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.
1. 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.
1.1 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.
1.2 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.
2. 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.
2.1 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 two years described being settled in their role compared to those who moved base placements every six 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.
2.2 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.
3. 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.
3.1 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.
3.2 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.