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What would the Regulation of Health Care Support Workers mean for Registered Nurses?

March 4, 2013

For Nursing, the Francis Report’s proposed regulation of Health Care Support Workers (HCSWs) is the probably the biggest, most frightening bogeyman in the whole damn shooting match. It takes nursing’s deepest, darkest secrets – the ones it would most like to suppress, the ones it would least like to confront – and explodes them into the sunshine. If it ever happens, it will force nurses to re-examine everything they thought they knew – their history, their job description, their day-to-day activities, and ask themselves the sixty-four thousand dollar question: what do nurses really do?

The Willis Commission (2012) anticipated Francis in calling for ‘registration’ (not ‘regulation’) of HCSWs but stipulated that ‘clearly defined roles’ would need to be drawn up for both HCSWs and the graduate registered nurses who supervise them. The question is: what will those roles be? For registered nurses, the concern must be that the ‘real’ caring work will increasingly be the province of the HCSW while they are left with a rump of co-ordination and supervisory functions (and the drugs round). When the history of early twenty-first century nursing comes to be written, the day when mandatory regulation of HCSWs made it onto the statute books may well be more widely remembered as The Day General Nursing Broke Itself In Two.

Fear of HCSW regulation partly explains the rash of recent journalism emphasising what Willis calls ‘the positive impact of registered nurses on patient outcomes’ (1). One interpretation is that these are shots across the bows of any HCSWs who might be harbouring exaggerated ideas of their own significance. And authors must have drawn much comfort from Francis’s (to my mind) outrageous and deeply insulting characterisation of HCSW work as ‘[an activity] involving a low level of skill’ (ch 23, para 132).

Seen from the standpoint of HCSWs, however, it seems quite reasonable that there should be (to borrow a very old campaign cry) ‘no taxation without representation’. In other words, if they are expected to pay for registration (as one assumes would be the case), then they are entitled to claim in return their own discrete knowledge base in their own sphere of operations. The problem for nursing as a whole is that this sphere of operations is already occupied – by nurses. For nurses to cede control of direct care – historically the sine qua non of their being – to a separate occupational group would be viewed by some as tantamount to giving away the Crown Jewels. But it is undoubtedly the case that for all its totemistic power, less and less personal care is nowadays performed by registered nurses. Why not formalise the arrangement?

If HCSW regulation/registration ever becomes a reality, registered nurses will have to ask themselves which way they want to go. Do they want to hand care work on a plate to the HCSWs (and leave themselves open to accusations that they never wanted to do it anyway, and are glad to be shot of it so they can devote themselves full-time to mini-doctordom); or do they want to fight to retain their share of it (and leave themselves open to accusations of fomenting workplace conflict and acting like dogs in the manger)? Alternatively, do they want to work towards a wholesale re-conceptualisation of what nursing is about? Only time will tell.

(1) See, for example, Ford, Steve (2013): “Failure to Rescue” linked to higher healthcare assistant ratio; Nursing Times; Vol 109; no 3.

Francis, R (2013): Report of the Mid Staffordshire Foundation Trust Public Enquiry; London; The Stationary Office.

Lord Willis of Knaresborough (2012): Quality with compassion: the future of nursing education. Report of the Willis Commission on Nursing Education, 2012: London; The Royal College of Nursing.

  1. HHmm very interesting from the viewpoint of a carer especially in the nursing sector.

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