Healthcare assistants (HCAs) comprise a large part of our nursing workforce. The Scottish Government (2010) recently defined healthcare support workers as persons who have:
‘The awareness and ability to address the basic care needs of individual patients/clients under the direction and supervision of healthcare professionals. They support the multidisciplinary team in the delivery of high-quality care.’ (Scottish Government, 2010:9)
The employment of HCAs on wards as nurses’ aides is historical. Yet, how their role should be defined, the level of training to be undertaken and whether or not they should be regulated continue to be debated, despiteongoing development of the nursing workforce in recent years (Kessler et al, 2010). In response to changes executed within the health service, registered nurses (RNs) have expanded their knowledge and expertise to facilitate them in performing a wider range of technical skills and specialist roles, while HCAs have been required to fill some of the void left by RNs and other health professionals in providing direct nursing care. Literature on the function of the HCA is inconsistent. Keeney et al (2005) suggest clarity with regards to the role and support for HCAs is required, as sometimes there is a blurring of HCA and RN roles (McKenna et al, 2004). HCAs are performing tasks normally carried out by RNs, but with minimal supervision and recognised training (Thornley, 2000). At times, HCAs agree to do jobs for which they are not qualified—or feel pressurised to do because demands on workload leave them without any option (McKenna et al, 2004; Spilsbury and Meyer, 2005). Conversely, Spilsbury and Meyer (2004) suggest that HCAs are not used to their full potential, and could play a significant role in acute patient care (James et al, 2010).
The Research Process
A convenience sample of 8 female HCA participants was purposefully selected from each of the medical and surgical wards, one participant from each ward. They varied in age, from 25 to 62 years, and in experience, from 2 to 30 years.
Ethics approval was obtained from the local research ethics committee on 1 July 2011. All participants were given an information sheet explaining the research study and associated consent form prior to interview. Written consent was obtained at the time of interview, following a verbal explanation of the interview process. Maintaining privacy and anonymity, the interviews were conducted off the wards and in the participants’ own time.
Data collection comprised in-depth, semi-structured interviews. The questions posed aimed to build a sequential representation of the HCA role, starting with their experience of nursing, their involvement in patient care, tasks and responsibilities undertaken and the training attached to these. It sought to end with what HCAs thought were their positive experiences of nursing, what they could improve upon and how they viewed the role in the future. Each interview was audio-recorded and transcribed verbatim, prior to analysis.
Data analysis was undertaken manually utilising Colaizzi’s seven-step framework for data analysis (adapted from Priest, 2002). The implementation of a conceptual framework acts as a step-by-step guide for data analysis (Smith and Firth, 2011). A process of conventional content analysis was implemented to examine and evaluate the data collected (Hsieh and Shannon, 2005). The codes that emerged from the analysis were categorised into four themes. These are presented graphically in Diagram 1.
This theme illustrated how the HCAs perceived the manner in which their peers and other members of the multidisciplinary team (MDT) recognised and valued their involvement in patient care. The evidence collated suggested that the support for HCAs was in parts limited and at times there appeared to be a clear division of roles and tasks performed, with expectation placed on HCAs to deal directly with patient care needs; this made the HCAs feel undervalued.
‘I think sometimes they [RNs] can take us for granted; it depends, like there are some nurses that I feel that ... see, if ever a bell goes, it’s a healthcare assistant to answer it, if a patient needs the toilet or if a bed needs changing and that it’s a healthcare assistant role, their job to do that.’ ‘Some staff nurses are reluctant to help out and it won’t work without teamwork.’
Nursing literature supports the claim that HCAs are unclear about the role they perform (Pearcey, 2000), especially as they become involved in more direct patient care rather than clerical or domestic duties (Spilsbury and Meyer, 2004). Likewise, changing RN roles is repeatedly reported to take nurses away from the bedside (Pearcey, 2008) to undertake more technical tasks and deal with increasing paperwork, leaving HCAs to often perform basic care needs for patients, with limited supervision (Jack et al, 2004). HCAs are highly committed to patient care, believing that the ‘real nursing’ is undertaken by nurses of a lower grade (Thornley, 2000). Reaffirmed in this study, participants identified that RNs’ focus was on providing indirect nursing care and completing paperwork and rarely on spending quality time at the patient’s bedside, unless the patient’s condition warranted it.
‘RNs do not have the time, because they have their writing to do; they have the observations and drugs to do.’
Certainly the HCAs reported that RNs have less interaction with long-term patients awaiting placement in the community. The pressure on RNs to take on more medical tasks as part of their extended role is steering the ‘traditional nursing’ aspect of the RN role into the domain of the HCA (Hancock et al, 2005). The delegation of nursing tasks to HCAs is contentious, as it raises concerns around patient safety in the absence of HCA regulation and accountability (Storey, 2005). Expansion of the HCA role makes the issue of accountability all the more important (Mulryan, 2009). Positively, HCAs appreciated that they were in a better position than RNs, as ultimately it was themselves that patients talked to and confided in, which on a personal level was a source of great job satisfaction. This bedsid role increases HCA visibility to patients. Patients prefer to talk to HCAs, as they are the ‘nurses at the bedside’ (Spilsbury and Meyer, 2005). HCAs in this study stated that RNs relied on them to be ‘their eyes’; such is the trusting relationship that has developed.
During busy periods, HCAs reported undertaking direct patient care largely unsupervised, seeking help when they are unable to perform the task alone or to report on findings that they require the RN’s judgement to confirm, approve or suggest an alternative to care. Yet HCAs reported that they feel RNs do not always trust their judgement, and will maintain closer supervision than others, even over what the HCAs perceive to be menial tasks. This in itself may be a reflection of the confidence in, experience and relationship the RN has with the HCA. Those HCAs who have worked on a ward for a long time reported experiencing less supervision; this suggests that they could be depended upon to assume more responsibility.
The study verified that HCAs working on wards that had adopted a higher HCA–to–RN ratio on shift, found they had better support from their peers and subsequently enhanced working relationships. Undoubtedly, the relationship between quality care and skill mix is multifaceted and all associated elements, including patient dependency, workloads and patient satisfaction, need to considered before decisions on staffing levels are implemented (Crossan and Ferguson, 2005; Currie et al, 2005; Duffield et al, 2010). Implementing a higher level of nursing establishment on shift increases nurses’ ability to cope with patient care demands and has a positive impact on job satisfaction (Adams and Bond, 2003). Such evidence chimes with the findings within this study. The HCAs voiced their acceptance of changes in care processes by certain RNs, so as not to cause a ‘bad’ atmosphere.
But HCAs voiced their frustration at having to wait for RNs to assist with direct patient care—or having to complete tasks entirely on their own because of a general shortage of HCAs on a particular shift to complete basic nursing care. ‘There are certain things to do, such as washes and hoisting people, but you can’t, because you have to wait for the staff nurse to finish doing her things.’
It seems that while RNs’ roles may be evolving in response to change, in this organisation, the potential to develop the HCA role remains static, countering UK concerns that HCAs are encroaching on RN roles. HCAs reported that at times they were unclear about the role they perform and the boundaries that govern what they can and cannot in fact do in practice. There is discord between what is learnt in the classroom and what HCAs are allowed to undertake in practice. This is compounded further by the level of confidence RNs have in HCAs by showing them how to perform tasks and allowing them to complete these unsupervised one day and not on other days. This is a source of frustration for HCAs; as one reported:
‘It aggravates me that they don’t trust me enough.’
Yet, there are certain responsibilities that HCAs feel competent in dealing with and in terms of accountability, the HCAs conveyed that they understood the limitation of their role and the importance of working within the boundaries of their job description.
‘You need to be able to account for your actions. You really shouldn’t be doing anything outside of your job description anyway. So, if you don’t feel comfortable with doing something, you should just say.’
This implies that the HCA role is ambiguous; the HCAs commented that each ward is unique as regards to its arbitrary procedures. Both the ward philosophy and daily routine are not only maintained according to patient requirements, but ward sisters and consultant preferences. Similarly, HCAs note discrepancies between wards where colleagues are allowed to practise, albeit limited expanded tasks, while their own practice is curtailed.
This study undoubtedly demonstrated that HCAs show great compassion towards the patients in their care— giving the HCAs immense job satisfaction. As one HCA declared:
‘I absolutely love my job.’
The examples they refer to confirm that HCAs understand the importance of delivering care with empathy and respect. This does not just relate to physical care; HCAs share an understanding of the psychological needs of patients and describe how they often find themselves sharing the burden of patients’ worries, acting as a confidante and counsellor as they comfort patients who are distressed. In many instances, they formed a close relationship with their patients.
‘There are a lot of patients that have an awful lot of worries … not only about the illness that they’ve got … all their personal lives and everything … you have to be a good listener with your patients. To be a friend to them.’
While HCAs are not working out of their job description, it could be argued that the manner in which it is applied in practice is variable, the level of HCA input into patient care fluctuating according to RN requirements, rather than patient needs. Clarification of the HCA role needs to be established through a review of the HCA job description. As Wakefield
et al (2009) state, ‘an ill-defined’ job description creates difficulties in establishing boundaries and more generally in ensuring accountability and responsibility’.
Likewise, RNs require clarification of the HCA/RN interface as they express concern about lack of control over tasks they delegate. They are also unsure as to what tasks can safely be delegated and who is responsible for the outcome (Bystedt et al, 2011). This suggests RNs need to be given the time to educate and supervise untrained nurses in the tasks that they delegate, so as not to compromise patient care.
Today, educational development for HCAs is offered through the national vocational award (NVQ) at both level 2 and 3. Learning through the NVQ process gave a positive response by encouraging HCAs to think about best practice in terms of the care they deliver. They understood that they need to be accountable for their actions and should only undertake patient care that they have been trained to perform. Any changes in patient status are referred back to the RN to act on. HCAs were concerned that they are unable to report on the care they deliver (Hancock et al, 2005). HCAs rarely wrote in the nursing kardex unless specifically encouraged to do so by the RN. Reasons cited included not having the time or because they deemed themselves inept, as minimal training is given. Yet HCAs felt that, as the person delivering an aspect of nursing care, they should document the outcome, both to save the RN time and because they feel accountable for the care given. To not do so leaves RNs with the responsibility of reporting on care and changes in patient status that they have not witnessed first-hand.
Disappointingly, many HCAs who have gained their NVQ award and as part of that received training in regard to phlebotomy or venepuncture are subsequently prevented from performing these skills on the ward. The inability to put into practice skills learnt in the classroom has dissuaded some HCAs from continuing with their academic studies or even to complete their nurse training.
‘I have only got NVQ level 2, because they were saying to me level 3 is not compulsory, so I didn’t bother. I know you learn things, but you are not learning to do things. No, it is only on paper.’
HCAs’ appetite for learning supports their desire to expand the role, as they were previously allowed to. They want RNs to delegate more of the technical aspects of care to them. HCAs recognised the pressure RNs are under to complete non-nursing duties and sympathise with them, supporting their desire to unburden RNs by taking on advanced tasks. Extending the repertoire of HCA skills would release RNs to spend more time at the patient’s bedside, which is where they thought RNs should be (Spilsbury and Meyer, 2004).
Ultimately, the RN’s role must not be forgotten: they need reassurance that HCAs recognise RNs are responsible for HCAs’ actions and that the accountability for expanded HCA roles does not solely rest with the nurse. HCA regulation may be a tool to provide this. If the HCA role is to develop, then they deserve their contribution to be regulated/registered (McKenna et al, 2006); attainment of a recognised national qualification is an important step in the process (Webb, 2011).
This research overwhelmingly supports the notion that HCAs are at a loss as to which direction their role is going. It could be argued that the lack of understanding of the HCA role lends itself to their misuse on the wards. The ambiguity is not only dangerous, but is not good for individual staff morale. We risk patient care by having a group of staff whose role has haphazardly developed from ancillary work to front-line care without recognition,training or accreditation. In reality, the HCA role is uncertain, and requires urgent review if uniformity of the role is to be achieved. Effectively, the organisation, or indeed the whole caring industry, needs to decide what it wants from the HCA role, in terms of skills performed, training undertaken and recognition to be given. As Cook (2010) reports, ‘good HCAs deserve the dignity and status of entry to the nursing profession: they are doing a nursing job’. The research makes three recommendations to support the role of the HCA
Clarity needs to be sought to endorse which core competencies HCAs must complete across all areas and the rationale supporting these, to ensure each HCA is consistently working to the same level, thereby lessening role confusion.
In an effort to address HCAs’ desire to learn more technical aspects of nursing, a re-evaluation of their role is necessary to acknowledge the contribution made by HCAs to patient care. Explicitly, the new role must clearly reflect an accurate and unambiguous job description, providing clarity for the type of work performed (Wakefield et al, 2009). Giving due consideration to both HCA grading and monetary reward are essential to providing a balance between HCA aspirations, and meeting HCA expectations, in addition to encouraging the potential for a future RN workforce (Kessler et al, 2010).
Regulation of the Healthcare Assistant
Issues of governance that surround the HCA role give rise to fears among RNs and management that HCAs may perform tasks for which they have not been given the appropriate training, and therefore open themselves and others collectively to litigation as a result of providing substandard care (Royal College of Nursing (RCN), 2006). Notwithstanding the controversy surrounding HCA regulation, it is assumed that its introduction would give clarity to the responsibility and accountability of HCAs and ensure professional standards are met (RCN, 2007). HCA usage must be underpinned by a clear definition of their roles and allocation of duties (Scottish Government, 2010), centring on what role HCAs are required to fulfil, to include level of competencies and responsibilities (Griffiths and Robinson, 2010). Sound policy must be implemented to regulate the HCA role and give credence to the skills they wish to develop, further supported by a structured package of training and supervision to provide a strong foundation for maintaining HCA accountability in care delivery.
Training and Supervision
The literature reassuringly claims that those HCAs who participate in structured training programmes significantly improve their knowledge and expertise (Keeney et al, 2005; McKenna et al, 2005). But this necessitates organisational commitment to support RNs in delivering a training programme that aptly enhances HCAs’ skills. Ultimately, HCAs need to be supervised if patient safety is to be assured (Griffiths and Robinson, 2010), but this can only be realistically achieved if RNs are given the time and training to undertake this. RN skill development in the area of preceptorship is essential to ensure they have the tools to appropriately supervise the tasks they delegate to HCAs (Alcorn and Topping, 2009). Extending the existing NVQ process would be one method of providing additional training, as it focuses on competency-based learning through work-related tasks that enable trainees to develop appropriate skills, benchmarked against national standards.
Limitations of the Findings
The findings of this study may be limited, due to anomalies associated with working on an off-shore Island (Jersey) and may not be representative of the wider views of HCAs throughout the UK.
The data relies on HCAs’ views only; further study to include the opinions of other health professionals may be beneficial for a more comprehensive evaluation of the HCA role in the acute care setting. Similar to other studies, a case–study approach may be preferable, to gather a mix of qualitative and quantitative data to determine the precise amount of time HCAs spend on direct and indirect nursing care in practice.
This study attempted to provide an insight into the role of the HCA working in an acute care setting of a general hospital. It discussed the experiences shared by HCAs in regard to where the role fits within the ward routine and how it contributes to the delivery of patient care. It acknowledged the frustrations HCAs have shared in regard to perceived role ambiguities, as well as the joy and compassion expressed when discussing their experiences in dealing with patients and their families. Finally, comparisons have been made with experiences of HCAs portrayed in the literature. Recommendations have been put forward to enhance their future role, which clearly needs to change.