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HCAs in nursing- What role should they play?

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As HCAs take on more tasks, Victoria Hoban looks at their developing status in the health service

Healthcare assistants, previously nursing auxiliaries, have always been key members of the nursing team. But in recent years, like the nurses they work alongside, their role has begun to evolve and extend.

In addition to traditional tasks, such as assisting patients with activities of daily living, many HCAs take observations, carry out ECGs, test urine and blood glucose, and even perform more invasive procedures such as taking blood, giving flu vaccines and dressing wounds. What’s more, some trusts are creating the band 4 ‘assistant practitioner’ for HCAs in more advanced roles, and NVQ levels 2 and 3 are being superseded by two-year diplomas – both for HCAs and assistant practitioners (APs).

These developments are raising the status of HCAs. While Unison has long welcomed them as members, the RCN traditionally has not. But, a few years ago, that changed. HCAs who have a qualification in health and care or provide health and social care and have their work routinely delegated by a registered nurse or midwife – can now join nursing’s largest union.

Alongside Unison’s three-year battle for regulation and a code of conduct for HCAs, the Scottish government is now piloting a system whereby healthcare support workers – who include staff such as porters and domestics as well as HCAs – have a proper induction and have a code of practice to which they and their employer must adhere.

But what do these changes mean for registered nurses and patient care? Just as many medics voiced concerns over nurses extending their roles and becoming cheap ‘mini-doctors’, now many nurses believe HCAs are becoming ‘mini-nurses’, eroding and devaluing key elements of the nurses’ role and being used as ‘cheap alternatives’ in times of economic belt-tightening.

‘If you have an HCA performing an invasive procedure and something goes wrong, who is responsible?’ says Angela Kydd, senior lecturer at the school of health, nursing and midwifery, University of the West of Scotland. But her concerns go beyond accountability. ‘Why train an HCA to take blood? We need to “up the value” of what it is to wash, feed, dress, talk and entertain, and stop trying to make everyone mini-doctors.’

Louise Green, principal lecturer (interprofessional working) at the University of Central Lancashire’s Department of Allied Health Professions, is training a new army of band 4 APs to work across the allied health professions. There are even plans to enable them to give some medications such as paracetamol. She says APs are a necessary development. ‘We can’t go on working as we are. Nurses resisting such changes are only making themselves feel uncomfortable.’

Laura Leatherbarrow, KSF nursing competency lead at the Royal Liverpool and Broadgreen Hospital Trust, says HCAs who receive proper training in extended roles are perfectly able to assess holistically, while remaining aware of their limitations. ‘We teach HCAs in the same manner as a student nurse and go in-depth. We don’t train HCAs to be simply task-orientated.’

Ms Leatherbarrow says the Knowledge and Skills Framework was a major turning point for HCAs at her trust as it revealed the wide range of tasks they already performed, often informally. Many were deemed skilled enough to be placed on band 3 and the trust decided to update their training, appointing Ms Leatherbarrow to do this.

However, education and training of HCAs varies nationally. While all registered nurses have completed a diploma or degree, HCAs may have had no training or, conversely, may have NVQs, a university-based access course or even a two-year diploma under their belt (see case study below).

Gail Adams, Unison’s head of nursing, argues that until funding improves, it will be difficult to rectify these variations. ‘Because HCAs aren’t considered a profession, no money is ringfenced,’ she explains. The union has worked with the Open University to develop Understanding Health and Social Care for healthcare workers wanting to study for a vocational higher education qualification. But, Ms Adams stresses it is still ultimately down to trusts to fund secondments. Without these, HCAs, many of whom have family responsibilities, cannot afford to survive on bursaries.

Inconsistencies in training also make HCA regulation difficult to achieve. For this reason, Ms Adams is against the development of APs which she feels is unnecessary. She calls for better career progression and recognition of HCAs instead.

This supports the findings of Karen Spilsbury, research fellow at the department of health sciences, University of York, who, in 2001, returned to the wards, working alongside HCAs as part of her PhD. She observed how their skills were used – or often not used – by nurses. ‘There were 17-year-old HCAs new to the job on the same grade as those with 20 years’ experience and often no difference in how nurses utilised their knowledge and skills,’ she says.

More vitally, while HCAs were ‘gathering intelligence’ at the bedside more than any other staff, Ms Spilsbury found no formal mechanism for them to pass this on. They could not write in the notes and, where they did attend handover, their input was not requested. This fuelled ‘game-playing’ and resentment. ‘As one HCA put it, “the clever nurses ask me what I have been doing this morning”,’ says Ms Spilsbury.

These findings suggest that nurses should focus on ensuring better communication with HCAs and utilising their skills rather than worrying about their regulation and extended roles. As Ms Spilsbury points out, nurses can’t have it both ways. ‘Nurses are often the ones dictating what HCAs can and can’t do in a particular area. An HCA might not be allowed to do blood glucose monitoring [when things are quiet], but when they are busy, they are allowed to do it. This is inconsistent and unfair.’

Ms Adams cautions nurses to remember they fought the medical profession to have their own skills recognised, and should not do HCAs a similar injustice. ‘HCAs are highly skilled, motivated and loyal staff. If you don’t value them, they will vote with their feet and move into other areas. Where they have aspirations and there is the need, they are entitled to be able to develop.’

‘I see my job as supporting nurses so they have more time to care’

In 2005, Margaret Stowe was promoted from cleaner to HCA at Carrington House Surgery, Buckinghamshire PCT, after completing the Open University’s Diploma for Healthcare Assistants in Primary Care Practice. Her current role includes giving flu vaccines, dressing wounds, removing stitches, performing ECGs, testing urine and taking blood.

‘I see my job as supporting the doctors and nurses so they have more time to provide care. If I take someone’s blood pressure and it is high, I send them to the GP so they have that information in front of them. With wound care, the nurse makes the clinical assessment and does the initial dressing. I do the dressings on subsequent occasions and if I spot any signs of infection or deterioration, I always go back to the nurse to reassess the wound.

‘I think the health service will want HCAs to take on more responsibilities, so regulation is a good idea. But employers should not push HCAs into anything they are not confident of doing.’

For further information about the OU diploma, email Lynn Wiggs

Sign up for Advancing the Role of Healthcare Assistants on 5 June, Cavendish Conference Centre, London

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