Healthcare assistants take over bulk of bedside care

22 June 2010 | By Ben Clover

Healthcare assistants take over bulk of bedside care

A healthcare assistant does twice as much direct patient care on the wards as a nurse, a pioneering study shared exclusively with Nursing Times has found.

What I do now is what a nurse did three, four years ago, and everybody gave them respect for what they did and paid them for what they did

The three year Department of Health-funded research says the extent to which HCAs have replaced nurses in delivering the majority of bedside care implies it is now HCAs, not nurses, who are at the heart of patient care.

The researchers, based at the University of Oxford, used ward observations to measure how much time HCAs and nurses spent on direct patient care such as feeding, bathing and helping with going to the toilet.

They found that, while nurses spent 15 per cent of their time giving direct care at the patient’s bedside, HCAs spent 30 per cent.

While overall HCAs spent the majority of their time on a typical early shift carrying out direct and indirect care, nurses spent the largest proportion of their time on organisational tasks such as answering the phone and handovers (see chart).

The researchers said the findings suggested the “core” of patient care had shifted from tasks performed by nurses to those performed by HCAs as nurses had “vacated that space”.

The study is the biggest ever examination of healthcare assistants’ role based on face to face interviews with and surveys of more than 1,000 nurses, HCAs, managers and patients.

Managers at nine trusts were also interviewed and 275 hours of observation time was recorded by researchers.

The finding come as NHS employers are looking to substitute nurses with cheaper HCAs. Nurses have expressed concerns about this, but the researchers said the close relationships HCAs develop with patients could help drive up trust performance scores because they make a “vital” contribution to the elements of care upon which hospitals are judged.

They said the “encroachment” of HCAs on the nursing role had created a split and “disconnect” in the nursing profession.

Coauthor Ian Kessler told Nursing Times: “There’s the nurse who is moving up the food chain and is leaving behind some of the direct care relationship.

“But, on the other side are those that say ‘We are the only workers that provide holistic care and if we give away some of our responsibilities there would be a gap’.”

Researchers found that half of HCAs enter the role with ambitions of becoming a nurse and many do complex procedures such as female catheterisation, taking bloods and ECGs.

The ambition of many HCAs is underlined by survey results showing that while fewer than one third of nurses thought observations were among an HCAs’ three core duties, it was the assistants’ second most relished task, with 46 per cent ranking it in their top three favoured tasks (see chart).

The report suggests tensions could occur between HCAs and nurses where assistants undertook more technical tasks. At the other end of the spectrum it says: “HCA dominance might be seen as a challenge to nurse claims to the provision of holistic care.”

There are roughly three nurses for every HCA. Interviews with managers suggest this could narrow as trusts look to cut costs.

The report said: “Any consideration of the HCA role at corporate level was usually within the context of a skill-mix review. While such reviews could be linked to broader, forward looking trust goals… they were typically guided by more pressing issues associated with cost efficiency.”

The report also reveals massive inconsistencies in HCA pay, training, duties and opportunities for advancement, with some HCAs feeling they are the victims of considerable injustice.

An interviewee in London told the researchers: “What I do now is what a nurse did three, four years ago, and everybody gave them respect for what they did and paid them for what they did. So now three, four years on I’m doing exactly the same role, why am I in a band 2 and getting no respect for it?”

The research was hailed as “groundbreaking” by Unison, which represents 100,000 HCAs across the country.

Unison head of nursing Gail Adams said: “It reinforces many of the concerns that have been raised by Unison members and reflects their concern about how the role is perceived by some in the health service.”

To see the report click here.

Readers' comments (62)

Anonymous | 22-Jun-2010 7:36 am
The reason why Healthcare Assistants are doing what Nurses did 3-4 years ago now is because NHS Bosses insist on all this beuracracy and red tape namely being paperwork has to be filled in by Nurses only and the more forms or assessments is introduced the further away from patient care a nurse actually gets.
Unsuitable or offensive?
Anonymous | 22-Jun-2010 8:43 am
Sadly this will get worse when nurses become degree only as more will be expected of them away from the bedside.
Bedside care is where the most can be learnt about a patient and trust and respect can be built up between nurse and patient.
Bedside care is invaluable.
I have a degree by the way just in case people may think I am bearing a grudge, but I attained mine after I qualified with a diploma having trained under Project 2000.
It was felt by the nurses trained before Project 2000 that hands on nurse care would be diminished by making the training more academic and they have been proved right.
Unsuitable or offensive?
Anonymous | 22-Jun-2010 8:45 am
Im an assistant practitioner and we are in the same situation - we still do the same as the RGNs irrelavant of the banding - many trusts have various do's and don'ts so ive spoke to many AP's from other trusts who feel they are doing above and beyond there role - but still for the same banding!
Unsuitable or offensive?
Anonymous | 22-Jun-2010 9:13 am
Surely we have gone back to the two tier nurse system of 30+ years ago! I trained as a State Enrolled Nurse (SEN) where we gave all the care at the bedside. the SRN's filled in paperwork and did drug and ward rounds. I am now an RN Child and am getting further away from the bedside nursing which I miss. it is good that there are HCSW looking after the patients needs.
Unsuitable or offensive?
Anonymous | 22-Jun-2010 9:21 am
This is so true! I have many nurse colleagues who wish they worked as HCA`s so that they could do `proper nursing`. And it is like the old days of the SEN/SRN - which is what it will no doubt return to as we all know the NHS goes round in complete circles!!
Unsuitable or offensive?
mike | 22-Jun-2010 10:19 am
Well said Anonymous | 22-Jun-2010 7:36 am.

As a Nurse, the level of paperwork is ridiculous, especially as the majority is repeated information over and over and over again!

I notice how the headline isn't stating the obvious 'Nurses spend more time giving specialist/clinical care'!!

Look, we all have a role to play here, health care ASSISTANTS (notice that distinction) are by definition there to perform the basic tasks, therefore allowing Nurses to concentrate on clinical tasks.

The tasks that HCA's perform do ensure that they spend more time 'at the bedside'. Making beds, doing rounds, doing 'the turns', etc. All these are by definition 'at the bedside', so of course they are often more visible.

But it isn't as if the Nurse is off skiving here. Our work does often keep us 'away from the bedside', but that does not mean we do not want to, or indeed do not spend as much time with our patients as possible.

Lets just get this into perspective.

And Anonymous | 22-Jun-2010 8:43 am, I'm sorry but the argument that this will get worse with degrees is absolutely ridiculous. Degree band 5's and Diploma band 5's do a different job? No, they don't.

Personally I think the fact Nurses have to spend less time with patients is down to problems with the profession and management, such as too much paperwork, poor/unsafe staffing levels, too many patients, etc etc etc.

Lets get away from this 'proper Nursing' and 'back to basics' rubbish.

We all have a role to play, we are all there to provide care for our patients. Yes our profession isn't perfect, let's sort out the problems first that will free up more time for us to spend with our patients, rather than splitting into warring factions again.
Unsuitable or offensive?
Anonymous | 22-Jun-2010 11:08 am
Hold on a mo...... just how many nurses really 'signed up' to spend the bulk of their (ward based) shift on paper handling tasks? ALL the nurses I know actually wanted to be hands on nurses and the vast majority of these say they are actively looking to move away from the NHS because of the direct lack of hands on time and the amount of paperwork they now do.
Of course things progress, no one is doubting this, and the inevitability of audit trails means nurses need to pay far more attention to the paper tasks. But lets us not get away from the findings of this research....... HCAs now absolutely do do the job of the SEN, so why on earth are they paid insulting rates of band 2 or if they are very lucky in their trust, at a band 3. I only know of a handful of Band 4 A. Practitioners, yet all the HCAs I know ALL undertake ALL obs including Neuro, they ALL do ECGs, and ALL the Band 3's catheterise and do bloods, trach care etc.
What a huge responsibility for HCAs!
I do not think HCAs are trying to undermine nurses, but I do feel that some nurses definately undermine HCAs.
I also believe that the degree only program will most certainly marginalise those HCAs who, under the Diploma program would have entered the profession with years of hands on experience to bring to the role. Now most will not get onto the program at all. How utterly ridiculous - what a waste.
Unsuitable or offensive?
Anonymous | 22-Jun-2010 11:32 am
mike shut up yr on again about you are worked to death with paper work everyone has to document?
i hold my hat off to the entry at 11:08 that is a real person and is not in goo goo land for godsake tell the primeminister and the dog that follows him?
Q,what would happen if there was no hcsw,hca's csw, ap's, nursing aux,or any body under a band 4? mike would be lost in paperwork ha!
Unsuitable or offensive?
Anonymous | 22-Jun-2010 12:00 pm
I would like to say that after working for years as a SHCA and now working as a staff nurse that I knew and performed the role for which I was paid and employed to do. I get mortified with HCA's moaning about how they should be paid more-they knew the job that they were employed to do when they went for the post!!! The pay in my area is over and above what an HCA or HCSW would get in the private sector. If HCA's feel they should be on a higher payband then they should train to be a qualified nurse-if the HCA was paid at band 4 and the RGN was paid on a band 5 what the hell are we training for???? I value HCA's and the role that they perform but there must now be a shake up in exactly what the roles are so that all the upset is sorted out, we will soon be at the state of SEN/SRN and where will that get us???
Unsuitable or offensive?
Anonymous | 22-Jun-2010 1:22 pm
This study seems to be hospital based. I am a District Nurse and although I don't have a HCA in my current team. I have worked with them they can take twice as long to undertake patient care and then require further nursing time for support and feedback. On paper they may seem cheaper but they are not as cost effective as a trained nurse due to the restrictions on what they can do and because they bring back problems a trained nurse would have dealt with during the visit. Management want HCA's as they are paid less but they refuse to look at how cost effective this is in real terms. I am aware that this sounds as if I don't value HCA's, that is not the case I have worked with some fantastic ones but they worked at a level more consistent with a trained nurse and if they are doing that work they should be paid what a nurse is paid.
Unsuitable or offensive?
Marjorie Lloyd | 22-Jun-2010 2:51 pm
This research does not tell us anything new. Support workers always spend more time with patients I know I was one, I wanted to get more involved in decision making so went to get qualified to do so. Being qualified means being professional and being able to justify decisions including work that is delegated to others. Qualified nurses remain responsible for documenting those decisions. If people want to spend more time at the bedside they should maybe get a support workers job?
Unsuitable or offensive?
Anonymous | 22-Jun-2010 4:16 pm
in respect 12:00pm entry, hca and hcsw have more skills than most above them?
and accountable?
Unsuitable or offensive?
Doug Langdon | 22-Jun-2010 6:42 pm
Similar research was done in Gloucestershire Royal Hospital in the mid 1970's so how can this be deemed pioneering?

That research also reached similar conclusions, but where has it improved things?

That research project didn't take 3 years to complete, so have our researchers slowed up or is it that the Department of Health and Universities have money to burn?
Unsuitable or offensive?
Anonymous | 22-Jun-2010 6:44 pm
Get rid of all HCA's is what I say. If the job is worth doing at all it is worth training people properly,(RN), and paying good wages. There are a few good HCA's but not many in my experience. I find them to be more keen on seeing how long they can make a job last, and being first to go on break, having extra fag breaks, in fact anything but doing a good job. Previous studies have shown that a richer skill mix of predominantly trained nurses does provide higher quality care. But its the same old story, if you do enough studies, you will eventualy get a result that favours your agenda. And note who commissioned this study. I cannot imagine that they have no interest in cutting costs. In my view this study is seriously tainted and if you look at the size of the study, is it realy large enough to reveal the true picture? No.
Unsuitable or offensive?
Sandra Joyce Powell | 22-Jun-2010 7:41 pm
The way i see it the HCA completes the role of the SEN. I know it has been said before. some of these carers have a interest in further training and want to go further. The majority of HCAs are housewives who have to go to work to help fund family life. And who do not want to take on the responsibility of training. We need to reinvent the bedside nurse. Yes go back to the SEN. offer those who want to train and have the ability the chance to do so. make them accountable . at the moment the Staff nurse is accountable for the HCAs actions on her /his shift. bring back the bedside trained and accountable nurse.
Unsuitable or offensive?
Anonymous | 22-Jun-2010 8:48 pm
It is not just the nursing profession that is responsible for this shift, since the WTD for junior doctors hours, more and more junior medical roles have had to be adopted by the RN's. Physio's, OT's, pharmacists, dieticians - none of these professions work around the clock, the nurse however is always there to fill in for the lack of MDT cover.

Over the last few years my role has changed, as a nurse I am now expected to cannulate, venesect, dispense drugs out of hours, provide physiotherapy, assess for OT equipment, initiate enteral feeding regimes and of course the rest of my job I always used to do.

Is it any surprise that the HCA does half the stuff I used to do, I don't have the bloody time!
Unsuitable or offensive?
Anonymous | 22-Jun-2010 9:27 pm
i am a HCA. As in every kind of work you will find some who are better or more willing than others.
I live my job and have nothing but respect for all the nurses i work with. That is why i am starting my training in september. I never would have done this if i hadnt worked as an HCA. We are all part of a team and can work well together. We are there to support the nurses, that is our job and it should be highly valued for the time it frees up so a nurse can do more skilled work.
Unsuitable or offensive?
Anonymous | 22-Jun-2010 9:48 pm
I'd just like to put my oar in and say that as a student nurse on placement at the present time, I have met some really good HCA's and some damn right lazy one's. I have learnt a great deal from HCA's and my mentor who would rather be hands on and most of the time he/she is. I have got a lot out of my placement and actually would rather just be on the ward performing patient care then be stuck in an office being a pen pusher. Yes nurses have to fill in paper work and there are a few who will stay in there all day or night doing so but most of the time when i'm on shift the ward is very busy, manic with elderly dementia, so none of us have time to sit around. I must admit its been good learning doing ward rounds, doing mental health act assessments but i want to care for the patient and give them the best possible life that they can have. There is only one thing that worries me, that if and when i qualify, i do not want to lose my registration for a HCA's incompetence to perform a task if it goes wrong. I will have worked hard for 3 long years and for what, to have nothing. So HCA's should be registered, accountable for thier actions and maybe someone in government could come up with an idea on bow to convert their NVQ's in to credits and then carry on learning while doing the degree of nursing. sorry for the rant.

there are some awesome HCA's out there and if they are that good then they should be registered and get the pensions, pay that they also deserve
Unsuitable or offensive?
mike | 22-Jun-2010 11:23 pm
Anonymous | 22-Jun-2010 11:32 am, first of all choose a name, I understand that you may find it difficult to make an intelligent contribution to a debate, but if you can't isn't it better to say nothing at all?

I agree wholeheartedly with Anonymous | 22-Jun-2010 8:48 pm and Anonymous | 22-Jun-2010 9:48 pm.

Lets just get this straight here, there are good and bad in every part of every profession, so this isn't about having a go at any particular group.

The HCA's of different bands DO perform an important role, and band 3 and 4's DO perform basic clinical skills, this is why they are paid a higher rate than band 2. They do this to assist the Nurse as required and free up the Nurses time for more advanced clinical roles. They do a good job and are valued.

HOWEVER, they are still not trained Nurses. Many are able to undertake the training and a lot do. When they ARE trained and registered Nurses the level of care and clinical skills they undertake is massively increased. The basic clinical skills such as obs etc are still part of the Nurses skill set, they are just performed with a deeper level of clinical knowledge. On top of that there are a whole load of extra clinical duties we are expected to perform. As the staff Nurse increases in band level and responsibility, further knowledge and clinical skills are expected. This is why higher levels of training and education have become the norm.

Just because Nurses of various grades perform at a higher clinical level, that does not mean we have lost our desire for patient care. That does not mean that we do not spend as much time with our patients as possible. It DOES mean that we have a lot more responsibilities and jobs to take care of. It is the fact we do not have the correct staffing levels to perform these tasks without compromising our time with the patients, it is the fact that we have far too many patients per Nurse to effectively give that 'one to one' care. THAT is the problem.

Yes of course HCA's spend more 'direct care' with patients, because their jobs are more often than not performed at the 'bedside'. It would be hard for example to do a round of turns/bedmaking/etc if they were not by the patients 'bedsides'. On the flip side it is very difficult to check the CD's in one of the bays. That is why the levels of technical/specialist care are dominated by staff Nurses!

I completely agree also that as HCA's are performing more clinical roles, they absolutely should be registered and accountable in the same way a staff Nurse is. There is room on the register to have a HCA register and a staff Nurse register.
Unsuitable or offensive?
Anonymous | 23-Jun-2010 1:17 am
Some good input here, but just want to clarify something....

SEN's were trained nurses who did more than just basic bedside care.
They are now registered as RN level 2.

There are RN level 2's working as Senior Staff Nurses,Deputy Ward Managers and higher. The reason many people are not aware of this is due to all being RN's.
Unsuitable or offensive?