1. Design

A 3‐year longitudinal qualitative study of trainee NAs in England using interviews and diary entries.

4.2. Sampling and recruitment

Trainees were recruited from a larger cohort study of NAs which commenced in 2019; the results of which are published elsewhere [authors] . Longitudinal data provided valuable insight into the shifting experiences and perspectives of participants in developing their professional identity as they moved through training and into the NA role (Neale,  2020 ). The Consolidated Criteria for Reporting Qualitative Research (COREQ) has been used to guide reporting (Tong et al.,  2007 ).

After volunteering to be contacted for interview via a survey (Robertson et al.,  2021 ), trainee NAs were purposively sampled to ensure diversity by geographical region, gender, age and ethnicity. Initially, 20 trainees were invited to participate by emailing a participant information sheet and consent form, and 5 more were invited to join the longitudinal study in year 2. A total of 14 trainees from across England agreed to take part in year 1; 17 agreed in year 2 (four new and one from year 1 did not respond) and 12 agreed in year 3 (one declined and five did not respond). Following recruitment, each trainee NA was given a numerical code (TNA 1 to TNA 18) (although they became qualified NAs during data collection, these codes were used throughout to ensure consistency). It is likely that the excellent retention rate across the study (with 10 participants volunteering to be interviewed on all three occasions) was aided by the careful development of rapport in year 1 (Hermanowicz,  2013 ).

4.3. Data abstraction

Semi‐structured interviews were undertaken in February 2020, March 2021 and March 2022, and diary data were collected via Google Forms throughout the 3‐year study. The longitudinal design allowed the interviewers flexibility to improvise and explore key issues during the natural flow of conversation. Interviews were arranged via email and undertaken over telephone or video call (Zoom or Google Meet) at a time convenient to participants. A total of 43 interviews took place over the 3‐year period. They lasted between 21 and 50 min (average 33 min). Data collection was undertaken by four researchers (RK, SR, BT, SL) (one male and three females), three are Registered Nurses and one is not a registered healthcare professional. All have extensive post‐doctoral experience in undertaking qualitative healthcare research.

The interview topic guide (see Box  2 ) was developed from key issues identified in policy documents and during previous preliminary research (King et al.,  2020 ) and piloted with two trainees to ensure clarity of the questions. The year 2 and 3 interviews explored the same broad themes as the first year of interviews in addition to revisiting and updating previous understanding in an iterative way (Neale,  2020 ). It is important to follow NAs during their training and into qualification as this is a crucial time in developing professional identity (Fitzgerald,  2020 ). Interviews were audio‐recorded using an encrypted device, transcribed and anonymised prior to data analysis. Participants were offered a £10 shopping voucher following each interview as a thank you for participating.

Interview topic guide

Motivations

Where did you work prior to starting NA training?

What made you decide to undertake NA training?

Experiences

How are you finding the TNA role? Has it met your expectations? In what way(s) ?

How does the TNA/NA role differ from your previous roles?

How are you finding the training?

What are you enjoying most about the TNA/NA role?

Are there things you are finding difficult? What are these ?

Can you describe your support networks?

How do patients and your colleagues respond to your role?

How do you think your role fits in the wider healthcare team?

Career aspirations

What are your career plans over the next 4–5 years? What has influenced that ?

Participants were emailed a diary prompt every 3 months over a 3‐year period with a link to an electronic Google Form which collected entries (see Box  3 ). A total of 20 diary entries were completed between Feb 2020 and May 2022 by five participants. Previous research has found that diaries are useful in capturing data about workplace identity (Radcliffe,  2013 ).

Diary prompt

We would like you to make notes of any experiences that stand out to you as important during your training/work, particularly those that make you reflect on your motivations for becoming a nursing associate, or that alter how you think about your career path. These experiences could be big or small, could be a single event or take place over a longer period.

4.4. Data analysis

We engaged with Braun and Clarke's ( 2020 ) six‐step framework for reflexive thematic analysis; data familiarisation; systematic data coding; generating initial themes; developing and reviewing themes; refining and naming themes; and writing the report, while attending to the dynamic nature of longitudinal qualitative data (Neale,  2020 ). In managing the data, we used Quirkos© (version 2.4.1) computer‐assisted qualitative data analysis software (CAQDAS). Data relating to identity formation were initially extracted and coded by [author initials] , then contributed to further refining codes, categories and to the developing and naming of themes.

4.5. Ethical considerations

Written informed consent was gained prior to collecting interview and diary data from participants. They were sent an email annually, inviting them to the next interview and reminding them that they could withdraw at any time, although anonymised data incorporated in the analysis would not be removed. Research Ethics Committee approval was gained from the University Research Ethics Committee [Ref: 026355].

4.6. Rigour

Rigour was enhanced using several strategies. A detailed description of the study design was provided and included both researcher and source triangulation (collecting both interview and diary data) (Ritchie et al.,  2014 ). Furthermore, we assured trustworthiness by attending to discrepancies in the data through collaborative team discussion. Pragmatic data saturation was reached through the generation and contextualisation of categories (Low,  2019 ).

5. FINDINGS

5.1. participants.

The demographics of participants are presented in Table  1 .

Participant demographics.

Data analysis provided two key themes relating to identity formation; firstly, through the acquisition of skills, knowledge and a greater sense of responsibility, and secondly, in relation to how the role is understood by NAs and their colleagues (Table  2 ). Extracts from interview and diary data are used to illustrate these themes, with examples provided of how perspectives and experiences have developed over time.

Themes and sub‐themes.

5.2. Theme 1: Development of knowledge, skills and responsibility

5.2.1. development of knowledge and skills.

During training, NAs developed a broad range of knowledge and skills to meet the needs of their new role. Participants valued the opportunity for professional development and felt able to provide a greater level of evidence‐based care than when they worked as HCAs; university learning enhanced their theoretical understanding and how this linked to vocational tasks. Some learning developed new competencies. One participant explained how the knowledge and skills acquired across the four fields of nursing enabled them to provide better physical healthcare for people in a mental health setting:

I've started doing shifts in mental health over the last month and I've picked up a lot of knowledge [through training] about physical health so, I'm finding I can delegate a lot more confidently than I would previously and, picking up if somebody's got this observation then, you know, it could be this, this and this. And I know what questions to ask because of what I've learnt. TNA9 (yr 3)

Other participants talked about their enthusiasm for university learning and how this has improved their work through increased knowledge. For example, TNA 11 demonstrates growth over time in their appreciation of evidence‐based practice; from the value of assessments to a broader view of understanding the evidence behind holistic care:

I've learnt so much from doing this, even essays that you think are pointless or you roll your eyes with, it's the terminology, the communication side of it. Every time I've done an essay or something, I've learnt so much. TNA11 (yr 2)

You have to look at the whole picture, you're not just treating [name's] broken leg, you're having a holistic approach to her and things like that. I love just the background to everything, everything you do, there's a reason why. TNA11 (yr 3)

Where I've always done stuff in patients' best interests, it's understanding the theory behind that a lot more and, you know…why we do what dressings or why we do what behaviour management we apply, it's not a case of because it's always been done, it's the research and understanding behind it. TNA13 (yr 1)

There was a change in attitude towards learning among some participants. For example, for one trainee, some of the academic content of training was perceived as irrelevant but, over time, they reflected on the benefits of developing evidence‐based knowledge and the confidence this brought:

There was a lot of government policy and a lot of stuff that I don't feel that I use now in my role. And I think if we'd had more medicines management and some more anatomy and physiology it definitely would have been a lot better. TNA17 (yr2)

I could underpin what I'm doing more now, whereas as a HCA I probably didn't. But I can look to research now as to why we're doing what we're doing, and I feel more confident since doing my nursing associate [training] to do the things that I do. TNA17 (yr3)

Increased knowledge led to increased confidence in clinical decision‐making, and enhanced care for patients. This is illustrated in the following diary entry:

I love learning new things but more importantly ‘why we do what we do’. The theory behind the practice. My confidence in my skills and ability has increased greatly TNA12 (diary)

The university elements of training often improved care by enhancing the knowledge of what lay behind the vocational tasks that had often been carried out for years by trainees in HCA roles. This improved care was complemented by changes in attitude as they further developed their identities through training.

5.2.2. Increased sense of responsibility

In addition to the impact of new knowledge and skills, participants described the difference that NA training has made in how they approached patient care compared to when they worked as HCAs, for example, by promoting shared decision‐making and person‐centred care:

I think it's just a really, really amazing opportunity to upskill and learn new things… being able to be person‐centred in your caring. Being a bit more useful in the process because as a HCA you're limited to the things you can do and as a NA you can do a little bit extra and help out more and you're more involved in patient care and empowering your patients and helping them to make decisions. TNA1 (yr3)

There was a new passion among some participants to promote learning and development across different professions; valuing opportunities for inter‐professional knowledge sharing and developing an identity more confident with such interactions. The following participant revealed in their first interview a new appreciation for the theoretical underpinning of clinical skills, and in their third interview, they described how they have a role in applying their new knowledge to supporting others:

You know, we can go and do ECGs, take blood, you know, so if there's a list of things that the patient needs, the NA could do that. Although HCAs in many places, such as A&E or the emergency floor, they do all of that anyway, but do they know why? TNA4 (yr 1)

We have doctors visiting our department, medical students, and I just went straight up to them and said, oh have you got any learning outcomes for today, is there anything specific that you need to look at? Just trying to make them feel welcome, and just informed as much as possible. TNA4 (yr 3)

Professional regulation with the Nursing and Midwifery Council (NMC), on qualifying as an NA, was another factor which promoted a feeling of responsibility for their own learning among participants. This increased vocational accountability contributed to their shifting and emerging professional identity.

Everybody's accountable, but when we have got that pin [NMC registration], we are even more so accountable. You've just got to think in a different way, you've really got to step‐up and become more professional about what you're doing. You've got to learn to question things, I've always been like that anyway…So, if I don't know something, I would look it up, but now it's just, kind of, really drummed into you that everything has got to be evidence‐based, which is how it should be. TNA12 (yr 1)

Enhanced knowledge and skills combined with improved confidence and accountability work together in the development of the NA identity. However, developing a new professional identity is not straightforward for the individual, or for others in the clinical settings where training occurs.

5.3. Theme 2: Perceptions of role identity

The development of NA professional identity is not only influenced by enhanced knowledge, skills and increased sense of responsibility during training and early career experiences. It is also shaped by how NAs perceive themselves, their role and how they experience the perceptions of others around them in the workplace.

5.3.1. How the role is understood by NAs

Participants in this study were among the first trainee NAs in England, and as a consequence lacked role models in the workplace. This, alongside delays in the development of national guidance on the role, led to some confusion regarding their scope of practice and their role identity. Some were unsure of what the role would entail when they started the programme, with several describing it as similar to the previous UK state Enrolled Nurse (SEN); a role that also sat between HCAs and RNs:

I went home and read what an NA is and, from what I could gather, it's almost like the old SEN role, that was my, sort of vision of it. TNA6 (yr 1)

We're, like a bridge, you know, the usual line, of bridging a gap between HCAs and RNs. And sometimes you talk about the SENs and how it's quite similar to that role and just that we've been to university and we've done our two years of nurse training. TNA9 (yr2)

One participant was more confident of their place in the healthcare team at the start of the study during their first interview. However, this confidence in their professional identity diminished over time.

So, like, the medicine round takes the nurse hours, even for the NA to be able to take over that to enable the nurse, you know, to go on to more complex things is…I think will really benefit the ward. TNA11 (yr 1)

I don't really feel I have a place, I don't really feel I've got an identity at the minute. TNA11 (yr2)

I just say, my role is similar to the old enrolled nurse and I'm just a bridge between them both, it's just in between. TNA11 (yr3)

Some trainees said that they were well placed to enable RNs to undertake more complex care, in light of nursing workforce shortages, by undertaking key tasks:

It's going to free up nurses [RNs] to do other stuff, to concentrate, because they have a lot to be dealing with and the buck stops with them, and there's just not enough nurses and not enough people to help. So, having that in‐between‐person between the HCA and the RN is going to help a lot because the HCAs will come to the RN a lot, ‘Oh, this patient's drip's sounding because they've got an occlusion’. ‘Oh, this person really needs their pain relief’. So, all that stuff that the HCA can't do that only the RN can do, then there's going to be a middleman that's going to be able to help out with that. TNA1 (yr 1)

There was some scepticism among participants about whether the role would meet initial policy objectives or whether it would be dependent on the needs of the organisation. For example, one participant voiced these concerns in the first interview and then described their experiences, which supported their initial concerns in a subsequent interview.

I hope it's going to be what the idea was set out to do and bridge the gap and improve patient care. But I think it depends on what kind of ward you are on and what the staffing is. I think, a lot of feedback I've had from people on the course is that they are just used wherever they can fit in… TNA3 (yr 1)

I feel like we were sold the dream essentially, we were going to be there to support RNs, but I've actually found we are the nurse…I suppose when we first took on the role, when it first came out and a lot of the older nurses said, oh you're cheap nurses blah, blah, and we obviously fiercely defended ourselves, like, ‘we're there for your support’. But actually, being in the role, they've got it right, we are being used to fill in the gaps for band 5s [junior RN grade]. TNA3 (yr3)

Such ambiguity was compounded by the nature of the training and the fact that most were still employed as HCAs with time release for university and alternative placements. This meant that when clinical areas became busy (e.g., during COVID‐19 but not limited to this), training and learning often took second place to vocational demands:

So I was fighting to get my role recognised, and all I was getting was, ‘you're being paid to be here, you're being paid’. So when they were short, I was being chucked in the [HCA] numbers, which is absolutely fine, but not every day. Because I was like, I'm just going to be a really expensive HCA with a PIN, at the end of my training. TNA 3 (Yr2)

You start off the day where you should be but then you just know that during the day it's going to change and you're just going to end up supporting the HCAs again, …I just think even though you know I've got that professional identity they don't still take that into account. TNA15 (Yr2)

Some had become disillusioned by the organisational expectation to work beyond the perceived boundaries of the NA role, as substitutes for RN staff. There was a realisation among some participants that the scope of the NA role was similar to the RN role, leading to a desire to undertake additional training to become an RN.

‘We all feel that we do the job anyway, we do the job as the [band] five, so why not get paid as a band five [junior RN grade].’ TNA11 (yr3)

‘We're told that you can gain any competencies that may be used in your work area. It seems that the only difference will be that we can't take control of a shift. I find this difficult to understand and wonder if we will just be a cheaper version of band five nurses’. TNA5 (diary)

Others had a broader view of the changing landscape of the healthcare workforce, recognising the increased level of decision‐making required by both RNs and advanced practitioners, which creates a space for the new NA role:

The level at which the RNs are coming out at now, they're expected to look after their more acute patients and they're almost working to junior doctor level. So the NAs, those that don't have any desire to continue their journey and they're happy to work as a NA, I think they've got a very firm place in the organisation. TNA14 (yr 1)

Some talked about the similarities between the NA scope of practice and that of the RN, often struggling to differentiate between the two. For example, one trainee predicted at the start of their training that the roles would feel very similar in their clinical setting, which they confirmed in their third interview:

Basically, what we do in theatres is, as a trainee NA and as a NA, we will be doing the same role as what a RN does. So, we will eventually scrub for minor cases, and, as we're learning, we'll probably move up to bigger cases. TNA1 (yr 1)

I know there are some differences between a RN and a NA in different areas in the hospital. In theatres it's pretty much the same. The only thing that we wouldn't do in theatres would be you wouldn't be a team leader for the day. TNA1 (yr3)

This is another example of where a participant's initial concerns are supported by their experience over time. In support of this, another participant had read guidance on the differences in scope of practice between an NA and an RN. However, in practice, over time, they realised that there was an expectation to move beyond those boundaries.

Basically, we do exactly the same as qualified RNs do. There's not a lot of difference apart from IV medications and co‐ordinating the ward really. TNA17 (yr 2)

There's a template on the NMC [website] that says RN on one side, NA on the other, and it says the things that we can do and things that we can't do, but I mean, you can merge the line slightly… Basically, for me, I feel that the only difference between being an RN and being a NA, is that you can't give IVs in our trust. But I've read on a lot of forums that a lot of NAs are now giving IVs, and I think they're crazy, I think they're absolutely insane. TNA17 (yr3)

Initially, NAs viewed their identity as sitting between the HCA and RN roles. However, it became apparent through clinical experience that, in some settings, the role was closer to that of the RN.

5.3.2. Colleagues' responses to the NA role

Most participants felt the NA role was misunderstood by their colleagues throughout their training journey, with some experiencing little understanding of the boundaries of the scope of NA practice. The following example illustrates little change in how the role is perceived by others over the duration of their training and as they transition into the workplace:

I don't think enough people actually know what a trainee NA is, maybe once it's been about for a bit, people will start to grasp it… I've just stopped saying that I'm a trainee NA anymore. When I do say it, I say, I'm just like the SEN [state enrolled nurse] you had years ago, because that's what they understand… you just have to adapt to what they understand, because they don't know what you can and what you can't do. TNA1 (yr2)

Unfortunately, because it's still such a new role, not everyone understands it. The clinical education team are amazing and they have a grasp and understand it. But…other teams; they don't really understand it fully yet, which is a shame, but hopefully as more go on the course and progress, then they'll understand.' TNA1 (yr3)

The vocational status of trainees, the fact they spent the majority of time working as employees, also meant colleagues often failed to recognise their student status. This had a direct impact on whether they were encouraged and facilitated to access learning opportunities which they felt were more often given to RN trainees who had a clearer student identity:

They'll spend time with [RN] student nurses, and show them things, but they won't spend time with you […] if you're on with [RN] student nurses, you can guarantee if there's a job to be done, or something to be learned, it won't be you that's picked. TNA6 (yr3)

Perhaps linked to this, some participants said that they were underutilised in their role being viewed more as HCAs than NAs by their RN colleagues. One talked about this in their first and second interviews, with no evidence that this perception had changed over time:

Because of the attitude of quite a high percentage of the RNs, they don't understand the role, and therefore, they don't treat us with any, well, respect really. We're just…we're treated as HCAs, but know a bit more than the other HCAs. TNA6 (yr 1)

A lot of the RN staff seem to think that this is just a slight upgrade from an HCA, as opposed to where we should be. They just seem to think it's a little bit of a step up from a HCA. It's like, yeah, you're an HCA that's done a bit of extra training rather than, you're a NA. TNA6 (yr2)

There was suggestion that some RNs were unsupportive of the role due to a reluctance to embrace change and that this influenced the offer of learning opportunities to trainee NAs:

I think some members of the team still actively resist the role, but they do it behind nursing rationale, when it doesn't need to be. I think nursing has its own language. And I think if you can speak it you get on a lot better, whereas if you can't… I think a lot of the RNs feel put out, a lot of them have been in the job a very long time. There's an in‐depth opposition to change. TNA8 (yr2)

In contrast to those feeling they were being underutilised, others felt they were expected to work beyond their scope of practice. This is evident in the clinical roles they were expected to perform, such as administering insulin to unstable people with diabetes or prescribing antibiotics:

On the wards, I think there is going to be an aspect of yes, you're an NA, but we want you to do extras, because I'm seeing it already, we want you to be doing more than you're supposed to be doing. TNA5 (yr1)

It's become a difficult thing to stand your ground when they are saying, ‘just go in, it's fine, they're fine’, and you say, ‘but they've had two hypos [hypoglycaemic episodes] in the last week, so I don't feel they're a stable patient’. TNA6 (yr3)

The persistence of this lack of understanding of the NA scope of practice over time is illustrated in the following extracts from one participant's interactions with medical colleagues, discussed in year 2 and 3 interviews:

People say to me… ‘oh you're a nurse now’, I'm like ‘no, no, I'm a Nursing Associate’. They're like, ‘well what's the difference’ …The doctors are like, ‘well why can't you give it’ and I'm like, ‘because I can't. I can't assess the patient, so I can't just go around just giving jabs here, there, and everywhere’. TNA16 (yr2)

The lack of understanding from GPs that I am not a RN. I'm a Nursing Associate and I have limitations to my scope of practice… I will often say to the GPs, ‘no, I can't do that, please don't put that in with me’… For example with a wound or something like that, a doctor will say ‘oh just prescribe antibiotics’… That's the sort of thing when I'm a bit like, ‘no, no, no that's your job, not my job’. TNA16 (yr3)

Participants were not passive in relation to such responses from colleagues though. Many developed strategies to help improve role clarity and thereby improve learning and development opportunities and the subsequent development of professional identity.

5.3.3. Strategies to improve role clarity

Some participants described how they responded to misunderstandings about their scope of practice, by sign‐posting colleagues to online guidance or explaining what competencies they are able to undertake. This required self‐confidence and excellent communication skills. Educating colleagues enabled some participants to expand their scope to that of an NA:

It's been a challenge breaking down the barriers towards this role, because they just didn't understand what they could give me. So at first they were trying to send me out on visits which, you're basically just a carer… So I sort of did that for a little while and I thought, I'm not happy with this, there's so much more I can be doing. I then started to kind of push because I thought, I can do all this, I'm competent, wound care is my thing, bloods is my thing’ TNA12 (yr3)

One talked in her diary entry about a presentation on the NA role that she sends to people who want to know more, and another talked about re‐educating colleagues:

I always try to be proactive and positive about the role, so much so I have made my own short presentation that states our role very clearly. If anyone asks me ‘so what is a Nursing Associate’, I offer to send them my little PowerPoint. TNA12 (diary)

I've done a bank shift back on my old psych ward, and instantly I met the barriers that I had encountered previously by the colleagues there. And I was like, ‘no, I can do this, I can do that – and I actually can do a lot more than what I was doing when I was here previously’. And it was having to re‐educate some of the older RNs, to my role and my new autonomy. TNA13 (yr2)

Perhaps due to initiatives like these, one participant noted an improvement in how the role was understood over time, which helped enhance communication within the healthcare team:

I'm often going in and bringing up the proficiencies for NAs and bringing those up, which are on their website….The reception team have got a lot more understanding of it now as well. They've started to learn the difference between a HCA and an NA, which has been really good. They know who to approach now as well. So it's getting there. TNA16 (yr3)

In mitigating role ambiguity, some participants talked about initiatives which could be, or were being, introduced, such as trust‐wide education. However, there was some scepticism about how helpful this would be in the long term due to the flexibility within the guidance.

It might be a really good idea for there to be some sort of training…I think that for nursing staff, it might be of benefit to have a training afternoon, teaching them what we can do. TNA6 (yr3)

Trusts are now doing a lot more webinars, and getting in people from the NMC, HEE, …and so they did a six week series on NAs that was designed for anybody that wants to become a NA, any managers that have got NAs, or anybody that's thinking of hiring NAs. And the conclusion was, you can do what you want with the NA as long as there's clinical guidance to support that, but we don't know what you want to do with them so we can't write any, so you decide what you want to do with it and you write it. TNA2 (yr3)

Self‐perception and the responses of others had a clear part to play in building the NA professional identity. Several participants described the lack of role clarity, both in terms of their own experiences and the perceptions of those around them. They outlined strategies used to mitigate the barriers they encountered caused by misunderstandings of their scope of practice and place in healthcare teams.

6. DISCUSSION

The findings from this longitudinal study of NAs as they transitioned from training into practice reveal how they developed key attributes which contributed to building their professional identity (Fitzgerald,  2020 ). They illustrate the impact of personal and organisational understanding of the role, in addition to the acquisition of knowledge skills and an increased sense of responsibility for patient care. This journey was not without challenges. Similarly, in a review of workplace transitions, Arrowsmith et al. ( 2016 ) describe the discomfort experienced by those striving for a new identity.

6.1. Development of knowledge, skills and responsibility

Participants described how their skills and knowledge developed over time, enabling them to provide an enhanced level of care for patients compared to their previous healthcare support roles. Similarly, Maginnis ( 2018 ) reflects on the importance of developing skills and knowledge through both academic and quality clinical placements in contributing to the building of professional identity. The ‘four fields’ nature of the NA training programme enabled them to care for patients across a range of settings and helped distinguish them further from RNs. RNs undertake specific training in adult, child, learning disability or mental health nursing, whereas the NA programme equips trainees to fulfil a generic role across all of these fields post‐qualification (NMC,  2018a , 2018b ). This gave some increased confidence in their clinical decision‐making and interactions with colleagues. Similarly, in their qualitative study of student nurses Fitzgerald and Clukey ( 2021 ) found that professional identity was enhanced through increased confidence in decision‐making; developed through stronger competence. Previous research has identified skills acquisition as an important step in developing competent practice (Arrowsmith et al.,  2016 ).

Professional regulation and registration with the NMC provided a further sense of identity, with a recognition by participants of the responsibility and accountability that registration brings. Those who had previously worked as HCAs reflected on the move from delivering task‐based care to becoming person‐centred decision‐makers.

6.2. Perceptions of role identity

Professional identity was also moulded through the self‐perception of the role by NAs and their experiences of the views of their colleagues. This is consistent with research on transitions, where nurses look to their colleagues as a reference when forming a new identity (Arrowsmith et al.,  2016 ). The current findings revealed that NAs perceived their role to be very similar to that of RNs, leading to frustrations; a common experience in situations of boundary blurring (Fitzgerald,  2020 ; Nancarrow & Borthwick,  2005 ). Although the role of RN and NA are distinguished in regulatory standards (NMC,  2018a , 2018b ), this study indicates that the NA role is sometimes stretched beyond these boundaries to meet service needs. Similarly, in a study of the nurse–medical boundary, Johannessen ( 2018 ) reflected that blurring of workplace boundaries was not always reflected in formal jurisdictions.

Boundary blurring between nurses and doctors was perceived by Allen ( 1997 ) as an inevitable consequence of the absence of doctors in clinical practice (Allen,  1997 ), therefore it is not surprising to see this being played out between NA and RN roles as the nursing workforce faces unprecedented shortages (WHO,  2022 ). In the present study, there are times when the colleagues of NAs expected them to work beyond their scope of practice. This boundary blurring caused tensions among participants; it could leave them feeling out of their depth and believing they did not receive adequate remuneration for their work. Previous research has shown that this frustration can lead some NAs to pursue further training to become RNs, a mechanism by which they can gain formal jurisdiction for their work (King et al.,  2022 ).

A lack of role clarity among colleagues led some participants to feel underutilised in their role, while others said that too much was expected of them. In their study of the implementation of the advanced practice role, Schober et al. ( 2016 ) found that role clarity was crucial, as ambiguity led to isolation and a lack of acceptance by other healthcare professionals. However, over time, inter‐professional resistance decreased as understanding of the role increased. Similarly, Rees et al. ( 2019 ) explored professional identity within interprofessional teams, finding both a persisting narrative of interprofessional conflict, in addition to one of interprofessional collaboration. They argue for work‐based training to embed both professional and inter‐professional identities in students and clinicians. Furthermore, Arrowsmith et al. ( 2016 ) argue that managers must ensure clarity of role boundaries in role transitions. Concerns about the impact of role ambiguity around second‐level nursing (Lucas et al.,  2021 ) have persisted in the NA role. At a time when the nursing workforce is experiencing a workforce and economic crisis (WHO,  2022 ), healthcare teams should pull together to support each other. Strategies to mitigate role ambiguity and enhance retention through valuing the work of this new member of the team are essential.

Concerns have been raised by the RCN, ( 2023 ) about how role confusion could lead to risks to NAs, who may act outside of their regulatory framework. In order for NAs to avoid the persisting ambiguity experienced by second‐level nurses internationally (Lucas et al.,  2021 ), there needs to be strong investment in clarifying the scope of practice and recognising role boundaries. NA role models who are clear about their place and scope of practice in healthcare teams will be crucial in establishing a professional identity in the future. They could benefit from communities of practice of NAs (Lave & Wenger,  1991 ) as a mechanism by which to strengthen their professional identity across England. The successful negotiation of a professional identity for NAs requires all stakeholders to champion the role and to educate the wider health and social care teams on the scope of practice of NAs in differing health and social care settings.

6.3. Strengths and limitations of the work

The strength of this study design lies in the longitudinal nature of data collection and the subsequent rapport developed between the researchers and participants (Neale,  2020 ). Also, the timing of this study has been valuable in exploring the concept of professional identity building at the early stages of NA role implementation across England.

This study included a small sample size, however, due to the longitudinal nature of qualitative data collection, a sufficient depth of understanding of NA professional identity formation was achieved. There was a small loss of participants across the 3 years but most continued to take part suggesting good engagement with the study. Although the sample achieved diversity of age and geography, most of the participants were female and white British, future research should therefore aim for greater diversity of ethnicity and gender.

6.4. Recommendations for further research

It is important to explore how the scope of the role is enacted in a range of health and social care settings to further understand the professional identity of NAs. Future research should explore the work of NAs in practice to understand the extent to which there is substitution of RNs by nursing associates and the impact this has on patient safety.

As the NA role becomes more established it would be helpful to study the nature of communities of practice and role models in supporting trainees and newly qualified NAs of the future. At a time when recruitment and retention of healthcare workers is paramount, future research should evaluate interventions to support the career development and well‐being of NAs and similar second‐level nurses internationally.

7. CONCLUSION

The professional identity of newly qualified NAs is developed through the acquisition of knowledge and skills, increased responsibility and the perceptions of the role by NAs and their colleagues. Regulation by the NMC professional body enhances professional identity by increasing a sense of responsibility through accountability.

NAs in this study clearly valued their new knowledge, skills and responsibility for patient care. Tensions arose when the scope of NA practice expected by organisations was over or under that expected by the NA. Frustrations also occurred when NAs felt their role was significantly blurred with that of RNs as they did not want to be perceived as substitutes for RNs in the context of nursing workforce shortages. National guidance and employers should provide clarity of the boundaries of the NA role which reflect the differences between the NA and RN roles to strengthen the professional identity of NAs and mitigate role ambiguity within health and social care organisations.

AUTHOR CONTRIBUTIONS

Rachel King: Conceptualisation, data curation, formal analysis, investigation, project administration and writing original draft. Sara Laker: Conceptualisation, data curation, formal analysis and writing original draft. Bethany Taylor: Conceptualisation, data curation, formal analysis, investigation and writing review and editing. Tony Ryan: Conceptualisation, funding acquisition, supervision and writing review and editing. Emily Wood: Conceptualisation, methodology and writing review and editing. Angela Tod: Conceptualisation, funding acquisition, methodology, supervision and writing review and editing. Michaela Senek: Conceptualisation, methodology and writing review and editing. Sally Snowden: Conceptualisation, resources and writing review and editing. Steve Robertson: Conceptualisation, data curation, formal analysis, investigation, methodology and writing original draft.

FUNDING INFORMATION

The project was carried out by the Strategic Research Alliance between The Royal College of Nursing and the University of Sheffield. The views expressed are those of the author(s), and not necessarily those of the RCN.

CONFLICT OF INTEREST STATEMENT

There are no conflicts of interest.

ACKNOWLEDGEMENTS

We are very grateful to the TNAs across England who took part in this 3‐year study.

King, R. , Laker, S. , Taylor, B. , Ryan, T. , Wood, E. , Tod, A. , Senek, M. , Snowden, S. , & Robertson, S. (2024). Development of the nursing associate professional identity: A longitudinal qualitative study . Nursing Open , 11 , e2131. 10.1002/nop2.2131 [ PubMed ] [ CrossRef ] [ Google Scholar ]

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