Regulate HCAs now, warns review

3 August 2010 | By Steve Ford, Charlotte Santry

There is an urgent need to regulate assistant practitioners because they are being increasingly used as substitutes for registered nurses, a major review has warned.

The review, carried out by the National Nursing Research Unit for the Nursing and Midwifery Council, says there are strong patient safety grounds for regulating all healthcare assistants.

But the report authors said there was a particularly “urgent need” to regulate HCAs working in band 4 assistant practitioner roles as they are used as a “substitute” for nurses rather than as a supporting and supervised role, as originally intended.

“A decision needs to be made as to whether this [regulation] should be as a senior support worker or as a second level qualified nurse,” the report states, before further decisions about assistant regulation can be made.

There have been long standing arguments over which body or organisation should be responsible for HCA regulation. The review recommends that the task should be led by the NMC as a large percentage of the assistant workforce is allied to nursing.

NMC chief executive and registrar Dickon Weir-Hughes said the report “makes clear the risks associated with patient safety if healthcare support workers continue to remain unregulated”. The report says the lack of regulation poses a risk to the public and there is a strong case that safety would be improved by its introduction - although it is “not possible to demonstrate unequivocally”.

It says the lack of regulation means it is hard for employers to check if new HCAs have previously been dismissed for poor misconduct. There is also evidence of HCAs undertaking tasks they are not trained to do in anunsupervised setting.

The review rejects a voluntary,employer led model of assistantregulation - such as that piloted in Scotland - on public safety grounds.

However, Nursing Times understands a voluntary system could be a likely first step.

The Department of Health’s arm’s length bodies review, published last week, proposed to extend the remit of theCouncil for Healthcare Regulatory Excellence, which oversees the NMC. Its new role will allow it to set standardsfor and provide quality assurance of “voluntary registers” held by regulators and professional bodies.

CHRE chief executive Harry Cayton told Nursing Times a register would be “easier to create” for HCAs than full blown regulation and could be a first step towards a more formal system.

Responding to the NNRU review, Royal College of Nursing policy director Howard Catton said: “The report presents an overwhelming care for moving ahead with the regulation of HCAs on the grounds of patient safety, quality and professional practice.”

Unison assistant national officer Jennifer West welcomed the review but warned that how HCA regulation was funded remained a major issue. She said: “It must be remembered that they are on a lower pay band to other nursing professionals. This must be taken into account when setting regulation fees and making decisions about who should pay them.”

Professor Weir-Hughes told Nursing Times earlier this year that he was “single minded” about ensuring HCAs were regulated nationally.

Readers' comments (118)

Anonymous | 3-Aug-2010 8:41 am
wow it has come to light! so where would i stand i have extended clinical skills and my discription is a higher clinical support worker on band 3? yes i know i am a h c a with extended role but i know people do the same as me but are band 4 and get put with newly qualified for goodness sake who is the superviser in the mixed skills
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mike | 3-Aug-2010 10:28 am
This has to be a contender for the no s**t sherlock award! (And there have been a lot of them lately!)

Not only should HCA's be regulated and accountable in the same way a Staff Nurse is, but they should have their duties and roles limited as at the moment they are in no way trained, educated or qualified enough to perform a lot of the tasks they are being asked to do. This is wrong.

If a Staff Nurse wants to perform at a higher level for example, then seperate qualifications in prescribing (amongst others for example) must be undertaken before they can do that, a HCA's NVQ does not compare to that level of qual, and even then we are still highly regulated, HCA's are not.
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Anonymous | 3-Aug-2010 10:47 am
If the NMC takes HCAs under their wing I will burn my registration card and leave the U.K. There should be no unqualified (RN) staff working in U.K. hospitals.

And Mike the NMC can't even pull a finger out to regulate 'advanced' practice in qualified staff, so your way off the mark with the comment about 'highly regulated'.
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Anonymous | 3-Aug-2010 11:15 am
Definitely needs to be some sort of control of HCAs. Have just left a job where very good HCA who has been operating in a role that should be filled by a staff nurse. She is unauthorised to be in charge so cannot legally be left on her own but because she has been there so long and has learnt to do extended role functions she is unhappy to be left the more mundane tasks eg cleaning.Essentially this devalues the role of the staff nurse who is meant to be her supervisor . The problem is the HCA has gone as far as she possibly can but the staff nurse who could use this as a developmental position is undermined and no one stays in the job for long as a result.
As a result of this experience I am against HCAs being given extended roles - they should have to go through full training as we did
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Anonymous | 3-Aug-2010 11:54 am
It is important to recognise the value of HCA's. Regulation may be one way forward. For those of us who have been around for a while - I can see this eventually emerging as the re-introduction of the State Enrolled Nurse (no doubt they would think of some other name, to avoid the embarrassment of having got rid of the title in the first place). SEN's were incredibly valuable part of the workforcee that should never have gone.
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mike | 3-Aug-2010 12:30 pm
Anonymous | 3-Aug-2010 10:47am:

You seem to be a bit confused about what you want here. Okay, apart from the fact that the NMC are pretty useless and yes they have faffed about with technicalities, do you believe for one second that if a qualified staff Nurse with advanced practice quals messes up they would not be dragged in front of the NMC? Don't think so. That is why we are still highly regulated regardless of technicality. Second of all do you want HCA's to be registered or not? You say you would tear up your card if they were accountable and regulated, but then say they should not be working if they are unqualified, which is exactly what is happening now?

Anonymous | 3-Aug-2010 11:15 am:

I absolutely agree! Yes there are limited basic roles a HCA can perform, and they should be trained, qualified and regulated for these tasks. However, the term Health Care ASSISTANT is a bit of a clue, there will always be a need for the most basic of tasks (such as bedmaking, washes) to be performed by unqualified staff to assist the qualified staff. If they want to do the job of a qualified Nurse, they should become a qualified Nurse, if they are able, not everyone is.

Anonymous | 3-Aug-2010 11:54 am:

Here we go again, before anyone gets started here noone is having a go at HCA's or 'not recognising their valuable contribution'! For crying out loud. It is the same thing in every one of these discussions. HCA's do perform a vital function, of course they do, but at the end of the day they are not qualified staff and should not be performing tasks that they are not educated/trained in, qualified to do, or accountable for. It is as simple as that.

The SEN is already here, albeit in a different guise of band 4's. However their training and qualification is still not up to standard for the tasks they are being asked to perform, and they are still not accountable for their actions. Both of these are wrong and need to be rectified.

IF these things are done, then I believe this will be a good thing for a HCA to expand and grow in their profession, either leaving it at that or using it to see if they want/are capable of becoming a qualified Nurse, in which case (providing they have the necessary academic and skill requirements to do the course) they can go on to do their training.

But that still does not mean that a HCA should not be accountable in the same way a staff Nurse is for their actions.

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Anonymous | 3-Aug-2010 3:23 pm
This article seems to have caused some inflamatory responces.There seems to be a lot of confusion about regulation, registation and qualified. As I understand it the drive is towards regulation of HCA's not registation, so don't go tearing up your registation cards yet. In any case this debate has been going on for years without any sign of an outcome.

As a trainee AP I support regulation. There is so much confusion about the role. We are qualified for the skills we perform, we are assessed by national standards, supervised and work in line with protocols. Any HCA performing tasks and skills that they have not been trained to do and competent to perform should be aware that they are also accountable as much as any nurse that delegates these tasks.

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Anonymous | 3-Aug-2010 4:51 pm
yes i do think there is some need for some kind of regulations ! There has to be reprocussions of actions!

At my place of work they have taken on a lady as a HCA who has NO qualifications at all ! no NVQ's or anything ?????
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mike | 3-Aug-2010 10:18 pm
Anonymous | 3-Aug-2010 3:23 pm, there have been a number of threads on the same topic so they all tend to get spillover arguments I think.

I have to disagree with you about HCA's being accountable though, they are simply NOT as accountable as a staff Nurse is. If a Nurse delegates a task to a HCA, it is the staff Nurse, not the HCA who will be held to account and face disciplinary action by the NMC.

And I am sorry band 4 HCA's are simply NOT educated and qualified to the level they SHOULD be, to perform clinical tasks such as take an ECG for example. A band 5 staff Nurse IS, and I know many who still struggle with the reading of an ECG, how can a band 3 or 4 with less education and training be expected to manage? I think most of those clinical tasks should be solely the realm of band 5 and above.

Anonymous | 3-Aug-2010 4:51 pm, that is what a HCA should be. You do not need qualifications to be a HCA, that is why they perform the basic tasks such as washes, bedmaking, teas, etc. Those who go on to get qualifications or have them beforehand perform at a higher level, band 4 and above.

I would like to reiterate there is nothing wrong with any level and all levels are needed to form the whole, but it must be an imperative that each band stay within the competencies of their role.
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Anonymous | 3-Aug-2010 10:47 pm
I have just completed a foundation degree to become an assistant practitioner, I have completed competencies in venepuncture , ecg's and several other tasks. All mentored and signed off by qualified staff and assessors. I work as a Band 4 on my ward . I work within my competency but under three senior staff members who no longer have competencies in venepuncture or ecgs or catherisation . They are Band 6 & 7. We also have newly qualified nurses on the ward who don't have the competencies either so when the need arises it is the Band 4 's who have the skill and come to the aid of the patients. I could carry on and convert to qualified status but I want to work with patients not paperwork .
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Anonymous | 3-Aug-2010 11:04 pm
Mike you say that everyone should work within their level but unfortunately whilst the trust is very happy for a HCA to undertake courses to extend their skill level they are not then offering any positions other than band 2. This leads to a situation where every band 2 has diffeent skills and training levels. You can not simply say every band 2 should be only bed making and giving out teas or many of those who are good experienced HCAs would leave.

I also disagree with your assessment of NVQs. The qualification does not give you training it is an assessment of your skill level. To be awarded a competency level the candidate must demonstrate both technical ability and an understanding of the reasoning for performing a task. They must also show that they know the normal parameters and understand when urgent notification of results should be passed to a registered member of staff. I found it interesting to note that one NHS trust is using the NVQ unit on intravenous administration for assessing competency of registered nurses for IVs. As they obviously feel that the level is sufficient for assessing registered nurse competencies surely it is also sufficient for assessing healthcare assistants.
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Anonymous | 3-Aug-2010 11:53 pm
I am one of the Assistant Practitioners/ band 4s and quite frankly annoyed that you all feel us to be somewhat inadequate to carry out some of the roles of a trained nurse. If you are honest with yourselves, before the new post came to light you were more than thankful for us to support you! Many of us have years of experience to offer, more often than not we prove ourselves to be more knowledgeable and sometimes more capable than many of the new Rn's because of our experience. Yes I can understand that you feel threatened by the role, and it needs regulating. Those of old enough and honest enough to remember the SEN will remember that there was little difference between job roles; as for those who do not remember, then ask, you may be surprised how many of the RN's you work with today were SEN's, converting to RN's and not THAT many years ago, it all worked fine then and the EN had only trained for two years. After we have finished the UNIVERSITY DEGREE next year we will have actually put in three years of training. Take time out to look at the UNIVERSITY course and the training we undertake within the trust before you judge us so harshly. So come on please give us some credit and support. Please remember we were ASKED to take on this role. This post is not going away.
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Anonymous | 4-Aug-2010 7:11 am
Everytime an article appears on NT about HCA's, this 'us and them' argument arises. I find it quite sad, as we are all working on the same team, towards the same end. Some of the arguments put forward are quite frankly pathetic; I don't know a single RN who can read an ECG. I even know some who can't even perform one correctly... so don't try to tell me that as a band 2, I can't perform an ECG as well as a band 5. The fact is, there are certain things you don't need 3 years training to do. So whats the problem with an assessed, competent Band 4 doing them instead?
I'm all in favour of regulation, I'd be willing to join a register, safety is paramount and of course anyone of any band should have enough training to safely perform their role. But to the person who will rip up their registration card if HCA's and AP's are registered... go ahead, sounds like you wouldn't be missed anyway.
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rachel5 | 4-Aug-2010 7:54 am
I love being a HCA but know where to draw the line no matter how reluctantly (I do know HCA's who do smears!). We have a clear job description and should not abuse it. I want to do more in my role so have decided to train as a nurse we should not be sneaking in the back door as it can, sometimes, devalue the nursing role which is already undervalued enough. All that being said Band 4's are very highly qualified and should have a new registered description but with the onus on HCA not nursing, they are (or should be) two seperate roles that support each other.
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Anonymous | 4-Aug-2010 9:42 am
I am seriously considering retiring too. As a nurse of 37yrs struggling with NP title and advanced practice I do understand the HCA frustration. It is the word 'practitioner' that I am jumping for today. Assistant or Practitioner in an unqualified post!!
My PM is sending our HCA on courses intended for RN's. She has got this mindset that she can be a nurse if she does an NVQ and sidestep her training to allow her to continue in GP.
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Anonymous | 4-Aug-2010 10:49 am
I think it's worth pointing out that all the arguements being made here are exactly the same as those made by doctors when discussing nurses' extended roles and advanced practice. I wonder if all those arguing vociferously against HCA's extended their roles would feel the same if the arguements were directed against them?
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Anonymous | 4-Aug-2010 11:39 am
HCA's in NO WAY replace the role of the SEN, the training an SEN undertook was a shortened version of the SRN training,back then if you decided you wanted to be a bedside nurse rather than a ward sister you were advised to complete the two year SEN training. There should be some recognition for HCA's who undertake NVQ qualifications but this is not a mandatory requirement for the role og the HCA and it seems unfair that those who choose not to complete any form of training are given the same title, maybe we need to call the untrained HCA by a different title, I also think to pay a HCA a band 4 is an insult to the many RGN's that are paid at band 5 level.
I have worked with some excellent HCA's over the years but sadly have worked in area's where the HCA's rule just because they have been there a long time.
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Anna Lincoln | 4-Aug-2010 12:57 pm
I am in two minds about this. If HCA's are regulated the hospitals will use it as an excuse to remove RN's from bedside care. This would kill thousands.

But if HCA's are not regulated we will continue with the safety issues we have as a result of that.

I just want out of the UK. I cannot have respect for a healthcare system that doesn't understand taht well educated RN's are needed at the bedside/
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Anna Lincoln | 4-Aug-2010 12:57 pm
And if they are regulated does that mean they will suddenly start realising that yes they do need to fill in fluid balance charts?
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Anonymous | 4-Aug-2010 3:20 pm
HCA, band 4 , assosciate practitioners call these people what you will, they are cheaper, they are here, Registered Nurses are all to be degree level - of course someone has to fill the gap.

But I have to say I get fed up with hearning non reg telling us how grateful we are that they help us. That is what they are paid for - but an NVQ level 3 or 4 is most definately not demonsrating the same level of knowledge as those satifying either Diploma or degree level study.

Yes you are correct, these band 4 are indeed the old SEN role under a different guise - but need regulation with some urgency as I dont doubt their current level of anticipated skills will be expanded to include drug delivery (in all its potential formats) in the very near future.

They are cheaper to train and employ than the Registered nurse, they must therefore be regulated in order to reduce risk to both patients and colleagues - in exactly the same way that Registered Practitioners do....just think yet more potential NMC income at £70 per annum!!!!!
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