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Time for a cap on job titles?

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The variety of job titles can mislead patients The variety of job titles can mislead patients

What’s in a name? A lot when it comes to the nursing profession a new study has revealed.

Published this July in the Journal of Clinical Nursing, Variation in job titles within the nursing workforce1 found there were 595 job titles in use in 17,960 specialist posts, once the specialism had been removed.

In explaining the aims of the study, researchers highlighted how ‘the work of specialist nursing has been under scrutiny for many years in the UK due to a perception that it is not cost-effective’. A common issue is the lack of consistency of job titles, which causes confusion to the public, employing organisations, colleagues and commissioners of services. This lack of consistency has ‘implications for the wider perception of advanced specialist practice in the worldwide community and the workforce more generally’, researchers said.

The study aimed to understand the variation in job titles in the UK population. A pre-existing data set of accrued studies into the work of nurses working in specialisms was mined for insight (N = 17,960).

Analysis of the data revealed the most commonly used titles were Clinical Nurse Specialist, Nurse Specialist/Specialist Nurse, Advanced Nurse Practitioner and Nurse Practitioner. There were three other primary groupings. These were variants with a specialist or technical prefix of suffix, for example Nurse Endoscopist, variants of seniority such as trainee, senior nurse for [specialism] or variants of function such as Nurse Prescriber. The clustering was driven primarily by pay band.

A total of 323 posts were recorded as holding titles such as Advanced Nurse Practitioner or Specialist Nurse who were not registered with the Nursing and Midwifery Council (NMC).

Researchers found there is a large array of titles, which ‘appear to have little relationship with other factors like education’.

It noted this variation and lack of clarity ‘appear to cause confusion to commissioners, colleagues and employers’ and it is ‘likely to be misleading to patients in that titles do not appear to confer assurance of educational background or levels of expertise’.

‘It also demonstrates that the previous assumptions by Council for Healthcare Regulatory Excellence that advanced practice labels are associated with career progression are unsound and should be addressed by the regulator,’ the study said.

The study concluded that the range of job titles in use in the UK today to describe nurses in specialist practice is ‘extremely varied’. Nurses who were not registered with the NMC were recorded in the data set using terms such as Advanced Nurse Practitioner and specialist nurse, which ‘could be an issue in terms of public understanding of these roles’ the research suggested.

Common framework

Researchers highlighted how the lack of a framework across England is an issue and recommended that ‘future role development and education from a common framework’ should be considered.

‘These roles are rarely considered despite the impact they have. Standardisation would help explain and also deploy the role to ensure that it delivers,’ researchers advised.

Commenting on the study’s findings, Crystal Oldman chief executive of the Queen’s Nursing Institute (QNI) says it is ‘timely, extensive, credible, and important’.

‘It has ‘shone a light’ on issues nurses have been aware of for a long time. It describes how misleading it is for patients when they do not know or understand that the person caring for them isn’t a registered nurse.’

For Debbie Brown, nurse consultant in Primary Care/ANP Burnt Ash Surgery, and also NHS Lewisham Clinical Commissioning Group, ‘it is good to see this study because it’s highlighted the urgent need to relook at titles and job descriptions across the nursing and non nursing sector.’

Looking at the study, what shocked Ms Brown the most was ‘the amount of different titles that are used by non-registered nurses’.

However, she points out that the study does not make it clear if the data features qualified nurses who have let their registration lapse, or healthcare support nurses given such titles as “advanced nurse practitioner”. And she is ‘disappointed’ to see non registered nurses having titles of advanced practice. ‘If they are not a nurse on the NMC register and haven’t fulfilled the requirements of that skill level to be on it, how can the title have “nurse” and “advanced” in it?’, she says.

Welcoming the report, Jane Warner, a nurse practitioner and associate lecturer in the south west of England, says its findings resonated so much when she read it she shouted ‘Yes!’ at every line of text.

She finds that job titles are so much more confusing, and ‘offer lip service to pay bands and levels of education, and where arguably the role of a Band Five equivalent Registered Nurse becomes of limited value to employers’.

‘For example, trawl through recent advertisements for NHS nursing posts and you will come across opportunities for employment as advanced nurses, associate nurses, nurse specialists, assistant practitioners, advanced practitioners, and nurse practitioners.

Many of these titles appear to be interchangeable she believes. ‘Indeed, one recent advert is for a Band Six associate nurse which actually asks for an advanced practitioner. Another is for a Band Four associate practitioner who will ‘work independently under the guidance and direction of a registered nurse’ – and purists may well argue that either someone can work independently or they can’t.

‘This is probably why topics such as accountability and delegation are always at the forefront of any agenda related to nursing practice and patient safety’, she says.

While the nursing regulatory body deems being an Independent Prescriber worthy of recording, Ms Warner says ‘debates still rage as to how to record and recognise advanced practice and the level of education required to achieve this standard’.

So what has caused this variation of job titles that is creating confusion within the healthcare profession and patients? Ms Brown believes it’s ‘a lack of understanding’ from healthcare employers about what roles involve’. She suggests that it also might be that trusts ‘think they can employ more Band Fives, without paying them for the role and salary of an advanced nurse’.

As highlighted by the new study, this confusion about job titles can cause problems ‘and is misleading’, Ms Oldman says. ‘If you are going to see a professional that has “doctor” in their title you understand their level of qualification. But if you see a health professional whose title is “assistant nurse practitioner” you assume you are seeing a nurse. However, the nursing profession has a plethora of names and titles, unlike medics who don’t have the same post-qualified structure,’ she says.

She suggests this means patients may be confused about the level of knowledge of practitioners looking after their care, and that potentially health professionals may not have the skills to meet the demands of patients. ‘What worries me is patient safety,’ Ms Oldman says.

Ms Brown emphasises the confusion caused by the many different healthcare job titles, recalling how patients say they think they’ve seen a nurse for a procedure and ‘are surprised to know they are not a qualified nurse’.

To resolve the confusion with job titles for healthcare staff and patients, Ms Oldman would like to see clear a ‘career structure that is underpinned by education, so that patients are assured a nurse is sitting in front of them with a general practice nurse level qualification that makes them competent to work in that role’.

Ms Brown hopes that the NMC will recognise the role of advanced nurses to make this a ‘recordable registration’. She adds that following this study she believes there needs to be a ‘part two’. ‘The work needs to be taken forward. We can’t ignore this issue of job titles and the confusion it causes.’

While potential employers and the general public are able to check on an individual nurse’s registration status, ‘because of these mishmashes of job titles we may need to go further, encouraging patients to access an online CV of the nurse specialist/advanced practitioner/nurse practitioner who is treating them’, says Ms Warner.

However, she warns that this plethora of titles ‘leads me to wonder whether this confusion will ultimately be resolved in arguably the worst possible way – the emergence of a generic healthcare professional, whose employment costs are kept to the bare minimum, and whose career development is destined to stall at the first hurdle’.


1. Leary A, Maclaine K, Trevatt P,Radford M, Punshon G. Variation in job titles within the nursing workforce. J Clin Nurs. 2017;00:1–6.

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