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Changing practice

Training assistant practitioners to deliver clinical care in specialist services

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Evaluation of a pilot project found that training band 3 nursing staff to take assistant practitioner roles reduced workforce problems in a chemotherapy unit

Authors

Donna McGowan, PGCert, BA, BSc, DN, RGN, is nurse clinician, Edinburgh Cancer Centre, Western General Hospital, NHS Lothian; Karen Campbell, PGCert, MN, BSc, RGN, is Macmillan lecturer/practitioner in cancer nursing, Edinburgh Napier University and NHS Lothian.

Abstract

McGowan D, Campbell K (2010)Piloting an assistant practitioner training course for chemotherapy day services. Nursing Times; 106: 12, early online publication.

The NHS has introduced the assistant practitioner role to combat staff shortages and provide high quality care. Edinburgh Cancer Centre, Jewel and Esk College and Edinburgh Napier University piloted a course for band 3 staff to train to become band 4 assistant practitioners in a chemotherapy day unit. 

This article describes how the course was set up, and the results of an independent evaluation that examined the challenges and opportunities of introducing this role.

Keywords Assistant practitioner, Chemotherapy, Role development, Cancer care

  • This article has been double-blind peer reviewed

 

Practice points

  • The assistant practitioner (AP) role is designed to deliver protocol based clinical care under the direction and support of registered nurses (RNs).
  • However, the evaluation highlighted that RNs were not clear about the AP role and its responsibilities, and where RNs’ accountability lay.
  • As a result, during the course a dedicated RN was appointed to oversee APs’ training and ensure they met their competencies. This full time mentor produced a weekly report on each trainee AP’s progress, which helped to clarify their role and RNs’ accountability.

 

 

Introduction

In recent years the role of the assistant practitioner (AP) has evolved (Nancarrow and Mackey, 2005; Warne and Andrews, 2004) as a response to health policy, staff shortages and demands for cost effective care (Scottish Executive Health Department, 2004).

APs are expected to provide a high level of support and assist registered nursing staff with managing patient care and workload in the clinical area. As part of a dedicated cancer team, APs working in a day chemotherapy unit are allocated their own patient workload by a registered nurse and are expected to work independently. They should assess patients’ care needs and deliver this care following local policies and protocols with minimal supervision, reporting to the registered nurse when problems arise outside their boundaries and capabilities (NHS Education for Scotland, 2008).

A regional review of chemotherapy services across South East Scotland Cancer Network (2007) identified new and improved ways of working. It recommended introducing the supporting role of assistant practitioner to address difficulties with recruiting and retaining registered nursing staff for chemotherapy administration and supportive care, which includes care of central lines, venepuncture, cannulation and managing blood transfusions. 

Table 1 provides a brief overview of the rationale for piloting APs in chemotherapy services.

The pilot project

NHS Education for Scotland (NES) invited health services to pilot innovative approaches to support healthcare workers’ education and role development. After a successful bid, Edinburgh Cancer Centre secured funding from NES to conduct a pilot project to develop the new role of AP.

The centre worked with Jewel and Esk College, which provided support worker Higher National Certificate (HNC) courses. In consultation with education providers, it was agreed that a core set of modules would be required at level 7 (Scottish Credit and Qualifications Framework) with a further module completed at Edinburgh Napier University. Students would attend the further/higher education college on a day release basis for the following modules:

  • Pre HNC course;
  • Physiology for healthcare professionals (SCQF level 7);
  • Positive healthcare for individuals (SCQF level 7);
  • Principles of healthcare practice (SCQF level 7).

Edinburgh Cancer Centre worked with Edinburgh Napier University to produce a new module at level 8 (Box 1 provides details on learning outcomes). The assignment was designed as an academic portfolio, including clinical competencies, a clinical practice workbook and four case reports set by the module team, ensuring students incorporated academic evidence into their practice. The portfolio was entitled ‘Caring for the Patient Receiving Chemotherapy’.

The next step was to nominate four support workers with the required skills and experience from the centre to attend training to become APs. Those who met the criteria and were available to start training began the course in September 2007.

 

Box 1. Learning outcomes for module at level 8

  • Use an evidence based problem solving approach in the management of patients/clients in the oncology setting.
  • Demonstrate the ability to safely perform cannulation, venepuncture and management of central vascular access devices.
  • Explore current guidelines and protocols on safe handling and administration of chemotherapy and blood products.
  • Describe professional and legal responsibilities as part of the multidisciplinary team.
  • Demonstrate an awareness of holistic and compassionate principles of care and how they can be embedded in the support worker role and the multidisciplinary team.

 

 

The evaluation process

As part of the funding from NES, it asked for an independent consultant to evaluate the pilot to ensure the views of all parties involved were considered. An initial consultation with the independent consultant took place in June 2008 with the project team from Edinburgh Cancer Centre, Jewel and Esk College and Edinburgh Napier University.

The initial consultation showed the project team had confronted and resolved a number of obstacles and issues as the initiative and educational programme progressed. Table 2 outlines these, along with the actions taken to address them.

AP and staff experiences

A further independent evaluation focused on the experiences of participants and views of other practitioners involved in the pilot.

Due to limited staff time this evaluation was conducted by telephone interview with APs and staff. Eight interviews took place with three course participants, one clinical manager, two staff nurses, one senior manager and one medical staff member. All interviews were tape recorded and transcribed. The local ethics committee was consulted before interviews started.

The evaluation generated three themes, discussed below.

Experience of course participants

In general participants initially felt apprehensive:

“[I was] sceptical about it as it was the first time it ran and a lot of people didn’t know anything of this role and the value it might provide, it was [a] new role.”

After their initial fear, participants felt they had gained a greater understanding of the purpose of the course and its content. They felt they had gained confidence in their abilities in clinical practice:     

“The course prepared us well for the change in the role”; 

“Now in my work I feel I can stand my ground with my opinion and fight my corner for the patient.”

Nurses and doctors working alongside course participants commented that their depth of knowledge was more than adequate and even exceeded the requirements of the AP role. One staff member regarded the project as a “positive development and a worthwhile investment,” indicating that it was well received.

The role seemed to create its own niche, as it showed there was greatest potential for development in outpatient/day care haemato-oncology. This was due to patients’ needs for increased levels of supportive care in the form of blood transfusions and venepuncture during treatment. In addition, trainee APs showed they could hold a patient caseload, providing continuity and high quality care under nursing/medical supervision.

As a result, once the pilot was completed, a job description at band 4 was created specifically for the haematology setting. One aspect of this new job description involved identifying areas of care that post holders can take on as a caseload, such as managing blood transfusions, which enhances job satisfaction.

After the telephone interviews the project team continued to tackle the issues related to role clarification in the different clinical areas, with the following suggestions to help develop the AP course: 

  • Review skill mix in oncology/chemotherapy and haematology areas and match against the Knowledge and Skills Framework (DH, 2004);
  • Plan AP role development and build into budget projections;
  • Carry out a situational analysis to identify service need before developing the AP role.

Another topic of concern for both course participants and other healthcare staff related to the number of band 4 posts that the cancer centre would need. Participants had assumed that after completing the course successfully all four would be employed at band 4. However, at the time of the interviews it appeared there would be funding for only two posts in the chemotherapy day unit and the possibility of one in the haematology inpatient ward. This created anxiety for trainees and clearly distracted them from their coursework:

“I am worried about the interview for the posts”;

“Main problem is there are only two posts, not four as I thought there would be. The competition will worry me.”

Academic/clinical support provided during the course

Course participants generally viewed the teaching, learning and assessment support from the two education institutions and the clinical areas positively:

Mentorin the clinical area was wonderful”;

“Support was good at the college.

Participants also described increasing anxiety when they moved from the further/higher education college to the higher education institution. This is not unusual, and those entering the undergraduate nursing programme after completing their HNC qualification have described similar feelings.

Participants also commented on the additional study/workload, with the needs and demands of the portfolio varying:

“The new assignment scenarios were difficult”;

Sometimes the support was ad hoc, just as we went along.”

Course participants expressed concern and anxiety about progressing from level 7 to 8. They felt there was a general lack of guidance once level 7 had been completed and when starting the level 8 portfolio. This created feelings of confusion and anxiety and there was a general lack of understanding around the validation process of the level 8 portfolio. The project team had to continually revisit the pilot to ensure the correct standards of education were maintained for band 4 posts.

Course participants and other staff highlighted the need for formalised educational and clinical support, adding that the level of support provided needed to be made explicit to both students and those in key supportive roles. However, it was unclear from the telephone interviews whether formal expectations of clinical and academic support were made explicit at the time of recruitment to the course.  

Continuous evaluation and student feedback on the course took place through the usual quality assurance mechanisms at the educational establishments and appropriate action was taken as required.

As a result of the comments received from course participants, the project team made the following suggestions to further develop and improve the course in the future:

  • Increase the formal study and writing skills component of the course;
  • Incorporate additional teaching sessions on the use of IT library skills and the use of electronic databases (such as Athens or Shibboleth) to assist the transition from level 7 to 8;
  • Include academic supervision from the higher education institutions on the prerequisites for level 8 modules;
  • Refer to two newly published frameworks in the programme: the professional development framework for healthcare support workers on working with people with cancer (NES, 2009) and the workforce development framework on safe use of cytotoxic medicines (NES, 2007).

Future developments

The project team had discussions about future developments, which focused on:

  • Recruiting and selecting future course participants: it was generally considered that the process should be more formal, planned and that potential candidates should be able to demonstrate capability at band 3; 
  • Enhancing the course: aspects of psychology should be included to enable APs to support patients and have a greater understanding of the impact of bad news and issues surrounding death. APs highlighted that future courses could consider including some anatomy, physiology and pathology of the common cancers, diagnostic investigations, staging and relevant treatments;
  • Clarifying roles: the roles of a newly qualified staff nurse, AP and nursing assistant need to be differentiated;
  • Academic/clinical support: to ensure equity of support and to monitor mentors’ additional workload burdens, a policy should be developed to identify mentors’ commitment when supporting APs in training;
  • Transferability of the AP course to other clinical areas: the higher education institutions in particular planned to take this forward, possibly by developing core portfolios for the AP role, then developing specialised portfolios for specialised areas of nursing. Locally, areas such as intensive care and mental health nursing have shown interest.

Those involved in the review process believe the AP pilot course has been successful, and they can see the potential for developing it further. Developing education and the workforce simultaneously is always challenging. To ensure sustainability, minimise organisational risk and enhance patients’ experience of care, the project team made the following suggestions:

  • Generic and specialist competencies for band 4 should be formulated, matching the specific requirements for different specialties;
  • Decision making capabilities of band 4 staff members should be clarified, according to context specific job descriptions, competencies and the Knowledge and Skills Framework;
  • Career progression opportunities should be incorporated into performance appraisal or personal development planning of band 2 and 3 support workers.

Conclusion

The South East Scotland Cancer Network now has a template that may enable further development of the assistant practitioner role and provide options for service redesign that can be transferred to other clinical areas.

The pilot also identified the potential clinical benefits of the role while allowing the issues that related to clinical and academic support and training needs to be addressed.

Further discussion and strategic planning is needed on the educational content and level of future courses to ensure the smooth integration of APs into practice, provide career opportunities and, most importantly, ensure patient safety at all times.

 

Background

  • Edinburgh Cancer Centre decided to introduce the role of assistant practitioner in the chemotherapy day unit to resolve a number of workload problems.
  • This also provided the opportunity to release trained chemotherapy nurses to carry out more complex care.

 

Acknowledgement

We would like to thank the following people for their contributions to the article: Claire Smith, chief nurse, cancer and palliative care and neurological science, NHS Lothian; Valerie Reid, practice education facilitator (non registered staff), NHS Lothian; Pam Dixon, head of curriculum, Jewel and Esk College; Rachel MacAngus: research nurse, NHS Lothian; Susannah Flower, education coordinator, NHS Lothian; andBernice West, director, Hive Design and Consultancy.

 

  • 4 Comments

Readers' comments (4)

  • Personally I don't mind who does what but it's the constant dumbing down of healthcare that infuriates me. Surely you can make a better case for recruiting and training RN's than recruiting and training unqualified staff to give chemotherapy? Because you have no idea about how to recruit and retain staff (a few clues for you Bonus? Look after and take an interest in them? Active deveopment?) it won't be too long before these wide eyed neophytes have moved on.

    “Main problem is there are only two posts, not four as I thought there would be. The competition will worry me.”

    Classic quote. We don't want competitive people working in the NHS, that would lead to all sorts of problems. Like competency and getting the job done.

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  • i also have concerns about non-qualified people taking on 'expert' roles. Who takes ultimate responsibility in the event of mishap? Having non-registered people managing blood transfusions goes against all policies I have ever seen- do they check the blood and start the transfusion, for example. It is unclear from the article whether these AP's actually administer chemotherapy, if so surely this flies in the face of all the work being done by UKONS and the NCAG report to ensure safe practice in this field.
    Table 2 mentioned in the article is not present so it is not possible to see what concerns were raised and how they were addressed.
    The whole process seems to be more about cost cutting than addressing the real issues of getting and keeping suitably qualified registered nurses. At this rate the whole discussion on whether the 'profession' should be degree based only will become academic as there will be no need for qualified nurses, AP's will be doing the role.

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  • "This also provided the opportunity to release trained chemotherapy nurses to carry out more complex care."

    What would this be? Having given the odd bit of chemo in my job I can clarify that it's not a case of hooking up a line to a cannula and letting it go. It seemed pretty complex to me.

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  • For your information:- Assistant Practitioners take a 2 year Foundation DEGREE course and may, if so desired, complete the 3rd year for a full degree. They are more than likely to be more up to date than some of the 'qualified' nurses ....especially those who bleat on about 'unqualified' staff taking over their roles. AP's are there to 'compliment' the team not to take over anyones job.

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