Misleading job titles: why are non-nurses called nurses, and band 3 roles ‘advanced’?
NHS job titles risk misleading staff and the public by use of ‘nurse’ designation in unregistered roles, and ‘advanced’ in band 3 positions. Nurses’ colleagues in support roles play a distinct and invaluable part in the multidisciplinary team, but this kind of job title inflation may be concealing inappropriate and unsafe reliance on them. #ProtectNurse campaigners says protection in law of the nurse designation is needed. Nursing Standard investigates
NHS job titles risk misleading staff and the public by use of ‘nurse’ designation in unregistered roles, and ‘advanced’ in band 3 positions
- ‘Nurse’ job titles have been assigned to unregistered support roles in the NHS for some time, as we investigate the extent of the issue
- The NMC says healthcare employers should not be using misleading job titles
- Misleading job titles may be concealing role substitution and over-reliance on support staff in a bid to get ‘nursing’ on the cheap
Many NHS employers may be using misleading job titles for some unregistered nursing staff, which nursing experts warn could pose a risk to patient safety.
Six years after we first investigated this subject, we have now found thousands of support staff in Agenda for Change (AfC) pay bands 1-4 continue to have job titles featuring the words ‘nurse’ or ‘nursing’.
Unregistered support staff with job titles that include the word ‘nurse’
The investigation, covering 104 NHS acute, mental health and community providers, found that 93% had unregistered support staff in post with job titles containing the word ‘nurse’. This accounted for at least 8,806 roles.
‘Support roles in nursing are a valued part of the workforce and as such should have defined titles and roles, and should not be used to substitute for a lack of registered nurses’
Lynn Woolsey, RCN deputy chief nurse
However, not every organisation specified the job titles their figures covered, and some included recognised titles, such as ‘dental nurse’ and ‘nursery nurse’, which we excluded from our count. We also excluded registered band 4 nursing associates. A further 2% said they had no staff at this level in roles using the word ‘nurse’, while the remaining 5% withheld the information.
Examples of potentially misleading titles we found include:
- Specialist nurse practitioner – band 4.
- Substance misuse nurse – band 4.
- Clinical nurse – band 3.
- Emergency nurse assistant – band 3.
- Nurse – band 3.
- Specialist nurse support – band 4.
- Senior nurse support – band 3.
- Transitional nurse – band 4.
- Assistant practitioner nurse – band 3.
- Trainee registered nurse – band 4.
- Staff nurse – band 4.
- Associate nurse – band 4.
- Pre-registration/aspirant nurse – band 4.
- Nursing auxiliary – band 3.
- Clinical support worker nursing – band 2.
We asked some of the organisations using these titles to respond. Most did not do so, but one revised the information it sent, claiming the original had been inaccurate. However, the updated version still included some job titles that might create a false impression.
‘It’s equally important to determine how much of this is deliberate role substitution and a cost-cutting strategy’
Paul Trevatt, #ProtectNurse campaigner
RCN deputy chief nurse Lynn Woolsey says the examples raise deep concerns about the ease with which the title of nurse can be used inappropriately.
‘Some of the titles can give a false sense of a level of qualification and practice, which can confuse the public and lead to safety issues,’ she says.
Unprotected title of ‘nurse’: raising awareness among healthcare colleagues and the public
The RCN called for the title of nurse to be protected in law, ahead of the July general election .
Ms Woolsey says: ‘Support roles in nursing are a valued part of the workforce and should have defined titles and roles, and should not be used to substitute for a lack of registered nurses.’
Paul Trevatt has been part of a nurse-led #ProtectNurse campaign team, which has worked over recent years to inform the public and healthcare staff that the title ‘nurse’ is not legally protected.
‘I’m extremely concerned to see how many roles here use ‘nurse’ in their title’, says Mr Trevatt, the RCN professional framework joint partnership board co-chair.
‘If I was a patient and someone introduced themselves to me as a clinical nurse or a substance misuse nurse, I’m going to make a series of assumptions that this person is a registered nurse, that they are regulated, qualified as a registered nurse and have the necessary expertise, experience and education as a registered nurse.
‘The concern here is not just for patient safety, which is by far the largest priority. It’s equally important to determine how much of this is deliberate role substitution and a cost-cutting strategy.
‘Advanced’ nursing roles at bands 1-4
Our investigation also found that some employers were using ‘advanced’ in job titles for staff in bands 1-4. This applied to about one in five organisations (16%). Examples included the following roles that were all graded at band 3:
- Advanced nursing assistant.
- Advanced clinical support worker.
- Advanced support worker.
- Advanced healthcare assistant.
This may suggest a degree of progress since our 2018 investigation when we found almost one in four organisations we surveyed were using this descriptor for unregistered nursing roles.
We asked all organisations on how often they reviewed job titles. Only 11 organisations confirmed they planned to review use of the ‘advanced’ designation for job titles in these pay bands, while 25 said such exercises were on an ad hoc basis or when roles became available. A further 42 said they had no plans to review job titles and another 26 either could not provide the information or did not respond to that question.
Will ‘nurse’ job title ever be protected in law?
The term ‘registered nurse’ is protected in the UK under the 1997 Nurses, Midwives and Health Visiting Act. To use it, an individual has to be registered as a nurse with the Nursing and Midwifery Council (NMC).
There has been a long-running campaign by nurses to safeguard use of the term and many harbour hopes the title ‘nurse’ will finally become protected by law.
RCN members passed a resolution at the college’s 2022 congress declaring the need to protect the ‘nurse’ title. Protecting the title by law was a key point on the RCN’s government policy wish-list published for this year’s general election.
Back in 2021, a petition to parliament received more than 33,000 signatures, and the #ProtectNurse social media campaign was established as part of that effort, spearheaded by London South Bank University chair of healthcare and workforce modelling Alison Leary.
RCN professional framework joint partnership board co-chair and #ProtectNurse campaigner Paul Trevatt, says there was hope that this reform would be included in the King’s Speech in 2023 and then in 2024, but this did not happen.
Risk patients and the public being misled
Mr Trevatt says: ‘Each day without protection increases the risk of more individuals using the title nurse and misleading patients and the public. Patient safety should be a number one priority here.
‘The NMC has stated it is essential we have the right protected titles, and it is of paramount importance the new government leads and supports the regulatory reform process which will hopefully lead to the appropriate legislation and role protection.’
The NMC says it has made it a priority to work with the government on reforms and is exploring changes that would mean the ‘nurse’ title wins legal protection.
Unregistered NHS support staff: ‘increasing reliance on vital but hidden’ work
The issues uncovered are not new.
A 2017 study by London South Bank University chair of healthcare and workforce modelling Alison Leary found hundreds of unregistered support workers in the NHS with job titles that described them as nurses with advanced skills.
Professor Leary now says the results of our investigation show some job titles may be misleading the public into thinking they are seeing a registered nurse. ‘It also means the increasing reliance on the support workforce and the vital job they do is hidden,’ she says.
- RELATED: Unregistered nursing support staff working under specialist nurse job titles, study reveals
The profession is awaiting the results of a recent consultation by the NHS Staff Council job evaluation group on proposed revisions to job evaluation profiles for nursing and midwifery bands 4-6.
The review came after a joint request to the staff council by the RCN and the Royal College of Midwives for job profiles to be updated for the first time in more than a decade.
Employers should not mislead or confuse patients
NMC executive nurse director of professional practice Sam Foster says that patients and service users should be in no doubt about who is caring for them.
‘If that’s someone with “nurse” in their title, then the patient should be able to assume that means a professional on the NMC register who meets our Code and standards,’ says Ms Foster.
‘While “registered nurse” is the protected title, employers should be mindful not to inadvertently mislead or confuse people about who is providing their care.’
Nursing Standard’s nurse title survey method
We asked 172 NHS hospital trusts and health boards to provide information on the numbers of Agenda for Change pay band 1-4 staff they had with job titles containing the word ‘nurse’ or ‘nursing’.
The data were collected through Freedom of Information requests emailed to the organisations in England, Scotland, Wales and Northern Ireland in May 2024.
A total of 104 organisations returned data, which were analysed by RCNi journalists.
