A tale of two bridges: Factors influencing career choices of trainee nursing associates in England: A longitudinal qualitative study

Abstract Aim The nursing associate role has created a new second‐level nursing role and provided an alternative route into registered nursing. For some, this provides a previously inaccessible opportunity for career progression. The aim of the study was to understand the factors that influence career choices of trainee nursing associates. Design A longitudinal qualitative study of trainee nursing associate motivations, experiences and career aspirations. Methods Semi‐structured interviews with trainee nursing associates from across England, UK, in February 2020 (N = 14) and March 2021 (N = 13). Diary data were also collected. Interview and diary data were analysed thematically. Reporting has followed COREQ guidelines. Results Nursing associate training was viewed by some as a bridge into registered nursing. Role ambiguity led several to seek perceived security offered by the Registered Nurse profession. Those preferring to remain as nursing associates were keen to embed the bridging role between healthcare assistants and Registered Nurses, valuing a positive workplace culture.

for HCAs is recommended, but not mandatory (Health Education England, 2015) and there have been calls to support career development of this group (Health Education England, 2015;Snyder, Dahal and Frogner, 2018;Wakefield et al., 2009). The introduction of nursing associates (NAs), a new second-level nursing role in England has been welcomed by individuals who would otherwise lack the opportunity for further training (Coghill 2018a, and;King et al., 2020aKing et al., ,2020b, particularly those who, for financial reasons, or due to a lack of academic role models (Burnell, 2015), have been unable to follow their aspirations of entering the healthcare profession.
Many high-income countries deploy second-level nurses, such as enrolled nurses in Australia and New Zealand, and licenced vocational nurses or licenced practical nurses in North America, who provide fundamental care, undertake patient observations and support rehabilitation (Lucas et al., 2021a;The Health Foundation et al., 2018). The scope of practice of second level nurses varies globally, but generally they work under the supervision of Registered Nurses and are prepared at diploma level, compared with degree level nursing programmes (Lucas et al., 2021a). The NA role is a new second-level nursing role in England and follows on from the second level "state enrolled nurse" (SEN) in the UK which was discontinued in the 1990s in a move towards an all-graduate nursing profession (Glasper, 2016).
Several assumptions have been made about the NA role that half of NAs will transition to become Registered Nurses (RNs), that the transition to nursing would be smooth and that there would be lower attrition rates than other student nurse programmes (Health Education England, 2015). Evidence from a national evaluation of the first two pilot cohorts of TNAs (Vanson & Bidey, 2019) supports this first assumption, with almost 47% planning to apply to join a pre-registration nursing degree programme. Furthermore, the majority of TNAs are motivated by local career progression, particularly the option of becoming Registered Nurses (Coghill, 2018b;King et al., 2020aKing et al., ,2020b. The role has been welcomed by organizations keen to grow their own workforce to fill nursing shortages (Kessler et al., 2020b(Kessler et al., , 2020c. TNAs are paid at band 3 of the NHS "agenda for change" pay scale (pay range £19,737 to £21,242) and join band 4 when qualified (pay range £21,892 to £21,157). Registered Nurses commence at band 5 (£26,970 to £30,615) and can progress to band 8a, earning up to £51,668 as advanced clinical practitioners (NHS Employer, 2020).
Barriers to the success of second-level nursing roles include role ambiguity, intra and inter-professional conflict and restrictions on practice (Lucas et al. 2021a). Furthermore, the importance of clarifying role identity and opportunities for career development have been raised by key stakeholders (Kessler et al., 2021), with some areas found to be less suitable for NAs such as intensive care, due to limitations in their scope of practice (Lucas et al., 2021b).
This study is situated within a larger mixed methods longitudinal TNA cohort study exploring motivations for undertaking training, experiences of training and career aspirations. This paper focuses on findings from the qualitative data relating to factors that have influenced career aspirations and choices.

| Design
This study has used a longitudinal qualitative design, collecting interview and diary data from the same TNAs over a 2 years period. This design enabled an exploration of how experiences and aspirations changed as they qualified and entered the workforce (Hermanowicz, 2013;Neale, 2020;Shirani and Henwood, 2015).

| Method
In 2019, TNAs were recruited to a cohort (N = 154) via email (sent from five Higher Education Institution course leaders across England to current students) and social media (Twitter). A subgroup of the TNAs in the cohort were purposively sampled to this longitudinal qualitative study (after agreeing to be contacted for interview) to ensure diversity of location, gender, ethnicity, age and previous healthcare experience. Twenty TNAs were invited to participate by emailing a participant information sheet and consent form. They were offered a £10 shopping voucher as a thank you. A total of 14 TNAs from across England agreed to take part; three were male and 11 were female, two were Black, one Asian, and 11 were White British. They represented the North-West, Yorkshire and Humber, East Midlands, West Midlands, London, South-West, North-East and South-East of England. Eleven had previously worked as healthcare assistants/support workers and three did not have any previous healthcare work experience.
Semi-structured interviews were undertaken at two timepoints (February 2020 and March 2021) providing flexibility, reciprocity and allowing the interviewer to improvise and explore key points using a natural flow of conversation (Kallio, Johnson & Kangasniemi, 2016). Interviews followed the six stages outlined by Ritchie, Lewis, McNaughton Nicholls, & Ormston (2014) and were undertaken via telephone or video call (Zoom or Google meet), at a time convenient to participants. Thirteen agreed to be interviewed in year two (one did not respond). The non-responder was female, white British. This excellent retention rate in year two was promoted through the careful building of rapport during the year one interview (Hermanowicz, 2013). Interviews lasted between 21 and 50 min (average 34 min). Three members of the research team (RK, SR and SA); one male, and two female, with extensive post-doctoral experience of undertaking qualitative research conducted the one-to-one interviews. Two of these researchers were also Registered Nurses.
The interview topic guide (see Box 1) was developed from key policy documents and areas of importance to TNAs identified in previous research (King et al., 2020a(King et al., ,2020b. It was piloted with two TNAs to ensure clarity of the questions. The year two interviews explored the same broad themes as the first year interviews in addition to revisiting and updating previous understanding in an iterative way (Neale, 2020). Interviews were audio-recorded, transcribed and anonymized.
Participants were also sent a diary prompt every three months over a two year period with a link to an electronic google form which collected the entries (see Box 2). Diary data have been shown to be useful in capturing data around work-life identity issues (Radcliffe, 2013). A total of 16 diary entries were submitted between February 2020 and April 2021, completed by five participants. Collecting data over time provided insights into how the experiences of participants unfolded during their training, and a depth of understanding about shifting career aspirations (Neale, 2020). Reporting has followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Tong, Sainsbury, & Craig, 2007).

| Analysis
Data were analysed thematically using Braun and Clarke's (2020) most recent iteration of their six-step framework as a guide (Box 3), attending to the dynamic, recurring and cumulative significance of longitudinal qualitative data (Neale, 2020). Quirkos © computer assisted qualitative data analysis software (CAQDAS) was used to support this stage of analysis. Initial coding was completed independently by [RK]. Further categorizing and collapsing of codes into themes was completed jointly by [RK, SR and SL]. Final confirmation of themes was agreed in discussion and agreement with the whole research team.
Rigour has been enhanced by undertaking recognized methods of data collection and analysis, providing a detailed description of the study design and using researcher and source triangulation (Ritchie et al., 2014). Triangulation of sources involved data collection using both interviews and diaries, ensuring a depth of understanding of the experiences of participants (Ritchie et al., 2014).
Furthermore, triangulation of analysis was achieved when data were analysed by one researcher, checked by another and discussed and refined in the wider research team (Ritchie et al., 2014).
Trustworthiness was further enhanced by attending to discrepancies in the data (Lincoln and Guba, 1985). Pragmatic data saturation was reached through the generation and contextualization of categories (Low, 2019).

| Ethical considerations
TNAs were sent an information sheet and consent form via an invitation email. Written consent was gained (via email) prior to the interview and diary data collection. Participants were reminded that they could withdraw at any time, although anonymized data incorporated in the analysis could not be removed. Confidentiality was maintained; however, participants were advised that if they disclosed any harm to themselves or others this would be re-

| RE SULTS
This paper presents the findings related to the career choices of TNAs. In the first year of data collection, six TNAs stated they would be keen to undertake RN training at the earliest opportunity, with five stating they would rather stay as an NA and three remaining undecided (see Table 1). In the second year, most participants were consistent in their choice of career trajectory; however, one participant who had been keen to stay as an NA had changed their mind to being undecided about their future career path (TNA 6), and one who had initially planned to pursue RN training altered their choice and decided to remain as an NA (TNA 9).
Factors that influenced participant career choices are discussed in relation to reasons for pursuing RN training (theme one) and reasons to remain as an NA (theme two). In theme one the RN role is viewed as the end point for some TNAs, and for others it is perceived as a more attractive option for those who were disillusioned with the NA role. In theme two, some participants who chose to remain as NAs were invested in embedding the new role, others enjoyed the positive experience of feeling valued in the workplace, and some faced barriers to accessing RN training.

| Theme 1: Factors influencing the decision to pursue a registered nursing career
Several participants planned to pursue further training to become RNs.
Some who expressed a desire to "top-up" their training perceived the TNA programme as an affordable route into registered nursing. They viewed it as an opportunity to achieve their goal of becoming RNs; a way for them to fulfil their aspirations, some with specific specialities and other relevant information. It also holds information for others about our role as still there are so many that don't understand it". TNA 12 diary The experience in the workplace was an important factor in influencing TNA career choices. Role ambiguity and the subsequent conflict experienced in work settings led several participants to become disillusioned with the NA role. However, others were keen to remain in the NA role, and the factors influencing those choices are discussed in the next section. For those who chose to remain as NAs it was important for them to feel they were making a difference as valued members of their teams;

| Theme 2. Factors influencing the choice to remain as a nursing associate
contributing to person-centred safe and effective care. This was enabled through a positive workplace culture.

| Barriers to accessing RN training
Participants described other reasons for staying in the NA role, in terms of the barriers to accessing further training. One TNA felt that, although she would have loved to progress to become an RN, she was too old. However, when interviewed a second time she said that many people had encouraged her to pursue the transition to RN, so she was then undecided. Furthermore, a lack of development opportunities led some to remain as NAs, with a lack of support from their employers to undertake the RN training: There was a sense among some participants that employers preferred to keep NAs in that role and were therefore not offering the top-up opportunities. The COVID-19 pandemic also caused delays in completion of NA programmes and subsequent "top-up" opportunities, leading to uncertainty and anxiety among participants:

| DISCUSS ION
The career trajectory of participants in this study presents "a tale of two bridges." The first is a bridge into registered nursing for those whose goal is to top-up their NA training to the degree level RN qualification, bypassing the obstacles they previously faced. Some never viewed the NA role as the end point, but as a bridge to their destination of RN, others had become disillusioned with the challenges they faced in their new role. The second is a bridge between the two roles of HCA and RN, a position which some participants were keen to embed in their practice settings, committing to educating wider stakeholders on the scope of the NA role, and valuing their new knowledge, skills and opportunities.
Affordable career development was a significant influencing factor for both those choosing to stay as NAs and those hoping to become RNs. Several participants had financial commitments such as mortgages and dependents which had previously prevented them from stepping out of work into higher education.
The funding offered by TNA programmes was essential to achieving their goals and ensuring widening participation; consistent with previous studies which found that NA training provided an affordable route into nursing and an opportunity for career development (Coghill 2018a(Coghill , 2018bKing et al., 2020aKing et al., ,2020bVanson & Bidey, 2019). This is an example of where the widening participation agenda has benefited mature students, as well as those straight from school (Boeren & James, 2017;Burnell, 2015), providing a strategy for employers to enhance staff retention by "growing their own" nursing workforce (Health Education England, 2020). In this way, the NA training programme has provided a crucial opportunity for the upward career movement of experienced HCAs called for by previous researchers (Health Education England, 2018;Snyder et al., 2018).
For some participants, role ambiguity and conflict led to unpleasant working environments and a desire to move into the more secure, well-known role of the RN. This is consistent with findings from the national TNA evaluation (Vanson & Bidey, 2019) which identified the negative impact on well-being resulting from role ambiguity and lack of acceptance by colleagues. Similarly, Lucas et al., (2021a) found that second level nurses have been plagued by both role ambiguity, and intra-and inter-professional conflict over the years. NA stakeholders in particular report a lack of a clear NA job descriptions and a requirement to jump between roles (Lucas et al., 2021b). Furthermore, King et al., (2020a) found that TNAs themselves were unsure of the scope of their role, adding to the confusion experienced by wider healthcare teams. Studies exploring qualified NA roles have shown that they are beginning to develop a distinct scope of practice and in some cases are meeting little inter-professional resistance (Kessler et al., 2020b(Kessler et al., , 2020c. The COVID-19 pandemic has exacerbated the lack of role clarity, with some TNAs and NAs extending their scope of practice, others being underutilized, and several experiencing delays in their training (King et al., 2021 Those who chose to remain in the NA role talked about making a difference and reflected on times when they felt valued through strong leadership and a positive workplace culture. These have previously been found to be key elements to optimizing professional development in nursing (King et al., 2020b), as opposed to a lack of support which can lead to demoralization in the workforce (Senek et al., 2020).
Finally, some participants faced barriers to progression, including uncertainty about embarking on further intensive training, a factor also reflected in previous research (Kessler et al., 2020c)

AUTH O R CO NTR I B UTI O N S
All authors planned the study and contributed the background literature. RK, SR and BT undertook the interviews. RK, BT, SR and SL analysed the data. All authors read and approved the final manuscript.

ACK N OWLED G EM ENTS
The authors would like to thank the TNAs who gave up their time to participate in this study.

CO N FLI C T O F I NTE R E S T
No conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.