NHS hospitals are deploying a new type of nursing staff—Nursing Associates (NAs)—but no one has systematically tested which ways of using them actually improve patient care without increasing risk. This matters because the NHS faces a severe shortage of registered nurses. NAs were introduced to bridge the gap between healthcare assistants and fully qualified nurses, but hospitals vary wildly in how they deploy them. Some use NAs effectively; others may inadvertently extend their duties beyond safe limits, potentially compromising patient safety. The research team has already identified three unresolved problems: unclear communication of what NAs can do, inconsistent models for integrating them into teams, and a lack of clear career pathways. If successful, this 30-month study will produce an implementation toolkit for NHS trusts. The toolkit will specify which NA deployment models work best in different hospital specialties—such as emergency departments versus surgical wards—and under what circumstances. This could help hospitals safely expand their nursing capacity without putting patients at risk, while also making more efficient use of healthcare resources and NHS budgets. The findings will be published in open-access journals and shared directly with patients, staff, and the public.
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Research question Implementation of the Nursing Associate (NA) in Adult Secondary Care: What works, for whom, how, why and in what circumstances? Background NHS registered nurses (RNs) are in short supply. One strategy to help build nursing capacity and improve healthcare has been the introduction of NAs; nursing employees who ‘bridge the gap’ between a Healthcare Support Worker and RN. Whilst there is recognition of the positive contribution that NAs make to nursing teams, there are also concerns about role substitution and extension of their scope of practice which could lead to increased patient risk. Our research has revealed three key areas in NA implementation that require further investigation: (1) communicating NA scope of practice (2) variation in models of NA integration and working and (3) NA career progression. To maximise benefits of the NA role, further information is urgently required to determine the contextual factors that support implementation, including healthcare resource use, clinical areas, patient management models and task allocation. Aim To evaluate the NA role in adult secondary care in England, including the impact on clinical outcomes, team dynamics, and utilisation of healthcare resources. Objectives 1. Analyse NHS secondary care workforce data to determine the prevalence and regional distribution of the NA 2. Develop initial realist programme theories (IPTs) on how the NA is working in secondary care 3. Conduct a realist evaluation of 16 secondary care sites testing programme theories and investigate NA impact on clinical outcomes, team dynamics and healthcare resource use Methods A mixed methods realist evaluation including qualitative, quantitative and economic assessments of the NA role in secondary care consisting of three work-packages (WP): WP1: NHS Secondary Care workforce data analysis to determine the prevalence and regional distribution of the NA secondary care workforce. WP2: IPT development and refinement through updating a realist review. IPTs will be developed and refined to provide preliminary hypotheses detailing mechanisms and contexts that suggest NA integration in secondary care is or is not successful. Four theory validation events will be conducted; two to both confirm theories and reveal new theories and two to refine Context-Mechanism-Outcome configurations (CMOCs) after testing in WP3. WP3: Four NHS Trusts in England will be recruited, within which four different clinical areas will be included, making a total of 16 case study sites for a mixed methods evaluation. Time-to-event analysis of patient and nursing workforce data will focus on the deployment of NAs and impact on patient outcomes and resource use (WP3a). Interviews with patients, carers, and staff will focus on the generative mechanisms and a staff survey will be linked with workforce data to investigate the NA impact on team working (WP3b). All data will be integrated and processed in the form of CMOCs to identify which models of NA work for whom, under what circumstances, how and with what resource implications (WP3c). Timelines 30 months Impact & dissemination We will work with patients and staff to ensure widespread dissemination to patients, the public and nursing staff in accessible and diverse formats, and publish in high-impact, open access journals. We will also produce an implementation toolkit to support secondary care NHS trusts to effectively implement the NA role within different specialities.
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