Healthcare professionals' views of a new second-level nursing associate role: a qualitative study exploring early implementation in an acute setting.

AIM
The study aimed to establish the views of a range of stakeholders about their experiences of the newly implemented nursing associate role in England and its potential to contribute to patient care.


BACKGROUND
Second-level nursing roles are increasingly used internationally within the healthcare workforce. In response to registered nurse workforce deficits, a new nursing associate role has been introduced in England to augment care provided by registered nurses and enable career progression of support workers.


DESIGN
Qualitative descriptive design.


METHODS
Semi-structured interviews and a focus group were conducted with a range of healthcare professionals in a large inner-city acute secondary care healthcare organisation in England. Interviews were guided by the Consolidated Framework for Implementation Research and analysed using Framework Analysis. The study was reported according to COREQ guidelines.


RESULTS
33 healthcare professionals were interviewed - directors of nursing, ward managers, nursing associates and multidisciplinary team members. Participants perceived the role was broadly adaptable to different healthcare settings and provided a positive professional development mechanism for healthcare support workers. Managers felt training commitments made implementing the role complex and costly. Participants argued the role had limitations, particularly with intravenous medicine management. Implementation was impeded by rapid pace and consequent lack of clear communication and planning.


CONCLUSIONS
The nursing associate role was perceived as an inclusive pathway into nursing but with limitations when working with high-acuity patients. Further evaluation is needed to investigate how the role has embedded over time.


RELEVANCE TO CLINICAL PRACTICE
The role should be seen as both a stepping-stone into registered nursing positions and valued as part of the nursing workforce. Consideration must be given to how the role can be safely implemented in different settings. Findings have relevance to healthcare leaders internationally, who continue to work in a climate of economic pressure and staffing shortages.


| INTRODUC TI ON
Second-level nursing roles are used internationally within the healthcare workforce to support first-level registered nurses in their work.
In countries such as Australia and Canada, workforce shortages and economic pressures mean that second-level roles have changed over time moving from the delivery of care to stable patients to an enhanced scope of practice including medication administration (Jacob et al., 2013), alongside increased educational preparation (Dahlke & Baumbusch, 2015;Jacob et al., 2016).
In the UK, a second-level nursing role-the enrolled nurse (EN)was discontinued in 2000 and nurse training moved into university settings (United Kingdom Central Council for Nursing, 1986).
Nurses in this role had reported issues with workload and stifled career progression unless converting to a registered nurse (RN) role (Royal College of Nursing, 2015). The removal of the second-level role led to a reduction in the size of the nursing workforce and an increase in the use of unregulated support workers-healthcare support workers (HCSWs)-thus impacting on overall skill mix (Ball et al., 2019). Systemic failings in some areas of care (Francis, 2013) prompted a review of such roles (Cavendish, 2013) and led to a reexamination of education and training to support high-quality care in nursing and to build the capacity and capability of the workforce heavily affected by staff shortages (Health Education England, 2015). As one part of transforming the workforce to deliver optimal care and to bridge the gap between HCSWs and RNs, a new second-level nursing role-the nursing associate (NA)-was subsequently developed. The NA role was designed both to support RNs and provide career progression possibilities for those in support roles into the nursing profession (Health Education England, 2016).
The development of this role sits within a broader picture of new clinical role development designed to address funding, recruitment and retention issues in the National Health Service (NHS) (British Medical Association, 2020).
International research on the use of second-level nursing roles continues to report on the increased use of the role in a broader variety of settings including acute care (Moore et al., 2019), alongside a lack of role differentiation between first and second nursing levels (Kusi-Appiah et al., 2018) especially when demarcated by tasks (Jacob et al., 2013). Research has also pointed to the devaluing of second-level roles (Janzen et al., 2013), which are positioned as focusing on physical care through practical tasks rather than critical thinking, thus reproducing problematic gendered divisions that are still attached to care work (Clayton-Hathway et al., 2020). Previous research has reported the need for more participation from secondlevel nurses in research to explore issues that have persisted over decades of practice in different countries and contexts (Moore et al., 2019). The advent of the nursing associate role in England provides a useful opportunity to understand how a new second-level nursing role is viewed as it is implemented to avoid replicating some of the problems that continue to be debated in research, policy and practice.

| Background and context
Registered nurses (RN) and unregistered healthcare support workers (HCSW) represent the largest proportion of the UK healthcare workforce (Leary et al., 2016). There are 40,000 nursing vacancies in health and care settings in England (Royal College of Nursing, 2020), a number which has been influenced by changes to the funding of healthcare courses and a drop in European nurses joining the workforce following plans to leave the European Union (The Health Foundation, 2020). The coronavirus pandemic in 2020 has also emphasised the need for a robust and sustainable healthcare workforce and although the spotlight on healthcare professions has increased recruitment to pre-registration nursing programmes (Department of Consideration must be given to how the role can be safely implemented in different settings. Findings have relevance to healthcare leaders internationally, who continue to work in a climate of economic pressure and staffing shortages.

K E Y W O R D S
implementation, nurse roles, nursing, nursing associate, nursing workforce, qualitative study, registered nurses, role development, workforce planning What does this paper contribute to the wider global clinical community?
• The study is one of the first to explore the implementation of the nursing associate role and assess how the new role was viewed by stakeholders.
• The nursing associate role needs to be clearly communicated, championed and supervised and its scope demarcated to build a clear identity within healthcare organisations to avoid it being reinterpreted as a repeat of previous second-level nursing roles.
• A second-level nursing role should not only be seen as a stepping stone into registered nursing positions but also needs to be valued and allowed to exist in its own right.
Health & Social Care, 2020), there is still a requirement for creative solutions to the registered nurse workforce deficit. Whilst several studies have been conducted on views of secondlevel nursing in different countries (Lucas et al., 2021), given the recency of this role development in England, research into how this role is being operationalised and how healthcare organisations have reacted and responded to its implementation is relatively limited.
Initial research into nursing associate trainees' experiences largely focused on the training model. In these studies, role ambiguity and the need for role clarity (Coghill, 2018) (King et al., 2019), as well as the need for education and communication about the scope of practice of the role has been reported (Health Education England, 2019). An evaluation of the nursing associate role including expert interviews, a survey with chief nurses in England and case studies of two NHS organisations providing community and mental health care has also been conducted (Kessler et al., 2020). However, the need to understand the implementation of the role in acute secondary care settings remains. Halse et al. (2018) identified seven key factors for healthcare leaders and workforce planners to consider when planning the integration of the new role into their established workforce. This includes wide consultation and engagement with stakeholders at every stage to allow the benefits of the role to be realised and integrated. Given the nursing associate role is new to the healthcare workforce in England, there is a need to understand how it is perceived by second-level nurses themselves and other healthcare professionals who work with them, to ensure optimum teamwork and patient care and to meet the recommendation from the first evaluation of the role by Health Education England (2019) to: 'conduct robust research and evaluation about how qualified nursing associates are being recruited and deployed over time' to help further understand and embed the role (p.8). The overall aim of this study was to explore the experiences of a range of stakeholders of the implementation of the nursing associate role within a large, inner city, acute secondary care NHS organisation. This study was conducted from November 2019-January 2020 before the COVID-19 pandemic.

| Theoretical framework
Our study was informed by the 'meta-theoretical' Consolidated Framework for Implementation Research (CFIR). This framework was developed from a synthesis of existing theories and was developed to help understand 'what works where and why' in implementation, in this case enabling us to understand how the nursing associate role was 'assimilated into the organisation' (Damschroder et al., 2009). As Damschroder et al. explain, the implementation period is a 'gateway' into consistent and skilled use of the intervention.
The CFIR framework consists of 26 constructs under five domains: intervention characteristics, outer setting, inner setting, individuals' characteristics and process. In qualitative studies, in the postimplementation phase, the CFIR can have an application both within data collection and analysis processes (Kirk et al., 2016).  (Tong et al., 2007) (Appendix S1).

| Data collection
Following ethical approval, information advertising the study was communicated to potential participants via email and flyers.
Potential participants included all nursing associates, their managers and relevant directors of nursing. Members of the multi-professional teams who had worked in clinical areas with nursing associates were also contacted. Although sampling was purposive, participants were self-selecting from within the potential participant group. A participant information sheet and consent form were sent or handed out to those who contacted the researchers and expressed an interest in participation. After a minimum of 48 h, two researchers (TT, DD) followed up to answer questions, confirm eligibility, provide further information or arrange a date for the interview to take place. The main reasons for non-participation included capacity issues within the workforce and a lack of knowledge or working relationships with NAs.
Interviews were conducted by three of the research team (JB, TT, DD). Two female researchers (TT, DD) conducted face-to-face interviews and a focus group within the four hospital sites. Both researchers were registered nurses, who were relatively new to qualitative interviewing, so pilot interviews were conducted before the researchers went into the field. Another academic-an experienced qualitative researcher and registered nurse-conducted telephone interviews (JB). The researchers did not know the participants before conducting the interviews. Participants were made aware of How did the structure of [organisation name] influence the implementation of the role? How was the role communicated across the organisation? How is communication generally across the organisation? How has organisational culture impacted on implementation? Has culture at the level of ward or unit influenced implementation and perception of the role? How ready is [organisation name] to implement this change?

Characteristics of individuals
Knowledge and beliefs about the intervention Self-efficacy Individual stage of change Individual identification with the organisation What did staff think about the role and the potential effectiveness or impact the NA role could have? Did you believe that you could make an impact with the role? Did you believe you could work effectively with NAs in clinical areas? How ready were you to take on the new role of nursing associate? Would you consider working in another organisation now that you are qualified? The team agreed on a minimum number of interviews to be conducted for each professional group: 5 nursing associates; 5 ward managers; 2 directors of nursing; and 10 multidisciplinary team members (MDT), to access a range of participant views. The minimum was achieved in all groups apart from for the MDT, many of whom were unable to participate in focus groups or interviews due to winter pressures within the National Health Service. Following a review of the data from 33 participants, it was concluded that the sample composition, sample size and the information collected was adequate to answer the research questions (Lincoln & Guba, 1985).
No repeat interviews were conducted.
As with other qualitative studies using CFIR ( Table 2. As advised by the CFIR guidance, broad open-ended questions were asked at the start of the interview to help establish rapport (CFIR, 2020). Follow-up, open-ended questions were used to allow participants to reflect further on their answers. Single interviews, conducted across the sample, were audio-recorded, lasted an average of 29 min and were transcribed by a professional transcription company. A focus group was also conducted, lasting 52 min and was both video-and audio-recorded to enable accurate transcription.
Given the pressures on healthcare professionals' time, it was decided not to return the transcripts to the participants for comment or correction. All researchers involved in data collection checked the de-identified transcripts against the audio recordings for accuracy.

| Analysis
Data analysis was initially deductive, using thematic framework analysis (Ritchie et al., 2013) with the process guided by the approach taken by Gale et al. (2013)-the steps are outlined in Figure 1.
Interview and focus group data were pooled and analysed collectively, with the role of the interviewee being given greater significance in the analysis than the nature of the data collection. NVivo Pro V12 (QSR International) was used to support the initial coding of the transcripts to the CFIR constructs, as it offered a predetermined structure for the different members of the study team (GL, TT, DD, LA) working concurrently on the transcripts. Data were then coded within a grid using Microsoft Excel, with the analysis framework predetermined by the CFIR. Once the data had been charted into the matrix framework, an inductive approach was taken to identify new knowledge related to the implementation of nursing associates in this context and themes were identified. All members of the research team were involved in the data analysis and themes were finalised through discussion and agreement where there was a diversity of interpretation.

| Ethical considerations
Written and verbal information about the study was given to the participants and consent received before interview. Participants were informed that participation was voluntary and that they could withdraw their participation at any time up to the point of F I G U R E 1 Steps undertaken for data analysis

| RE SULTS
Thirty-three participants were recruited to the study. The sample comprised ten ward managers, nine nursing associates, five directors of nursing and nine members of the multidisciplinary team consisting of healthcare assistants, physiotherapists, advanced nurse practitioners and practice development nurses. Synthesised results are presented in the following sections, and the key themes and associated CFIR constructs are presented in Table 3. For some of the CFIR constructs, for example the outer setting, no themes were identified during the analysis; therefore, these have been omitted from the results section. In addition, the MDT participants were unable to discuss the role at length as they were mainly unaware of it. Where they have raised relevant points, they have been included in the sections below.

| Domain 1: Characteristics of the intervention
In terms of assessing the characteristics of the NA role, themes related to four constructs of adaptability, complexity, design quality and packaging and cost.

| Design Quality and Packaging of the NA role: 'How do you identify them?'
The presentation and identification of the NA role was reported to be an issue across the stakeholder groups. NAs did not have a specific uniform due to their low numbers in the workforce and this

| Costs of implementing the new NA role
The cost of the NA role was discussed by all the different stakeholders. For DoNs and WMs, cost related to backfill to allow for HCSWs to attend training and the challenges associated when NAs were not able to fulfil all the role requirements before they had completed their training. Across the other stakeholder groups, it was broadly perceived that the NA role was a long-term costeffective intervention to reduce the numbers of agency staff and fill RN vacancies. Additional cost benefits related to the NA apprenticeship providing a route into the nursing profession for those who were unable to afford to go through the traditional university route. One DoN also expressed that there had probably TA B L E 3 Summary of the factors influencing implementation of the nursing associate role by themes

Characteristics of the intervention
Varied adaptability of NA in clinical practice 'We have limitations, so we can't do certain things and it's not always possible to have all the patients who will fit in terms of me being able to look after them. So that's the difficulty, and some wards' patients, their dependability on the nurses is much more -so if they are at risk or they are very sick' (NA8) 'Having people skilled up in physical and mental health working in enhanced care for example. The nursing associate role is brilliant in that context and it's been an opportunity for us to look at roles across pathways' (DoN4).  'We're lucky we had a very flexible leadership who were willing to embrace it, very good education academy who just went for it.' (DoN4) 'We're only now just getting these PDN roles to support' (DoN1) 'I think that the role of the ward manager is an incredibly challenged one and whilst email information and using intranet and face to face conversations about the nursing associate, and the lack of real detailed policy description as well has been probably an element of concern' (DoN3)

Characteristics of individuals
Knowledge and beliefs about the NA role: 'a stepping stone' 'The ultimate goal is to be a registered nurse, which I felt being a nursing associate would be a stepping-stone into the nursing full registration.' (NA2) 'For me, whilst there a number of concerns that I have about the nursing associate programme, I do see it as an opportunity to actually grow our local workforce either through ensuring that we can provide mechanisms for our current support workers or nursery nurses to actually step onto the nursing associate programme and secure a foundation degree programme, or perhaps in the longer term to actually look at direct recruitment from our local communities.' (DoN3) Individual stage of change: 'getting used to it' 'When we started, they [nurses] just couldn't be bothered but they're getting the hang of it now. I think because it's like mother, child. So, "OK, you do that, you're supposed to do that, you don't do that, OK" […] So, they're getting used to it now.' (NA2) 'Well, I can understand the difference from being healthcare support worker from just reporting to the nurse or the sisters, I can actually know why this is happening and act on it without, I will tell her but if I can fix it myself then I will do it and I can know evidence base behind that, that one I, I've learned a lot.' (NA8) been an 'emotional cost' in terms of the introduction of a new role and the questions it might have raised for ward managers around ensuring safety (DoN1).

| Domain 3: Inner setting
The inner setting within the CFIR includes the structural and cultural contexts for the implementation. In this study, stakeholders focused on how the implementation climate of the healthcare organisation had transitioned to become more accepting of the role and how the organisation lacked readiness for its implementation.

| Readiness for Implementation of the NA role: 'it was slow'
In terms of the tangible indicators of the organisation's decision to implement the intervention, ward managers and DoNs expressed that the organisation was not ready for the role because NAs could not 'function at the level that they're trained at' (WM1) and lacked guidelines in terms of how they function within teams. However, DoNs suggested that there would never be an ideal time for implementation and that this problem was not unique and affected the health service as a whole.
Three sub-constructs were identified within the themes related to the organisation's perceived readiness for the role. Leadership engagement and available resources to support the role implementation focused on the role of practice development nurses (PDNs) in supporting and supervising the role, which was seen by WMs and DoNs as critical for embedding and clarifying the role in the organisation, although potentially the resource was insufficient to support a 'huge

CFIR Domain Theme Quotations
Process Role planning: 'had to get the ball rolling' 'I think there are always opportunities for us to have got more ready, to have actually had a specific allocated team with people in post and directly project managing the implementation of the nursing associate programme' (DoN 3). 'I felt when they first started, they came in very quick and I thought it was a little bit disorganised because, that's how I felt because I think with the initiative, it, all of a sudden, we knew it was happening but I felt like [organisation] all of a sudden took them.' (WM6) Executing the NA role in practice: 'it will take a while' 'Today we're quite fully staffed and there aren't enough HCAs, so I'm having to take on my, well HCA role […] Well it's sort of a back step […] all that training, all that learning, if you're not really using it' (NA3). 'They practice on their own. They do everything on their own, within their limit. If they need anything, that they can't do, they escalate it to the nurse in change and the nurse in charge will do that for them' (WM10) culture change' (DoN1). In terms of access to knowledge and information about the NA role, several WMs considered that the speed of the implementation and its 'pioneering' aspect (WM8) meant that 'the detail wasn't there' in terms of information about the role (WM1). This was reiterated by DoNs, who felt that more 'detailed policy description' was needed for the role (DoN3). All the nursing associates interviewed described the impact of a lack of knowledge about the role amongst staff as they had to explain their role to colleagues. Interviews with MDT members confirmed that this is how they had found out about the role. Knowledge about the role was also impeded by a lack of perceived visibility for the role given the relatively small numbers of NAs, as one NA explained, 'we're just a drop in the ocean' (NA4).

| Domain 4: Characteristics of the individual
The fourth domain within the CFIR relates to individuals involved in the implementation and their attitudes and behaviours.

| Knowledge and beliefs about the NA role: 'a stepping stone'
All WMs, NAs and some MDT participants saw the NA role as a positive innovation that could provide a pathway and 'stepping stone' (WM6) for support workers to develop their careers. This fitted well with the staff development aspect of WM roles and all the DoNs spoke with some level of enthusiasm for the potential of the role, particularly from the perspective of a socially inclusive agenda and an opportunity to grow the local workforce either from within the organisation or the community.
All NAs discussed the value they saw in the role and the new focus on their knowledge of why action was taken, critical thinking, being able to work with more independence and increased responsibility. Whereas NAs believed in the value of their work, some WMs expressed some personal concerns that this was a long-term solution to RN vacancies. Some saw it as recreating the 'enrolled nurse' role that they had experienced earlier in their careers.

| Individual stage of change: 'getting used to it'
WMs reported that they had to adapt to the role over time (WM4).
One WM commented that they had not seen any benefit thus far in the NA role implementation. It was not clear that all WMs were progressing to enthusiastic use of the intervention but there was a general sense of optimism that there would be expansion and continued use of the role. Ward managers felt that it was the HCSWs who had experienced the greatest change from the introduction of the new role and described them as 'invigorated' as they wanted to get on to the NA programme (WM1). NAs themselves discussed how they had enhanced skills, were able to offer 'upgraded care' (NA5) and had 'improved confidence' (NA2) and how it made them want to recommend the route to others. However, whilst they had moved ahead, NAs felt the progress was slow and not unanimously shared by nursing colleagues who were still 'getting used to' the role (NA2), or indeed by every NA, as adapting to change was an individual journey. Participants from the ward manager and MDT groups explained that there was a 'big jump' between the HCSW role and the NA role (MDT6) and sometimes 'in their mentality' some NAs were still HCSWs (WM9).

| Domain 5: Process
In terms of the implementation process, in this study, participants particularly focused on the planning and execution of the NA role.

| Role planning: 'had to get the ball rolling'
Across participant groups, there was a sense that the introduction of the role was a 'rush' (WM7) and they just 'had to get the ball rolling' (WM1). Most of the ward managers felt that they were not prepared and were 'thrown in at the last minute' leading to a 'sink or swim outcome' (WM3). Directors of nursing held similar views in terms of the lack of preparation time and its impact on the initial quality of the implementation. However, both managers and directors felt this to be usual within health care and expressed pragmatic views of needing to 'design it as we went along' (DoN2), although reflecting that a 'more structured way' of planning roles would be beneficial (DoN4).
3.14 | Executing the NA role in practice: 'it will take a while' There were mixed views of the role execution, with some NAs and other professionals feeling that they were able to execute the role and could 'feel the difference' of working as an NA (NA6). However, across all professional groups, including around half the NAs, there was criticism that the NAs were not 'fully functioning' or working at full scope (WM1). Indeed, sometimes the NA role was seen as unhelpful by WMs because of its limitations and it became a 'burden on nurses' rather than a support as planned (WM5). Although the role was planned to enable HCSWs to enhance their skills, this was sometimes not being executed in practice due to staffing issues coupled with the lack of a clear job descriptor within the organisation.
Overall, there was an understanding that the role might take 'a year to embed' (WM1) and that it would improve over time. Success was seen to be dependent on NAs being 'utilised appropriately in the clinical areas' (MDT6). Indeed, as one DoN explained, there was a relatively small number of NAs working in practice and they worked best in areas 'that designed what they needed' (DoN3). Two WMs also commented on the NA intervention against its planned objective as a pathway into nursing stating that NAs may not be ready to go straight into nursing training and required time to 'consolidate' the role first (WM8).

| DISCUSS ION
This is one of the first qualitative studies of the new nursing associate role in England and the first, to our knowledge, to use the CFIR to explore how the role has been perceived by healthcare professionals. Given the challenges reported with second-level nursing roles internationally over recent decades, the use of a meta-theoretical implementation science framework has enabled us to systematically explore a range of constructs that stakeholders perceive as impacting the implementation of the role.  (Janzen et al., 2013) and organisational failings with job descriptors have been identified in a review of nursing roles (Kusi-Appiah et al., 2018). Other studies have reported that trust and value developed over time helps to cement identity for these nursing roles within healthcare teams (Huynh et al., 2011) (Melrose et al., 2012.
The cost and complexity of the NA role implementation were identified as entangled for ward managers and directors of nursing.
The complex process of taking HCSWs through training into the NA role and then into RN training had knock-on effects in terms of staffing and thus in terms of costs. NAs also discussed that the transitions between the roles and the multiple hats that had to be worn during this process added to the complexity. Although a longer-term cost benefit was generally perceived to have influenced the role development, shorter-term cost pressures were discussed both in financial and emotional terms. As Halse et al. (2018) (Kessler et al., 2020) . However, views of the former UK second-level enrolled nurse role also impacted some views of the nursing associate role. Given that enrolled nurse position was devalued and had poor prospects (Kenny, 1993), this lasting impact again suggests the need for communication that clarifies the NA role.
Participants' views on the process of the implementation of the role focused on planning and execution. There was an overall consensus the organisation and its staff had to quickly adapt to the role and work out how to use it and make it work without much time to plan. This arguably had an impact on how the role was executed.
Some NAs commented that they had to work below their level and were not able to fully take on the role in practice due to patient needs and staffing shortages, which proved frustrating. Given the recency of the role implementation, participants felt it would take longer to embed. Indeed, overall, participants reflected that the role would take time to integrate fully into the workforce, reflecting interim findings from research into the NA role conducted within community and mental healthcare settings (Kessler et al., 2020). The process of embedding the role was felt to be assisted by educators, echoing the findings of a review of new workforce roles that emphasises the importance of clinical educators in work-based learning (Halse et al., 2018).

| Limitations
This study took place in one large healthcare organisation in an inner city context in England and thus transferability to other settings may be limited. Whilst participants were drawn from a range of wards and clinical areas within the hospital, overall a relatively small number of professionals were interviewed. Furthermore, the study did not look at how the NA role was perceived in settings outside of the secondary care environment. This qualitative interview study used purposive sampling to recruit a sample that varied by healthcare professional group. However, recruitment was challenging-particularly amongst MDT members-this can be partly explained by the finding from this study that there was poor communication about the role and issues with its identification affecting knowledge of the role and thus the ability for MDT members to voice an opinion. Overall, due to the recency of the role and the small numbers of NAs throughout a large organisation, some participants felt their views were partial because their interactions with NAs were limited. This points to the need for a 'critical mass' of the role to impact across an organisation (Wood et al., 2011).
The use of the CFIR framework offered several advantages, most notably that it allowed us to focus on constructs most apposite to our findings (Stokes et al., 2018) and make sense of the data (Warner et al., 2018). However, participants' knowledge and time impacted on our ability to ask the full range of questions. We found that participants did not specifically comment on some constructs such as reflecting and evaluating on the NA intervention. Furthermore, participants were unable to draw conclusions about the 'relative advantage' of the role because there was little to compare it with and there was an awareness that the recruitment of more RNs was not an option.

| CON CLUS ION
This study provides one of the first analyses of the nursing associate role in England in an acute care setting. In this study, the nursing associate role was well received in terms of its ability to provide an inclusive pathway into nursing and to build the careers of healthcare support workers but the speed of implementation and issues with communication and information affected the understanding of the role across the organisation.
The interview data highlighted the interconnection of individuals' views on the implementation, and the range of voices allowed us to understand the different perspectives of the stakeholders. It was apparent that the characteristics of the healthcare organisation had a significant impact on the implementation and studying these through the lens of the CFIR allowed us to understand the complexity of implementing and embedding a new role. Further evaluation is needed to investigate the role more thoroughly over time, as well as examining how it operates in different settings. This is especially important in the wake of the COVID-19 pandemic, which may have impacted on the embedding process.

| RELE VAN CE TO CLINI C AL PR AC TI CE
The nursing associate role needs to be clearly communicated, championed and supervised and its scope demarcated to build a clear identity within healthcare organisations to avoid it being reinterpreted as a repeat of previous second-level nursing roles. The role should not only be seen as a stepping stone into registered nursing positions but also needs to be valued and allowed to exist in its own right. The safe limits of the registered NA role are clearly defined and as such, consideration should be given to the most effective contexts for NA practice. These findings, based on the development of a new nursing role, have relevance to all healthcare leaders when planning and implementing new clinical roles in the workforce, particularly in a climate of economic pressure and staffing shortages.

ACK N OWLED G EM ENTS
We are grateful to all the participants who took part in this study.
We would like to thank Liz Wright for her support, and Debbie Dzik-Jurasz (1966-2020) whose clinical education leadership was central to the implementation and evaluation of the nursing associate role.

CO N FLI C T O F I NTE R E S T
The authors report no conflicts of interest.

AUTH O R CO NTR I B UTI O N S
Supervision and funding acquisition: DS and JB. All interviews: TT, DD and JB. Data analysis: All authors. First draft of the article: GL and JB. Manuscript finalisation: All authors. Reading and approval of the final manuscript: All authors.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data are not publicly available due to ethical restrictions.