Background: A long-standing component of the nursing workforce, the nurse support worker has recently emerged as the main bedside presence. However, as support workers are unregistered employees, positioned at Agenda for Change pay bands 2 to 4 and assisting registered nurses, there has been caution regarding their use. This caution has deepened just at the point when the cost pressures facing the NHS have prompted trust managers to reconsider how they organise their nursing workforces. Building upon previous, largely diagnostic studies, the current project explores how trusts have sought to change their approach to nurse support workers. In so doing, the research contributes to an applied and forward-looking agenda on the use and management of such workers in the current challenging times.
Objective: The project centred on three related themes, each with its own objective: first, an innovation theme to identify and facilitate the development of innovative practice as it relates to support worker roles in an acute health-care setting; second, an evaluation theme to evaluate various acute trust policies and practices designed to improve the efficiency and effectiveness of stakeholder interaction with support worker roles; and third, an engagement theme to secure the engagement of various stakeholders in sharing knowledge, practice and learning on support worker roles.
Design: The innovation theme comprised a scoping phase involving discussions with stakeholders (n = 100); a national survey of directors of nursing and human resources (n = 94) on innovative practice; and six trust case studies exploring different forms of innovation. The evaluation theme assessed six support worker initiatives: medicine management by assistant practitioners; an accelerated development programme in maternity; a support worker development nurse role; an assistant practitioner roll-out; an extended induction programme; and support worker beginner competencies. The engagement theme comprised four regional workshops involving stakeholders (n = 109) in a facilitated discussion on the use and management of health-care support workers.
Results: Innovation in the use and management of support workers remains patchy. It is more commonly reflected in new approaches to the management of support workers than in new roles or ways of working. The six cases highlighted the contribution made by contextual features, different systems and various actors to the emergence of innovative practice. Evaluating according to organisational objectives being pursued, doubt was cast on the efficacy of many of the initiatives assessed. Change in the way support workers were used and managed often became lost among other trust priorities, drawn into complex decision-making procedures, and contested and resisted by actors who felt threatened. Engaging in the regional workshops, stakeholders highlighted dilemmas concerning the development of the role. Nonetheless, a new management model was emerging based on more robust recruitment and induction, competency-based training and development.
Conclusion: While support workers remain at the forefront of policy seeking to improve care quality, developing new approaches to their use and management remains difficult. Effective change often relies on a balance between top-down and bottom-up approaches; addressing resistance to extended unregistered roles; the activities of ‘institutional entrepreneurs’; and ‘institutional work’ based on partnership and inclusion. Institutional rigidities create challenges which need to be addressed by trust policy-makers and practitioners as they seek to further develop and embed nurse support roles. Strategies are needed which nurture key organisational actors with a stake in these roles; ensure that key organisational functions are co-ordinated; and ensure that all of those involved in workforce change, particularly at ward level, are fully informed about it.
Funding: The National Institute for Health Research Health Services and Delivery Research programme.
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