Your browser is no longer supported

For the best possible experience using our website we recommend you upgrade to a newer version or another browser.

Your browser appears to have cookies disabled. For the best experience of this website, please enable cookies in your browser

We'll assume we have your consent to use cookies, for example so you won't need to log in each time you visit our site.
Learn more

How a new health care assistant role can support junior doctors

  • Comment

VOL: 99, ISSUE: 13, PAGE NO: 32

Jacqueline Leigh, MSc, BSc, RGN, is lecturer in nursing, University of Salford

Government policy, particularly its vision for modernising the NHS (Department of Health, 2000a; 1998; 1997) requires trusts to develop practitioners in clinical roles responsive to patient needs. This is despite a growing crisis in some of the professions to recruit and retain staff.
Government policy, particularly its vision for modernising the NHS (Department of Health, 2000a; 1998; 1997) requires trusts to develop practitioners in clinical roles responsive to patient needs. This is despite a growing crisis in some of the professions to recruit and retain staff.


The need to think more creatively about ways of delivering patient care has led in part to a proliferation of roles. There is a particular interest in developing new roles to work across the health-care professions that will break down traditional professional boundaries (Easton and Burns, 2001; Greater Manchester Workforce Development Confederation, 2002). The emphasis is on developing roles that will contribute effectively to the journey of the patient through the health-care system rather than on developing roles within professions (DoH, 2000a; 2000b).


There has been a steady shift towards using unqualified practitioners in the delivery of patient care, with increasing evidence suggesting that the role of health care assistant (HCA) can positively contribute to meeting the needs of patients. Examples include implementation of the role of health care assistant in general practice (Mountford, 1999).


Role development


Salford Royal Hospitals NHS Trust, an acute teaching trust in the North West of England, has implemented a new health care assistant role to support junior doctors working in the surgical area.


Currently six full-time health care assistants work in the following clinical teams:


- Colorectal;


- Upper gastrointestinal;


- Urology;


- Orthopaedic;


- Obstetrics and gynaecology;


- Breast.


The HCAs cross-cover all the clinical teams and work evening and weekend shifts.


Rationale for introducing the role


The impetus to develop this role stemmed from the need to meet targets set out in Department of Health documents, which included the need to reduce the hours that junior doctors work (DoH 1991; 1997; 2000a).


The trust felt this could be achieved by maximising the contribution made by HCAs, who often provide great stability to clinical teams without compromising the quality of care delivered to patients. It is important to note that there was also a desire to create a role that would not only offer the HCAs a greater sense of job satisfaction and help them to feel that they were a valued part of a multidisciplinary team but also to offer them career progression.


Evaluation strategy


An evaluative framework was drawn up to measure the effectiveness of implementing such a role. It consisted of the following components:
- Carrying out a survey questionnaire of junior doctors and senior house officers working in the surgical area before implementation of the new HCA role to identify issues surrounding junior doctors' working day and to identify tasks that could be performed by HCAs and other staff;


- Repeating the survey questionnaire after the new system had been in operation for three months to evaluate the impact of the role;


- Undertaking an analysis of diary documentation to identify the roles performed by HCAs to assess whether their skills benefited/complemented the role of the junior doctor;


- Undertaking an analysis of reflective diaries kept by the HCAs to gain a valuable personal perspective of the issues surrounding the new role.


Development of the role


The role was developed following discussion with the general surgery head nurse and senior nurses in other areas of the trust who had implemented a similar role, from ideas from surgeons and ward staff, and from the results of the baseline questionnaire that was distributed to doctors.



Twelve questionnaires were distributed to junior doctors and senior house officers, five of which were returned. The following key tasks were identified, and were incorporated into a two-week intensive training programme for HCAs:


- Peripheral cannulation;


- Venepuncture;


- Electrocardiogram recording;


- Clerical support;


- Results chasing;


- Understanding the medical record.


Although junior doctors identified further tasks, these were considered to be outside the remit of the new role: included were tasks such as male catheterisation, the administration of intravenous morphine and arterial blood gas sampling.


Because the HCAs were now expected to practise with more responsibility and accountability, the training programme also covered the subjects of litigation, risk management, clinical governance, record-keeping and professional issues.


HCAs employed in the new role had either already achieved an NVQ Award in Care at level 3 or its equivalent, or were working towards obtaining the qualification. The units achieved by individual HCAs through the NVQ level 3 route were mapped out to ensure that these were pertinent to working in an acute surgical setting. A top-up of units would be required if an HCA was found to have knowledge and skills deficits.


Individualised training plans were then developed with the education lead. Each HCA was assigned a motivated assessor who, in conjunction with the education lead, ensured that the training plan was implemented and subsequently evaluated. This enabled the HCAs to receive appropriate support and training to help them to develop in the role.


Evaluation after implementation of the role


After the HCAs had practised in this new role for a specific period, house officers and senior house officers were asked to respond to a further questionnaire to identify the key skills performed by the HCAs that had help ease their workloads. Of the 12 questionnaires distributed, six were returned.


The key skills identified from the questionnaires included:


- Peripheral cannulation;


- Venepuncture;


- Electrocardiogram recording;


- Organising tests and filling in forms (clerical support);


- Blood cultures.


Analysis of the questionnaires once again identified other skills currently being performed by the junior doctors which they felt could be carried out by other staff, including the already-cited male catheterisation and writing out drug discharge prescriptions. These skills, however, are still considered to be outside the remit of the new HCA role.


Analysis of diary documentation


The HCAs were asked to keep a diary for three months of the tasks they performed during this period. This seemed to be a common audit methodology in identifying the roles/skills undertaken by practitioners functioning in a new or established role.


The roles/skills identified were categorised into key themes and the designation of the person contacting the HCA to perform the role was identified (Table 1; Boxes 1 and 2).


Despite the existence of an extensive phlebotomy service in the department, the HCAs performed more than 600 venepunctures. The reasons for this were explored, resulting in a re-examination of phlebotomy resources.


Although the HCAs were now largely undertaking venepunctures, peripheral cannulations and electro-cardiogram recordings, it was found that junior doctors were still occasionally having to undertake these tasks. This served to highlight two issues: first, it indicated that more support staff may be needed in the wards to perform these skills; and, second, it demonstrated a partnership role between the HCAs and junior doctors rather than a deskilling of doctors.


Questionnaires that were completed after the implementation of the new role identified a positive effect on the ability of junior doctors to function in their role. Among a range of things, it enabled them to do the following:


- Make more effective use of their time;


- Spend more time with patients;


- Spend more time focusing on medical issues and problem-solving.


One junior doctor commented: 'The health care assistants are worth their weight in gold' and 'It is unimaginable to think how we coped before'. In short, the HCAs are viewed as a welcome addition to the surgical team.


Doctors have identified weekends, especially Saturday mornings, as well as weekday evenings between 5 and 9pm as times when they have particularly benefited from having the extra support.


Analysis of the post-implementation questionnaires suggests that the new role has not affected the time doctors start work or explained why they still finish later than 5pm when not on call, and that the amount of free time during the day has generally remained the same.


Reflective diary analysis


Each HCA was asked to keep a reflective diary to provide a perspective of the issues surrounding the new role. These helped both to identify the effectiveness of the role in supporting junior doctors and to gauge whether the HCAs felt they were a valued member of the team.


Analysis of the diaries established that the HCAs felt that the roles they were performing complemented the house officer role. In addition, they felt that they could perform other tasks that were cited by both doctors and nurses, such as insertion of nasogastric tubes, and undertaking male and female catheterisation.


However, analysis of the diaries did not reveal any consensus on a specific critical time of day when HCAs were most needed. One participant asked a house officer for his view on when their busiest time was, and he replied: 'When you are not around'. It was also evident that the HCAs were working closely with the junior doctors and that flexibility in rostering is crucial to the success of the role.


The reflective diaries were analysed to identify key themes that preoccupied the HCAs. These were: getting to know the system; working with practitioners other than junior doctors; feeling part of a team.


Getting to know the system


As this was a new role, the HCAs spent about two weeks getting to know both the wards and consultant team routines.


Diary recordings dating to the time when the HCAs began their new work in the wards was centred on the following issues:
- The need to develop a system with the doctors;


- Understanding how the phlebotomist organises the service at ward level;


- Joining ward rounds with junior doctors and specialist nurses to make notes on possible jobs that need to be completed;


- Informing the switchboard and wards that the HCA is on call.


As the role has developed, the nursing staff have become increasingly aware of the fact that they can bleep an HCA to undertake certain tasks instead of a junior doctor. In fact, nurses were the group that most frequently made requests for an HCA to perform a task (Box 2). One HCA's diary entry said that 'this, in turn, helps make the junior doctor's role easier and our role more established'.


Working with practitioners other than junior doctors


Although the role was established to provide support for junior doctors, the reflective diary analysis revealed that the HCAs also worked closely with other practitioners - for example, they worked in the wards until they were bleeped by the house officer or worked with phlebotomists. One diary comment read: 'I have helped out in the ward as the nursing staff were snowed under; it was much appreciated'.


Feeling part of a team Diary analysis identified that feeling part of the team was very important for the new HCAs, with one commenting in her diary: 'My role is developing as days go on. I am enjoying it immensely, especially working in the wards and getting to know the patients.'


Conclusion


The introduction of the new HCA role has been shown to have had a positive impact on the working lives of junior doctors, who have suggested that it has enabled them to make more effective use of their time. (A limitation of the project was the small response rate.)



However, the questionnaire surveys identified that not all the tasks that junior doctors had identified as suitable for other staff to do can be addressed by developing the HCA role. There is a need to re-examine roles across all disciplines so as to identify the most appropriate person to deliver patient care. Such an analysis could indicate, for example, that the ward pharmacist could become more involved with the discharge drug prescription and that nurses need to develop further their assessment and clinical skills.


However, if qualified nurses are to be able to advance their clinical skills further, strategies need to be put in place to ensure that the 'traditional' elements of nursing, such as attending to patients' nutrition and hygiene needs, continue to be performed to a high standard. Indeed, the trust recognises the role of HCAs in undertaking these roles and is encouraging them to take NVQ qualifications in care to enhance further their knowledge and skills.


Continuous structured evaluation of the role needs to be undertaken with each intake of junior doctors to ensure it is fulfilling its potential.


A positive outcome of the evaluation was the personal growth and development of the HCAs taking on the role. It is often easy to underestimate the knowledge and skills of unqualified practitioners. However, their vision for future role development, which includes further education and training to perform clinical skills and clinical audit to demonstrate effectiveness, suggests that they could develop and change to meet the future needs of both the patient and the service.
  • Comment

Have your say

You must sign in to make a comment

Please remember that the submission of any material is governed by our Terms and Conditions and by submitting material you confirm your agreement to these Terms and Conditions. Links may be included in your comments but HTML is not permitted.