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Introducing generic workers to the care of spinal cord injury

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VOL: 102, ISSUE: 32, PAGE NO: 33

Barbara Simmons, BSc, RGN, is resettlement community liaison officer

Christine Wilson, MSc, BA, is consultant clinical psychologist; Catherine Gardner, BA, is assistant psychologist; all at Midland's Centre for Spinal Injuries, Shropshire

The generic worker is one of several broadly comparable roles that extend the scope and skills of HCAs. The develop...

The generic worker is one of several broadly comparable roles that extend the scope and skills of HCAs. The development of this role took place at the Midland's Centre for Spinal Injuries (MCSI), a purpose-built centre for both acute and rehabilitation spinal injuries services.

Generic workers assist patients in the pre-discharge phase of rehabilitation, improving their independence levels, increasing their confidence and filling in identified education gaps. The role enables the centre to implement government policy by encouraging patient self-care, extending cross-boundary rehabilitation roles, and by offering individualised rehabilitation.

A description of the role

The generic worker is a multidisciplinary role working closely with members of all departments, including nursing, physiotherapy, occupational therapy, psychology, resettlement, social work and medicine. The post is suitable for HCAs or equivalent trained to NVQ level 3 with a minimum of three years' experience in spinal cord injury care (although to date generic workers have had 15 years' experience). On starting the generic worker post, HCAs undergo a five-week induction with the multidisciplinary team.

Generic workers are accountable to the resettlement team (Box 1, p34), which is made up of staff from a range of professional backgrounds such as nursing and occupational therapy.

Identifying who is accountable for generic workers is essential when introducing the role. In introducing a similar post, Rolfe et al (1999) noted staff concerns about who would be accountable for generic workers, especially where the work they were doing was delegated from different professional groups. The bottom line is defining who will shoulder 'the liability for actions taken by a worker who is not registered as a professional and therefore is not professionally accountable' (Rolfe et al, 1999).

Towards the end of their rehabilitation, patients who are identified as suitable to work with the generic worker are transferred to a separate bay. In this bay patients work on a one-to-one basis with their generic worker. Individual goals are set by using the Needs Assessment Checklist (NAC), a recognised measure of rehabilitation outcome (Kennedy and Hamilton, 1999), and fortnightly goal-planning meetings. Thus, generic workers are able to promote a goal-driven and individual rehabilitation programme for each patient.

The patient and the generic worker plan the patient's daily routine of washing, dressing and eating that will be used on discharge into the community. This is in contrast to the situation on the main ward, where patients' routines must fit in with those of the ward. This individual routine is then practised daily with the patient. On a trial-and-error basis, problems in the routine can be identified, and the routine changed and fine-tuned as necessary with the advice and support of staff at the centre.

Constant application of rehabilitation skills in a setting that is as close as possible to the home environment aims to instil the patient with greater competence and confidence. The generic worker practises other essential life skills with the patient, such as doing the laundry and ironing, using facilities available at the centre.

The generic worker role also aims to facilitate the social reintegration of the patient following discharge. Generic workers go out into the community with patients to practise skills in real-life situations, such as going to the bank. This is intended to give patients greater confidence in approaching new situations once they leave the centre. Generic workers' hours are flexible according to patient need.

Context of role development

The generic worker role was developed to meet service needs identified by resettlement officers during follow-up visits post discharge. The role also meets the requirements of a number of policy initiatives regarding cross-boundary working and the development of HCA roles and accords with core principles of rehabilitation theory. A fuller explanation of the role requires a description of its place in the multidisciplinary team and its relation to other roles at MCSI. It can be compared with similar roles developed in other specialisms.

The notion of 'empowerment' is a cornerstone of rehabilitation. It 'transcends the connotations of 'maximal restoration of function' since achieving such functional restoration does not necessarily imply its appreciation or utilisation' (Banja, 1990). Resettlement officers identified cases where functional independence had been achieved without empowerment. For example, at one post-discharge meeting it was discovered that a patient had not left his house after being discharged from the centre. Although he could perform skills competently and therefore had functional independence, he was not confident in using these skills and so was not willing to leave his house. Following hospital discharge and outside of a 'safe environment' some patients were not using the skills they had learnt in rehabilitation because of a lack of empowerment.

Skills they had performed proficiently in the purpose-built unit could not be practised in the 'camp-out' situation (the temporary solution between hospital stay and permanent accommodation) and therefore the patients' ability and motivation deteriorated. Unless patients have the confidence to employ the skills they learn they quickly lose them. Moving from functional independence to empowerment is vital. The role of the generic worker was designed to meet this need in three ways (Box 2).

The generic worker role realises two 'high-impact changes' promoted by the NHS Modernisation Agency. The first focuses on 'the application of a systematic approach to care for people with long-term conditions' (NHS Modernisation Agency, 2004). It emphasises the key role 'that self-care/management plays in the daily life of everyone with a long-term condition'. In spinal cord injury rehabilitation patients are taught to manage their own care independently, either caring for themselves or directing others in caring for them. Kneafsey and Long (2002) note that nurses are perceived as givers of care rather than promoters of independence. In attempting to meet basic needs, patient independence becomes a lower priority for nurses. Because generic workers assist patients on a one-to-one basis there is time to develop greater independence in self-care. However, generic workers can only step in after the nurses have taught patients basic skills.

The other high-impact change regards 'the redesign and extension of roles in line with efficient patient pathways' (NHS Modernisation Agency, 2004) as important in attracting and retaining an effective workforce. The importance of career development opportunities for the retention of nursing assistants has been demonstrated (Maier, 2002).

According to Castledine (2004): 'Some auxiliaries claim that it is difficult for them to advance in their roles because of the lack of a career pathway.' The generic worker role is one opportunity for HCAs to advance within the specialty of spinal injuries. This provides them with an incentive to stay in the specialism and helps to retain skilled workers in a field where skills take a long time to build. Generic workers have a level of knowledge and skill beyond those of the traditional HCA or support worker. As such they are 'assistant practitioners' under the definitions put forward by the NHS Modernisation Agency (2004).

Policy initiatives have promoted the development of generic roles within other rehabilitation settings such as with older people (Department of Health, 2001). However, there is a dearth of literature on the specific role of the rehabilitation assistant or similar workers (Pullenayegum et al, 2005).

Supporting the multidisciplinary team

The generic worker is not expected to teach basic skills for the first time. Specific goals are identified and skills taught by qualified professionals. Terms such as 'support' or 'assistant' used in describing these roles recognise this. At MCSI, generic workers only enter the rehabilitation process following agreement by all members of the multidisciplinary team that the patient is ready for this level of independent working.

Generic workers should work with patients according to their own level of skill and also according to the level of independence that the patient is capable of achieving. They step in after the foundations have been laid to support patients as they practise the skills they have been taught by therapists, and do not replace professional staff. This should be made clear to avoid the role of the generic worker being seen as a threat to qualified staff, a concern identified by Knight et al (2004).

Roles such as the generic worker meet the need for a patient-focused service that transcends traditional professional boundaries (Department of Health, 2000). Generic workers (and similar) work closely with nurses and therapists to provide a coordinated rehabilitation programme for patients (Pullenayegum et al, 2005). They are integrated into the goal-planning process, which aims to promote multidisciplinary and individually focused rehabilitation (Foley, 1998).

Patients have fortnightly goal-planning meetings attended by the whole multidisciplinary team, at which rehabilitation goals are set with and for the patient individually. When they are working with a patient, generic workers attend these meetings. They liaise with many different specialists and by attending these goal-planning meetings the generic workers can gain a clear idea about their patients' goals (Rolfe et al, 1999). Working on a one-to-one basis, generic workers tailor services to meet individual patients' needs.

Areas for future development

Audit of the generic worker role at MCSI is vital. Potential areas for consideration include:

- Patient perceptions of the generic worker role and the difference it has made to their confidence and independence;

- Measuring the actual difference that working with generic workers makes to different aspects of patient rehabilitation;

- Measuring the perceptions of other members of the multidisciplinary team about the new role.

The generic worker role has only been in existence for 18 months, and we are currently endeavouring to collect patient and staff opinions and to evaluate how the role affects rehabilitation outcomes for patients. We hope to report on this in the future.

Patient comments collected so far include:

- '[Working with the generic workers] gives the confidence to address any problems that arise';

- 'While independence is encouraged help is always there if needed';

- 'You are encouraged to do normal activities and not to become a recluse';

- 'People [working with the generic workers] give an example to other patients'.

The greater levels of skill and responsibility of generic workers are not reflected in their salary. In fact, because they are not required to work unsocial hours or do nightly shifts, the take-home pay of an HCA in the generic worker role is less than that of an HCA working on the ward. This is a major disadvantage in attracting and retaining generic workers, despite the role's other appeals. Financial difficulties have led to the loss of one generic worker back to the main ward. The importance of this issue is also raised by Maier (2002): 'Pay raises serve not only as reinforcements for increased responsibility but also as a measure to recruit.'

There have not been any special education programmes set up for the new role, except for a five-week induction programme. Workers in similar roles have undergone short rehabilitation courses (Galloway and Smith, 2005) or BTECs covering modules in nursing, physiotherapy and occupational therapy (Knight et al, 2004).

The lack of specialist training for generic workers is partially ameliorated by the requirement that HCAs have a minimum of three years' experience in spinal cord injury, and by the fact that all HCAs who have taken on the role at MCSI have a minimum of 15 years of experience in the specialty. However, the introduction of a formal education system is one development that should be considered. Having further training as part of the job description may also reflect in the pay scales that can be agreed.

Conclusion

Development of the generic worker role constitutes good practice. The role is intended to increase patient empowerment by boosting confidence, encouraging independence and by filling identified education gaps. The role offers patients individualised rehabilitation, enables us to implement government policy and is welcomed by HCAs as a way to develop their skills and role within the multidisciplinary team. It leads to greater independence of work and greater responsibility for the HCA who takes on this role. However, there remains room for improvement, development and audit of the role.

- This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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