Reprinted from the Nursing Times, June 28, 1968

When is a Nursing Auxiliarynot a 'Nursing' Auxiliary?Anthony J. CarrPrincipalWilliam RathboneStaff College, Liverpool

A resolution from the Ward andDepartmental Section of the Rcn, tobe debated in Cardiff in July, is thesubject of this article

The nursing profession will be dis-cussing in Cardiff during July this yearwhether to operate further restrictivepractices within its discipline; theWard and Departmental Section with-in the Rcn has drafted a resolution forthe Rcn Representative Body to dis-cuss. The essential theme is to removethe word 'nursing' from the title ofnursing auxiliary.

Restrictive PracticesThis proposed action could be termed

a restrictive practice. It seems quiteextraordinary that a profession maydeem it acceptable to restrict peoplefrom doing work in their particularprofession, while restrictive practicesin force on the shop floor in industryare condemned out of hand by thosesame professional people.

By calling a recognized body ofpractitioners 'professionals' it isassumed that they will have taken suchformal training as will allow them toperform adequately the tasks set beforethem. It also implies that those notwilling or able to take the trainingare not adequate to undertake the sametasks.

To safeguard their standards, mostprofessions will seek ways and meansto limit those unqualified, thus restrict-ing the practice of those skills to aspecialist group of people. The range ofskills thus restricted, together with theessential knowledge, is wide and varied.This can be seen from engineering toaccountancy, medicine to architecture,and from teaching to Holy Orders.Some of these restrictions are allowedfor by law while others are enforced byemployers who will only employ personsfor specific posts who hold certainrecognized qualifications.

Effects of the ResolutionIt is not the purpose of this paper to

discuss the merits or otherwise of thissystem of restrictive measures but onlyto make the reader aware that this typeof behaviour is widespread both in theprofessions and in almost every otherwalk of life. The writer would muchrather examine in greater detail thelikely effects of the passing of such aresolution within the nursing profession.

To be fully operative the resolutionwould have to be accepted by the Rcndelegates, the Council of the Rcn and

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then in turn by the Nurses and Mid-wives Whitley Council and the Ministryof Health. Before those implications areconsidered, first look at the short his-tory of the nursing auxiliary. It has beengrowing for the last 20 years into quitea story.

Since 1949 the 'other nursing staff'have increased from 27,525 to 57,650by 1966, a growth rate of 112% orover 6.5 % per year over the wholeperiod. In fact in 1965 this figure washigher but the opening of the Roll forpersons with experience in the psychia-tric field reduced the numbers ofauxiliary staff by about 9 %. The graphshows the growth for most grades ofnursing staff in the form of percentagesup to 1966.

The only grade not shown is that ofpupil nurses. Their numbers have in-creased since the smaller general train-ing hospitals have changed to pupilnurse training and other hospitalshave opened training schools to trainnurses for the Roll. This trend is clearlyreflected in the growth figures for the

Other Nursing StaffEnrolled Nurses

Registered Nurses

,,---~o Student Nurses

1965 1966

enrolled nurse. These show an increaseof over 30% from 1965 to 1966.

It can be readily seen that the nursingauxiliary growth has been a real one.This growth is, of course, interpreteddifferently according to who is readingit. To the nursing profession it isusually seen as a threat to standards ofpatient care together with a gradualand continuing dilution of the professionby untrained personnel. To manage-ment, on the other hand, this growthis seen as the answer to the manyemployment problems facing them.

Who is Right?Who then is right? The answer

probably lies somewhere in betweenthese two views. The increase in nursingauxiliaries must not be considered inisolation but rather in the context oftremendous change. Medicine, and con-sequently nursing, was much simplerand slower in pace 20 to 30 years ago.Many of the now common drugs andtechniques were then unknown. Theskill of the trained nurse in making her

patient comfortable was her prero-gative and her most understood role.In this the nurse found security andsupport both for herself and her patient.Unfortunately for some, times havechanged. It is therefore essential thatthe nursing auxiliary be viewed as partof a well-trained nursing team of 1968and not that of an individual in ahospital of 1948.

Should the resolution have the ulti-mate success its sponsors would ·wish,the question must be asked as to whatthe results are likely to be for thenursing profession in general and for thenursing auxiliary in particular. The firstreaction of the nursing auxiliary is likelyto be a great psychological one. Thiseffect could be quite significant. - r

It should be remembered that at thepresent time, nursing auxiliaries aremaking a very considerable contributionto the nursing of the patient. In somehospitals auxiliaries are holding posts ofresponsibility. It is becoming commonpractice for nursing auxiliaries to r~lievenurses for meals on night duty and actas the second nurse on the same duty.Just removing the title 'nursing' fromher title will not stop these practicesfrom continuing but rather lower themorale of these people as they see theprofession taking deliberate and cal-culated action against them and theirwork.

Since the introduction of the 1964syllabus for pupil nurses, some hospitalshave been unable to offer all the ex-perience necessary during the two yearsof training. This has meant secondmentto other hospitals, while yet other hos-pitals possessing only geriatric patientshave ceased to become training schoolsat all. The only replacements availablefor both these types of hospital havebeen nursing auxiliaries. The word'nursing' may be removed but nursethey will because the situation demandsit. Therefore this cannot be the logicalreason for the demand for theremoval of this word.

The second effect that this resolutionwould have would be most disastrousfor the nursing profession. It is possiblethat the effects would be felt for manyyears to come, if not for all time.

New Controlling Council?Once the 'nursing' part is removed,

organizations representing the interestsof the nursing auxiliary on the Nursesand Midwives Whitley Council couldask for this grade of staff to be re-moved completely from the control ofthe Council and be transferred toanother, more appropriate Council.This request would receive the un-qualified blessing of the professionalorganizations as they would see theirfuture negotiating strength increased atthe expense of those other organizations.The reason for this probable reactionwould be that some of the trade unionshold some of their seats by reason of

their auxiliary membership.This is not meant to imply that these

organizations do not represent, theregistered nurse. Many of these' move-ments do have quite large numbers ofnurses in membership. However, havingtaken this action the next step would beto transfer the employment of the nurs-ing auxiliary to the hospital secretary.Thus would continue unabated theprofession's continued demise in themanagement sense.

The Prices and Incomes Board re-port clearly indicated that grade Iin the Salmon structure was to be thenursing auxiliary. In other words thebasis and foundation of the wholepyramid would be the nursing auxiliary.Is the profession going to continue touse to its own disadvantage that well-worn phrase, 'It's a non-nursing duty'?

This needs to be explained in manage-ment terms to show the full effect of thisargument. Many staff formerly con-trolled by the nursing services (lineauthority) have now been transferred tothe supporting services. These servicesare called 'functional' and each hasits own 'line' manager. The great faultwith this newer system of managementis that the staff involved have not beentrained to understand the effects ofsuch changed relationships, and there-fore find themselves in impossiblesituations.

For instance, the domestic assistantin many hospitals is given a new linemanager in the form of a domesticsupervisor but all senior people expectthe ward sister to change overnight herrole of line manager to that of co-ordinator of ward activities. Thiscan and does make for difficult re-lationships if communications are poorand job descriptions inadequate. Buttrying to divide the nursing team in thisway, is in a sense, to commit managerialsuicide. .

It is perhaps also interesting that asthe nursing profession seeks to managefewer and fewer people, so the demandfor greater remuneration and higherstatus continues unabated. Surely thisis restrictive practice in its purest form!

The Future of the Nursing AuxiliaryHow is the nursing auxiliary to be

managed and trained in the future?Immediately this type of question isasked, the profession faces a dilemma.

There is much discussion at themoment regarding job descriptions fornursing staff. Salmon project leadersthroughout the country are busy writingjob descriptions at this present time.Unfortunately, although there seemsto be lots of information about theseexercises in the professional journals,very little, if anything, is heard aboutjob analysis.

Is it that this information is notthoughtnecessary to put into print or isit rather that two very large steps havebeen taken at once and that jobs have

first been described and then analysedfrom the description? Surely it is essen-tial that on-the-job analysis is performedfor every grade of staff in every workingsituation in all hospitals. When thefurther work of job description is per-formed the place of the nursing auxiliaryin the ward nursing team will be veryclearly seen. It will show that in mosthospitals she is occupying a very im-portant place and playing an essentialrole in the profession of nursing.

New Type of TrainingOnce jobs have been carefully

analysed in the working situation andnot in an office, and job descriptionswritten, thought has to be given as tohow to train the nursing auxiliaryeffectively. It has been proved in otherfields of human activity that unskilledpeople can be taught skills to a veryhigh level of efficiency, the secret beingthat the range of skills should be limited.If the hospital has developed a highlyorganized, reliable system of per-formance appraisal of its staff, thencertain skills will be shown to be per-formed well by the majority of thebetter auxiliaries. These skills then needto be further analysed on the job andbroken down into their componentparts. This process is termed skillsanalysis.

A completely new form of trainingskills then needs to be undertaken. Asmall team should be formed consistingof one or two experienced nursingauxiliaries who have developed highlevels of skill, and an experienced wardsister and a clinical instructor to leadthe team. This small unit could trans-form the nursing auxiliary standardswithin a large hospital within months.The effects should be of lasting value.

ConclusionThe aim of this paper has been to

draw attention to the effects on thenursing auxiliary of passing a resolutionof this kind. Action, if taken, could soaffect nursing that it would never fullyrecover. It has tried to show the con-fusion existing at ward level regardingchanged relationships with ancillarystaff. It has also attempted to suggest,in broad outline, new techniques oftraining and ways in which this couldtransform the performance of thenursing auxiliary grade.

As a last plea the writer would like toemphasize that nursing auxiliaries inmany hospitals are at present under-taking a wide range of nursing duties.They only do this work because regis-tered nurses are either unable or un-willing in particular areas of the countryto do this work themselves.

Let the whole profession recognizethis contribution and welcome thesepeople into their nursing teams andgive to them the true status that theyhave already earned and call themnursing auxiliaries. ~