Developing National Standards Determining the role of the

Developing National Standards: ‘Determining the role of the health care assistant within acute medicine’ Liz Lees Consultant Nurse & Senior Research Fellow Heart of England NHS Foundation Trust The Society for Acute Medicine, 7 th International Conference, 3 -4 October 2013

Session overview • • • Background drivers Tensions Four perspectives on role definition A framework in evolution? VITAL development for HCAs Future practice

Background drivers Broad Policy: • 2000 – European Working Time Directive • 2005 – Modernizing Medical Careers • 2006 – Modernizing Nursing Careers Specific/related evidence /policy: 2010 – Nursing Midwifery Council (towards 2013) 2011 – NIHR – SDO (Kessler et al) 2011 – DH: Enabling excellence 2012 - The Francis Report 2013 - The Cavendish Review 2014 …. The CQC – Certificate in Fundamental Care

Background drivers • 2012 – “Joint response from RCN, RCM and Unison on Minimum Training Standards and Code of Conduct for health and social care workers in England” Five areas within this for consideration: 1. Code of conduct 2. Common induction standards 3. Core and Common competencies 4. Technical and social care – training framework 5. Technical and health care – training framework

Healthcare assistants 'should get standard training' By Michelle Roberts Health editor, BBC News online • • Healthcare assistants provide vital support Continue reading the main story There is no minimum standard of training for healthcare assistants before they can work unsupervised, an independent report has found. Workers should get at least two weeks' training to prepare them for providing basic care in hospitals, care homes and at home in England, its author said. Journalist Camilla Cavendish also said some staff were only given a training DVD to watch before starting work. The review was set up in the wake of the Stafford Hospital scandal. Ms Cavendish found that HCAs - who provide basic care such as feeding and washing patients - were given no "compulsory or consistent" training, and said some were doing tasks usually performed by doctors or nurses, such as taking blood.

Patients are at risk as hospitals axe 5, 000 nurses, warns union Royal College of Nursing claims switch to healthcare assistants is putting lives in danger • Carter said: "We are concerned that there is a dilution, to the detriment of patient care, of the ratio of qualified nurses to health care assistants. That has been compounded by so many employers not giving their health care assistants any training. • "So you have the double whammy of not having enough registered nurses and replacing them with people who do not have rudimentary training. "

‘Compulsory and Consistent’ EMERGENT

Tensions • • • Blurring the boundaries between RGN & HCA Merge all the information? Transferability of competencies across settings Multiplicity of employers Delegation and Accountability Contextually specific issues – particularly in social care • One size will not fit all !! The Cavendish Review , July 2013

Role Definitions In looking specifically at Hospital settings there is some clarity in the literature: 1. Relief 2. Substitute 3. Apprentice 4. Co-Producer The Nature and Consequences of the Support Workers in a Hospital Setting, NIHR, SDO, 2011 (Kessler et al)

Relief ‘The standard HCA is more likely to deliver direct and in-direct care than the Registered nurse and is generally valued for taking routine tasks away from Nurses’

Substitute ‘In taking on routine technical tasks HCAs are extending their role into traditional nurse activities. A substitute for registered nurses’. • The question is where do we draw the line? • Some HCAs extend the role significantly beyond this point - raises the issue of cheap labour.

Apprentice ‘Many HCAs show an enthusiasm for in-role development but this can be frustrated by weaknesses in the operation of the Trust or NVQ frameworks. HCAs have enduring nurse aspirational tendencies, but Trusts show little inclination to manage or address these expectations’.

Co- Producer ‘Health care assistants have distinctive contributions to make to care. They find it easier to deal with certain difficult patients and more readily relate to patients than registered nurses. IF the role of the HCA were made clearer to patients this relationship to care contribution would be even stronger’.

How would you describe the role? • How would you describe the HCA role within acute medicine - without describing the tasks that a healthcare assistant or health care support worker carries out?

A framework in Evolution: Basic tasks • • • Bathing Feeding Bed making Collecting TTO Escorting patients Stocking up Taking bloods Cannulation Simple dressings • Taking observations • ECG recording • Blood glucose monitoring Modernization of the nursing workforce: Valuing the health care assistant: 2012. Kessler et al (Oxford University Press)

Framework in evolution: Advanced tasks • • Complex dressings Female catheterization Monitoring using diagnostic machines Change of tracheotomy tubes Giving an injections Updating care plans Relating medical information to relatives Kings College Nation Nursing Research Unit: moving forward with healthcare support workforce regulation (2010)

Framework in evolution – Glasgow Conference Research 2013

Purposeful Audience – research participants • • • Glasgow (October 2013). Audience of 50 – voluntarily enrolled Responses from 30 Methodology: Framework analysis of free text responses to key research questions • Participant coding • Existing HCA framework (basic & advanced) to extract % data • Vignettes to illustrate comments

Key research questions: 1. Were asked to describe the role of a HCA in Acute Medicine. 2. Is the HCA role ‘different’ to elsewhere in acute medicine? 3. Were asked to agree or refute basic tasks 4. Were asked to agree or refute advanced tasks 5. Finally if you had the opportunity to create a certificate of specialist training – what would you include?

1. Description of the HCA role in acute medicine (framework analysis) Core themes: Related Construct 1 Related Construct 2 (1) Support registered staff Assist Supervised by Directed by RGN (2) Meet basic Care needs Essential care Tasks (3) Report to Communicati on Feeds back (4) Quality care Safety Vital Related Construct 3 All care

Excerpt from whole content descriptions P 01: “ to work as a support to the nurse in delivering care. The registered nurse will supervise and direct this care, assessing all the time, the capacity and capability of the HCA. This situation will depend on the HCA as an individual. P 30: “They are fundamentally vital people to ensure patient safety as the eyes and ears of the clinical environment, able to feedback clearly to the registered nurse”

Excerpt from the whole content descriptions P 13: The HCA works with and under the direction of the registered nurse to deliver safe and good quality care. They are first in line to deliver nursing care, washing, dressing and feeding – but under the direction of the registered nurse. P 21: The HCAs form a team with trained nurses to provide all aspects of patient care. The roles are fluid and would depend on both sides of the partnership – the experience of both RGN and HCA – tasks can be agreed on this basis.

Q 2. Is the role different for HCAs working in acute medicine? • 15 (n=30) 50% said YES • 5 (n=30) 16. 5% said NO • 10 (n= 30) 33. 5% said they were unsure • Comments made: • P 15 – “they have to think on their feet, proactive’ • P 02 – “they are far more skilled than a ward HCA”

Q 3. Are you in agreement with basic tasks? Full agreement Bathing 100% (30) Feeding 100% (30) Bed making No agreement 100% (30) Collecting TTO 6. 5% (2) Escorting patients 6. 5% (2) Stocking up 6. 5% (2) Taking observations 13. 5% (4) Blood glucose 16% (5) ECG recording 20% (6) Stocking up 23. 5 % (7) Cannulation 30% Simple dressing 33. 5% (10) (9)

? Q 4. Are you in agreement with advanced tasks Fully agree Disagree Female catheterisation 10 Updating care plans 14 Monitoring using diagnostic machines 15 Change of tracy tubes 15 Complex dressing 16 Giving injections 17 Relaying medical 20 information to relatives P 10: Clear definition is needed to provide demarcation in Pay Bandings (i. e. ) Band 4 can do both Basic and Advanced – depends where employed.

Q 5. If you created a Certificate of Specialist training – what would you include? P 09: Understanding of care of skin, dressings, nursing assessment and interpretation of vital signs (NEWs) P 12: Involve HCA in Nursing Risk assessments P 13: Understanding vital signs, dementia care and acting as a special for patients. P 16: Aseptic technique training P 26: Infection control principles, ECG recording P 29: Care & Support of dying patients.

General discussion arising • Titles of HCA role are potentially confusing and this needs to be cleared up 1. 2. 3. 4. 5. Support workers Assistant Practitioners Clinical Support workers Health Care Assistants Nursing Auxiliaries – Salaries do not represent skills

Desirable attitudes – recruitment to values • • • Listening Observant Diligent Mature (stable emotionally) Caring Compassionate Courage Commitment Communication

Concluding points • • That there was a need for parity - nationally Smaller and larger units do operate differently Could put together a core framework Could call it a specialist role and this raises the profile of HCAs in acute medicine • Think carefully about how to accredit existing experienced HCAs • Needs to be practice based framework • Needs to rewarded with pay progression

VITAL ‘virtual interactive teaching and learning for HCAs’ – HEf. T work 1 2 3 4 5 Demographics The learning experience Impact on practice Fit with 6 Cs for Nursing The Acid test

Survey Method • • • Surveyed all HCAs who had completed VITAL Voluntary enrollment via email link Survey Monkey platform with 23 questions 50 HCAs enrolled with 41 completed surveys Used pre-piloted questions from a question bank created by research team

Part 1 – HCA Demographics

Age range of HCA Age: 3. 2% 16. 1% 6. 5% 9. 7% 18 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 Over 60 29. 0% 9. 7% 16. 1%

Gender of HCAs 19. 4% Male Female 80. 6%

HCA Workbase • Huge spread of areas (16) • OPD, Theatres, Respiratory, Ophthalmology, Dermatology, General Surgery, General medicine, Renal and ENT

Highest educational attainment 13. 3% GCSE A-Levels NVQ Diploma Undergraduate Degree Postgraduate Degree 73. 3%

Part 2 – Experience reported

Utilized variety of learning approaches 9. 7% Strongly Agree 22. 6% Agree Unsure Disagree Strongly Disagree 67. 7%

Rating the experience Out of 10, how would you rate your experience of the course, in terms of: (1 being the lowest and 10 being the highest) Usefulness of the materials The course assessment (Scenarios) Accessibility of the materials The relevance of the materials 7. 09 7. 29 7. 49 7. 69 7. 89 8. 09 8. 29

Part 3 – Impact on practice

Has VITAL has a positive impact on your practice? No 25. 8% Yes No Yes 0. 0% 74. 2% 20. 0% 40. 0% 60. 0% 80. 0%

Vignettes – positive impact ‘Informative, enabled me to have greater confidence’ (p 02) ‘The course has made me more aware, I think what, why and when to do a task now’ (p 04) ‘The information has re-instated my thirst for learning’ (p 23) ‘it has helped me to work better with doctors and nurses in the team’ (p 46)

If not positive impact – why? • ‘The VITAL course was not relevant to my area of work in clinic’ (p 04) • ‘I think we need a VITAL for theatre HCAs’ (p 05) • NB: 7 responses in this category only, same themes

Part 4 – fit with 6 Cs

CARE VITAL provided me with knowledge to effectively care for my patients 7. 4% Yes 92. 6% No

Care (safety) My learning through VITAL has enabled me to identify potential risks to patients in my clinical area. Strongly Disagree Unsure Agree Strongly Agree 0. 0% 10. 0% 20. 0% 30. 0% 40. 0% 50. 0% 60. 0% 70. 0%

Compassion You have become more compassionate as a result of completing VITAL 7. 4% Strongly Disagree 25. 9% Unsure 25. 9% Agree 33. 3% Strongly Agree 0. 0% 7. 4% 5. 0% 10. 0% 15. 0% 20. 0% 25. 0% 30. 0% 35. 0%

Communication

Confidence (competence) Undertaking the course has made you more confident in your practice. Strongly Disagree Unsure Agree Strongly Agree 0. 0% 10. 0% 20. 0% 30. 0% 40. 0% 50. 0%

Commitment I am more committed to meeting patients’ needs in my clinical area. Strongly Disagree Unsure Agree Strongly Agree 0. 0% 10. 0% 20. 0% 30. 0% 40. 0% 50. 0% 60. 0%

Courage • ‘By preventing complacency through ongoing learning’ (p 08) • ‘Made me aware and to assess situations differently’ (p 15)

The acid test! I would recommend VITAL to other HCA’s. 3. 2% Yes 96. 8% No

A way forward? • We need to provide clarity on what skills, competencies & attitudes we want out HCSW or HCAs to have to work in acute medical areas • We need to set out minimum training standards • We need to work with our educational providers to achieve, these with continuity & quality assured. • National guidance will come along soon enough – but we have to set our stall in acute medicine.

Thank you for listening Liz. lees@heartofengland. nhs. uk