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Investigation: Many HCAs start work on wards without training

A quarter of trusts allow healthcare assistants to start work on the wards without undergoing any training for the job, an investigation has found.

Senior nursing figures described the finding as “shocking” and “worrying”, coming a year after the Francis report highlighted the impact of poorly trained, unregistered nursing staff on patient care.

All hospital trusts were asked how many hours training their HCAs had done before their first shift. Of the 104 that responded, 26 said HCAs were not required to have any formal training before starting.

Of these, 12 did not expect HCAs to have any formal training beyond being mentored on the ward or being given supernumerary status – usually for about two weeks.

Five said their HCAs always had an induction, but received no specific training in their support role. Three trusts stressed they encouraged ward managers to organise training for new HCAs as soon as possible.

One acute trust nursing director said even if new recruits had previous care experience, managers could not be sure of the quality of any training. She said: “Trust induction is usually just a box ticking exercise that all staff go through. To just employ somebody off the street without any training is truly shocking.”

Royal College of Nursing head of policy Howard Catton said it was “worrying and surprising” that some trusts were still not ensuring HCAs received training before starting on wards, given the focus on the issue over the past year.

Howard Catton

He said evidence on the quality of preceptorship for newly qualified nurses suggested other staff had too little time to properly supervise them, which raised questions about whether mentoring and supernumerary status were appropriate for HCAs.

There were also marked variations between trusts where HCAs were expected to attend some formal training, the investigation by Nursing Times’ sister title HSJ found.

Time ranged from one hour and an induction at Mid Yorkshire Hospitals Trust – although its HCAs work alongside a mentor – to three weeks at Southport and Ormskirk Hospital Trust, North Tees and Hartlepool Foundation Trust, Northampton General Hospital Trust and Great Ormond Street Hospital for Children Foundation Trust.

Last February Robert Francis QC called for the full regulation of HCAs. The government has consistently rejected the idea and instead commissioned Sunday Times journalist Camilla Cavendish to review HCA training and supervision.

Her report, published in July, uncovered a lack of “compulsory and consistent” training and recommended the introduction of a national certificate of fundamental care that all staff should complete before working unsupervised.

The idea was backed by ministers and Health Education England has been asked to lead its development.



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Readers' comments (21)

  • Yet more damning evidence of the willingness of "directors of nursing" and nurse "mangers" in general to deliberately expose patients to significant risk.

    These people need removing from the register.

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  • Absolutely. There are many fantastic, caring and conscientious HCA's out there who slog their guts out on a daily basis for a modest salary. This isn't a dig at them, but like Jenny has rightly identified, many HCAs are being asked to perform tasks for which they've not had any training whatsoever. It's not the HCAs fault, it's Trust management who must be held accountable if things go wrong.

    Trust must make sure that HCAs are appropriately trained before they're allowed anywhere near patients.

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  • This is what needs sorting out before revamped revalidation proposals for qualified nurses.

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  • Anonymous | 6-Feb-2014 12:26 pm

    Completely agree. Revalidation for nurses is more about the shortcomings of the NMC than its registrants

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  • michael stone

    Although I'm not convinced about HCA 'registration', there definitely should be a system of compulsory 'induction training' in place.

    Mentoring/shadowing/helping and then some sort of assessment of basic competence, as a minimum.

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  • I am a HCA and I had no formal training before I started this job and had no care experience at all!
    On my first day I was shown the basics by one of my fellow HCA's, I shadowed her for two weeks and that was as far as my training went.
    I strongly agree there should be a system in place or a course that new healthcare assistants could attend, after all peoples life's and private information are at risk!

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  • Possibly more shocking that this is news now, this has been going on for years. Sadly when Enrolled Nurses were phased out, formally trained carers (without management responsibility) effectively disappeared. Whilst NVQs were meant to provide HCAs the training they needed few staff in the clinical environment have the time to train people from scratch. Most training is now on the cheap with little face to face training, e.g. for annual updates. You get what you pay for, and for some it is just a job, so the chances of people doing extra to learn in their own time.

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  • Project 2000 is directly to blame for the situation we now find ourselves in: the creation of 'one level of nurse' [sic] (we now have now have four levels instead of two) meant that those who did the majority of the 'basic nursing care' were spirited away into classroom (in the case of students) or into blue dresses and a huge void was created which had to be filled. The HCA was born.

    Unlike Auxiliaries (who had to spend time in the classroom learning the basics), HCAs were often recruited from domestic staff and were put to work immediately on the wards and had to learn as they went.

    Thinking of the skill mix now compared to that of 20 years ago when it was at least 80% qualified to 20% unqualified, who then would've believed that 'progress' would make the converse true?

    HCAs do vital work, but I think even they would recognise that they need even a couple of weeks learning how to wash, dress and change a bed together with other aspects of nursing craft before they're let loose on the public. The NHS would be so much the better for it!

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  • This is just another example of exploitation of HCA's. The NHS and Government expect the service to run on untrained personnel on the cheap. Physicians Assistance (Dr's on the cheap just because they can't do certain things), HCA's (untrained nurses), Phlebotamists (task orientated blood takers, who can only do simple tasks and vital blood tests go untaken if bleeding a patient is beyond their remit), Nurse night practitioners (cheap and minimally trained Dr replacements). More nursing posts are being replaced by HCA's and then we treat them like this. More pressure put on ward staff to train them as well. I agree that if you are going to call them 'trained HCA's' why not bring back a SEN type qualification? It worked before. Then they would also perhaps have a more protracted pathway to registration if they so wished. Sadly it is all about money not quality or workforce recognition or appreciation.

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  • The reason we cannot bring back the EN is because it devalues Nursing as a whole. Their limitations are frank and obvious and it steals away the fact that we are a professional class, not merely trained units. Already nursing education is at least a year too short, woefully redundant in regards to teaching the science of the human body and saddled with culturally redundant baggage from five decades ago.
    yes. Nursing (NOT healthcare) assistants ought to have valid hospital based training, but they are OUR assistants. If yours are poorly trained, you cannot blame anybody but yourselves for utterly abandoning them.
    The reason why many don't do well is because the profession as a whole still uses redundant self descriptions such as 'caring' rather than recognising that we do a scientific job, and a scientific job only. Thusly our NA's ought to be lectured in the same fashion. Nursing is a science. It is not a caring vocation. Nor was it ever one. And simply insisting that despite the evidence that it is betrays new graduates into accepting outdated social mores as fact.
    to care is a human trait. Care or don't care, the outcome on your patients is zero if you actually do what you are obliged to do properly and with skill and intellect.

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  • I absolutely agree that HCAs should have standard induction training, with mandatory updates.
    Having sad that, those comments about ENs, obviously weren't around we ENs were. I 'trained as an SEN, before doing the conversion course. I think most SENs will tell you they ran the wards on many occasions. You cannot compare SEN training of 2 years to HCAs or the level 4 Practitioners. In our Trust, existing SENs that haven't converted to RN, are band 5 and more than capable of fulfilling that role.

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  • Excuse the missing letters, 4th line, 2nd
    word should read 'when' It seems to be a problem when typing on this site.

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  • michael stone

    B R | 8-Feb-2014 0:49 am

    B R, I agree that the idea that HCAs are comparable to SENs crops up in this debate, and that it doesn't make much sense.

    This issue is about how well-trained HCAs need to be before they start 'actually working', and nobody is saying that HCAs should be trained for 2 years before they start working. However, there is a different but valid question of career progression for HCAs who continue to acquire new skills and gain experience: some might become RCNs, but I suppose someone who has been an HCA for a decade, diligently up-skilling during that time, might at that stage possibly be sensibly compared to a newly-qualified SEN under the old system ? I'm not sure - I wasn't an SEN, I'm not an HCA, and I don't know enough to be sure of that.

    But there should be both a minimum standard of competence/safety before new HCAs 'are sent solo' as it were (and I know HCAs are supervised), and also career progression for HCAs.

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  • I didn't need to be around. They did not 'run the wards'. Actually they were deputizing for as SRN which is not the same thing as doing so in your own right. That you don't know that is actually the issue. That SEN's could outdo the SRN showed that there was no point having both.
    SEN's are not in any way comparable to our assistants because they are not registered nurses, thusly... discussion over.

    The SEN was a mistake. The only benefit of two tiered training and roles was at best a way to divide labour amongst a broad base of people with low educational qualities and at worst a representation of the rigidity and backwardness of British society at the time; a class system within a class system is not something to be celebrated or nostalgically liked back at. It is an embarrassment.

    Todays RN's aren't afraid of the work that the nostalgics want to palm off to a subordinate, which is the crux of the entire argument for those in favour of reprising this role.

    Back to the NA training. Yes we should create better training for assistants. What i really hate is terms like Associate practitioner'. What a load of cobblers. I've yet to meet a band 4 with a bigger scope of practice than a very good band 1 or 2, nor have i ever met one that is doing anything that even requires greater remuneration. Seeing as they only get education in 'care' and not Nursing, how are they our associates?. We're not partners and they have no autonomous function that matters. Therefore i propose that nothing should affect our de facto control of NA's as assistants only. This is our group to control and we are in a unique position to do so. As i said before, bad assistants knowledge and skills are a reflection of the clinical environment and its practitioners.

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  • One community trust is planning to recruit Band 4 unregistered staff following 6 months training at a college. These will then be doing Band 5 registered nurses workload with the corresponding dissolution of band 5 nurses.

    This to me is very worring as to the patiemnts they will beliveve that they are being treated in their home by a qualified accountable nurse

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  • Anonymous | 7-Feb-2014 10:23 am

    Whilst I agree that nursing is a science, you ask a patient which nurse whilst providing the scientific care provide also gave better "care" and how it made them feel.
    We have always had knowledgeable well educated nurses but we also had Mid Staffs. It doesn't need a degree in science to know that leaving someone in a soiled bed is a lack of "care".

    SENs had the academic background so that there work was not just a series of tasks. They were aslo the associate nurse to the RN. The RN did not have to inform them of why they were doing whjat they were asked to do. they were also accountable.

    I do not aplogise when I say that my best role models were those who not only where knowledgeable in the treatment they were providing but also displayed compassion to those they were "caring" for. The two are not mutually exclusive.

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  • tinkerbell

    Jane | 12-Feb-2014 9:31 am

    Agreed. It should be a given that we know what we are doing and are competent, but mostly patients don't want to know how much we know but how much we care.

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  • Jane | 12-Feb-2014 9:31 am

    Patient satisfaction is not and should not be used as a marker for anything other than point scoring or to waste time confounding decent arguments.

    Making people feel better is not an aspect f the job, rather an aspect of the human experience. It is the drugs and treatment you give that has a better measurable outcome. What you think you are offering in terms of interaction is not as clean cut or as effective as people (read women) like to think it is.

    It might be important to the patient but seeing as 'feeing better' and 'being better' are two separate things I don't see it as relevant.

    Mid Staff' was a case of Nursing not big respected enough and a series of weak martyr managers who did nothing whilst standards and numbers slipped (Matrons and Ward Sisters)
    Their helplessness and lack of guts is a nationwide problem we face because people won't let go of a past they have imagined into being better than t actually was

    tinkerbell | 12-Feb-2014 2:52 pm

    Well that's too bad because only one of those things is actually relevant. giving a damn but being ineffective (the default setting or most nurses) is not on.

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  • Anon 12 Feb

    This has been on the cards for about the last 10 -15 years. All of those nurses who have called for HCA regulation and HCA this and that have been doing the NHS employers bidding for them.

    Remember when the City & Guilds where brought out for Auxiliaries and HCAs? The plan always was to have one Registered Nurse working in a managerial/coordinative role for each shift with all hands on care being provided by 'unqualified' people.

    Many dismissed this as 'pie in the sky' and could never foresee a time in which this could happen; well it's happening now - big time. Many of us have warned colleagues repeatedly about the threat formally trained or registered or qualified HCAs are to the primacy of Registered Nurses, but were largely ignored.

    In the next few years, what we will see is the wipeout of Registered Nurses in theatres, anaesthetics and recovery - all to be replaced by ODA's and HCA's. On wards and departments, many band 5 posts will be replaced by band 3 and 4 assistant practitioners. Outpatients will largely be run by HCAs with some band 3/4 assistant practitioners.

    Sad thing is, we've allowed this to happen. The nurses union allowed HCA entry - we've done this to ourselves!

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  • To Anonymous 10 February, 2014
    Todays RN's aren't afraid of the work that the nostalgics want to palm off to a subordinate,

    Well I think they are ! I think every man and his dog think they are.
    Nurses need a reality check. Nurses like you , that is.

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