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The role of nurses in long-term care

VOL: 98, ISSUE: 08, PAGE NO: 36

Steve Smith, BSc, PGCE, RGN, is a clinical nurse tutor at Gables Care Homes, Ely, and lecturer at the school of nursing and midwifery, University of East Anglia

The current drive to establish national standards in the education of care workers could be the hammer the government has been looking for to knock a permanent wedge between what might be seen as personal, or social care, and nursing.

The current drive to establish national standards in the education of care workers could be the hammer the government has been looking for to knock a permanent wedge between what might be seen as personal, or social care, and nursing.

When the Care Standards Act 2000 is implemented in April, nursing and residential homes will be reregistered and brought under a single registration authority as 'care homes'. It has been said that the act will provide regulators with unprecedented power, but will this power be used to ensure the appropriate training of care staff? And will the regulators understand the difference between the skills and competencies of nurses and health care assistants (HCAs)?

The perceived role of nurses
In a survey of 20 HCAs and 20 nurses working in three care homes, the respondents were asked what skills nurses contribute to long-term care that could not be provided by HCAs (see Table). The respondents mentioned tasks that they felt could be carried out only by professionals with three years' training. For example, three HCAs and 11 nurses felt that nurses were needed for the administration of medication.

However, 18 HCAs said there was nothing that nurses do that could not be done by HCAs. None of the nurses agreed with this. While some nurses suggested skills such as supervising staff, assessment, care planning and evaluation, most did not refer to these skills.

Professor June Clark, chair of an RCN taskforce that aims to develop a definition of nursing, says that what justifies the need for a nurse is not the task, but the condition of the person the task is being undertaken for: 'not the bath but the person being bathed' (Parish, 2001).

The implication is that nursing tasks can be taught to most people with reasonable capability fairly quickly. However, it takes training and experience to acquire the ability to understand, analyse and think clearly about the needs of individual clients.

A clear definition of what nursing is would be an important step in ensuring that the need for nurses in long-term care is fully acknowledged.

Government initiatives that aim to equip HCAs with the skills to carry out long-term care appear to be based on assumptions similar to those made by most of the HCA respondents; if competencies can be ticked off, the worker is ready for anything.

The government has its financial reasons for viewing nursing as a series of tasks. HCAs however, who believe that nurses do not offer more than they do, are not aware of the full role of nurses.

In the face of these challenges to their professional status, nurses need to ensure that their work is not devalued. If they are to stake their claim to leadership in long-term care, nurses must be able to demonstrate their skills and assert their belief that their contribution gives patients benefits that cannot be provided by staff with less training.

Education standards for care staff
The Training Organisation for the Personal Social Services (TOPSS) England has set new induction standards for care staff. While they are not designed to provide a qualification in their own right, they have been developed to provide the foundation for NVQ care level 2. Half of all care staff in care homes must achieve this qualification by 2005 (Revans, 2001). The key topics include: the principles of care, the organisation and the worker's role, the experience and needs of the service-user group, safety at work and the effects of the setting upon service provision.

TOPSS England will also be approving national occupational standards for registered managers of adult residential homes and for regise been developed to provide the foundation for NVQ care level 2. Half of all care staff in care homes must achieve this qualification by 2005 (Revans, 2001). The key topics include: the principles of care, the organisation and the worker's role, the experience and needs of the service-user group, safety at work and the effects of the setting upon service provision.

TOPSS England will also be approving national occupational standards for registered managers of adult residential homes and for regisare limitations inherent in this approach. For example, how long does someone remain competent in an ever-changing environment, when new clients with different care needs are admitted?

The nursing profession has accepted that practitioners need to continue their education and development beyond registration, but there is currently no such requirement for HCAs.

If all training resources (staff time, effort and money) are spent on providing a safety net and reaching minimum standards, how will the group develop? Nurses must grasp the opportunity to reclaim their status as experts and leaders in their specialised area.

Taking responsibility for education
If much of the hands-on care in a nursing home is carried out by HCAs, it is vital that nurses manage the assessment, planning, implementation and evaluation of this care. This will ensure that it is carried out to an appropriate standard and that any changes in a patient's condition are noticed and acted upon. This is part of nursing and defines the duty for which we are all accountable. It would be made easier if staff at all levels shared the same concept of what it is to be a nurse.

It is a relatively simple exercise to map the national induction and NVQ standards onto the Roper, Logan and Tierney conceptual framework (Roper et al, 2000). This nursing model consists of five components:

1) A client's problems relate to one or more of 12 activities of living (ALs):

- Maintaining a safe environment;

- Communicating;

- Breathing;

- Eating and drinking;

- Eliminating;

- Personal cleansing and dressing;

- Controlling body temperature;

- Mobilising;

- Working and playing;

- Expressing sexuality;

- Sleeping;

- Dying.

2) The level of nursing intervention required relates to the client's level of dependence or independence regarding these ALs.

3) The client's position on a lifespan continuum from birth to death, as assessed by the nurse, will have a bearing on the level of independence.

4) A range of factors influence ALs: biological, psychological, sociocultural, environmental and politico-economic.

5) Individualising nursing (applying the nursing process).

For example, one element of the NVQ care level 2 requires that HCAs 'enable clients to access toilet facilities'. The assessor is required to check that: 'appropriate safe assistance is given to clients who need help to reach and return from the facilities.' This may seem straightforward in the context of residential care. However, it may be applied to a person who has a progressive disease or is recovering from an acute illness and is in the care of a nurse. In such cases, how can HCAs understand the 'appropriate level of assistance' or what they should be looking for that may influence the appropriate level?

It is part of nursing to ensure that there are sufficient resources to give the client adequate nursing care. In the context of a care home in which HCAs are relied on to deliver nursing care, they must surely be the most important resource at the nurse's disposal. When making an assessment, the nurse must be satisfied that the HCA providing hands-on care has the knowledge, skills, experience and any other appropriate qualities necessary to carry out a given task.

When planning the duties of an HCA the nurse must take account of any shortfalls in these qualities. In this case it may be necessary for the nurse to teach the HCA, or to choose another HCA who has the appropriate skills. When the task has been completed, evaluation by the nurse will identify any further training that the HCA requires.

Conclusion
If nurses who work in care homes oversee the education of other carers at the home they will be assured that the HCAs understand the needs of clients from a nursing perspective and the safety net provided by NVQ standards will be secure. What is most important is that flexible education will be provided. Rather than depending on standardised box-ticking, it will be tailored to meet the changing needs of clients.

The shelf-life of national care standards qualifications seems undetermined. A certificate implies competence until the next set of changes is introduced. Nursing is not like that. It involves continual improvement, planning, implementation and re-evaluation by practitioners who continue to develop their knowledge and skills.

If they are to ensure that people in need of long-term care are treated appropriately, nurses need to extend this continual improvement to HCAs by taking responsibility for their continuing education and development. This will require nurses to lead from the front, to take their own professional skills updating seriously and to appreciate the skills that are needed to work in long-term care.

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