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How risky is it for individuals with complex needs to be cared for by unqualified staff?

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Self-titled Risk-Averse Nurse, Clare, explores how risks surrounding the delegation of tasks by nurses to carers can be reduced.

Sometimes I refer to myself as a ‘risk averse nurse’. I’m jokey as I say it, but there’s a serious undertone.

I remember the first time I heard that people with complex health needs were being cared for in their own homes by unqualified staff. Aargh! My pulse started to race as ‘RISK’ flashed through my brain repeatedly! By ‘complex needs’ I mean things like support with enteral feeding or caring for someone with a tracheostomy tube, for example.

As a student nurse and many times in my qualified career I’ve been to lectures on accountability and discussed in clinical supervision sessions how it relates to the role of nurses.

There have been times that I’ve felt terrified into trying to remove the risk from every situation. As a nurse I am accountable for every decision I make, and rightly so. But this has been instilled in me with such vehemence that on occasion I’ve been at risk of not taking a person centred approach.

No, scrap that. It was person centred, but the person at the centre was me protecting my PIN!

I see this in other nurses regularly; we don’t want to take risks. Much of that is sensible, it could be your life in my hands and I’m not going to put you at risk if I can avoid it. But if my determination to keep you safe restricts your freedom and your decision making then this is clearly not right either.

With this in mind, I can’t help asking: how risky is it for individuals with complex needs to be cared for at home by a carer?

”Recruitment is increasingly challenging across the sector, impacting on the availability of nurses to support people at home”

To answer that question I first need to explain that “unqualified” does not mean not qualified to care, it means not qualified as a registered nurse.

Let’s face it, recruitment is increasingly challenging across the sector, impacting on the availability of nurses to support people at home. Does it not seem a practical solution, then, for specific care interventions to be taught to people who have an interest in a caring role and other outstanding qualities that enable them to be the right person for the job?

With that in mind my attention turns to how carers are trained and monitored in care delivery, and who is responsible for ensuring they are competent in the skills they are using.

“Who is responsible for ensuring care staff are delivering safe and effective care?”

Both the Care Quality Commission (CQC) and the Nursing and Midwifery Council (NMC) have expectations that care staff are deemed competent before independently undertaking care skills delegated to them. Neither body however defines what competence looks like, the qualifications required of nurses delegating these care interventions or the frequency that competence should be reassessed.

While the CQC regulates care providers and the competence of care teams, it offers no regulation of care for those people in receipt of a direct payment, so who is responsible for ensuring care staff employed in this way are delivering safe and effective care?

I often hear that an assessment of competence only reflects one moment in time. While this is true, if we never make this initial assessment how do we know that someone ever achieved the required level of understanding in the first place?

”There is great reluctance among nurses to deem carers competent due to the risk and responsibility it carries”

As nurses when we train someone to undertake a care intervention we retain the professional responsibility of appropriate delegation of that intervention.

One could argue that regardless of whether I deem someone I have trained competent the very fact that I allow them to undertake the intervention means I consider them competent.

Re-enter Risk Averse Nurse.

There is great reluctance among nurses to deem carers competent due to the risk and responsibility it carries, but this must be balanced with a consideration of how risky it is not to.

”Identify who might be harmed, and what you can do to reduce the risks of the hazards occurring”

I’m presenting a whole load of issues here and perhaps it’s time to think of some potential solutions. What is the key to safe and effective care delivery using this model of care?

Firstly, a robust approach to risk management is essential. Consider where the potential for harm is both for the person receiving care and the people delivering care. Identify who might be harmed, and what you can do to reduce the risks of the hazards occurring.

Discuss the risks with the person or family receiving care, investing in risk reduction as a team approach.

On the same theme, we must recognise (and accept) that we are only ever going to be able to reduce risk, we will never eliminate it. Training carers to competently deliver safe and effective care is a necessary standard to reduce the risk of harm to someone in their care, not a way of challenging nurses to put their PIN on the line!

The very fact that carers are human and caring for other humans means that we will never eliminate risk.

”We are only ever going to be able to reduce risk, we will never eliminate it”

The facilitation of honest and open communication will enhance the quality of care provision. Encouraging those receiving care and care staff to raise concerns, questions and report incidents without risk of being chastised will promote learning and lead to the development of safer care practices.

In addition, effective communication between the commissioners, consultants, specialist nurses and community teams is essential when delivering care. In order to consistently meet someone’s needs and preferences the multidisciplinary support team must be up-to-date as to what these are.

Nurses who are delegating care skills, training carers, and ensuring people living at home are receiving the care they need in the way they want, need to feel safe and supported as practitioners. It can be a lonely life out there as a nurse training carers to deliver life-sustaining support.

Surely a sensible risk reduction strategy would be for regulatory care bodies to collaborate around the training requirements for specialist carers, for the nurses training them and for the commissioners purchasing the care provision.

”I suspect we would all, commissioners through to care providers, welcome clarity”

I suspect we would all, commissioners through to care providers, welcome clarity around what skills can be delegated to specialist carers and what remains the role of the nurse as well as what level of competence people receiving care can expect from their carer whether employed by them directly or through a registered care provider.

In today’s world where people with complex health needs are rightly being offered increased choice about how and where they would like to live, some structure around the expectations of those supporting these choices will offer clarity and create robust and sustainable care provision in the community.

Until that day comes I’ll keep going, fighting my aversion to risk and offering support to nurses, organisations and individuals to ensure their carers are delivering safe and effective care.

Clare Flynn is a registered nurse, currently working with organisations and individual employers to develop and deliver training and competency frameworks for carers providing complex care in community settings

 

RCN: Accountability and delegation

PERSONAL HEALTH BUDGETS GUIDE Personal assistants – delegation, training and accountability

The RCN produced a document called ‘Managing children with health care needs: delegation of clinical procedures, training and accountability issues’ in 2008 which looks at clinical procedures that may be undertaken by non-qualified staff, delegated by nurses following training and competency development.

If you are a nurse working in a community setting and overseeing or delegating care skills to health care assistants, assistant practitioners and support workers/personal assistants we would really like to hear your views. Please visit https://www.surveymonkey.co.uk/r/HVMFPRW and take our anonymous 10 question survey.

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