One of the main characteristics of science - including medicine and nursing - is continuous questioning, development and progress. We do not treat diseases in the same way as we did 100 years ago - so why are we reinventing nurse training in the early 1900s model?
A hundred years ago, training was still mostly different in different institutions. Some curriculums had been written and were applied across the country - for example, to train district nurses - but there was no need for any nursing school to adhere to one, since there was no national registration of nurses requiring comparable standards.
Qualifications were awarded by the training institution. The type and quality of training depended on the individual teachers, supervisors and role models on the wards of the training hospital.
‘It is essential that we protect vulnerable patients - as well as low paid staff themselves - from providers’ temptation to deliver care via an unregulated and variably trained workforce’
With nurse education now based in higher education, and all nursing courses soon to lead to a degree level qualification, it would appear that we have solved the problems that the Victorian approach threw up: inconsistency in approach, parochialism of outlook, variation in inputs and serendipity of outcomes.
But we are recreating exactly these issues in relation to the preparation of healthcare assistants.
There is no doubt that this is a concern for nurses. Healthcare assistants, including assistant practitioners, are delivering nursing care in hospitals, surgeries and patients’ homes. They carry out catheterisation, venepuncture, percutaneous endoscopic gastrostomy feeding, vaccination, cervical screening, wound dressing, ECG recording, initiation of continuous positive airway pressure, and a host of other tasks that would once have been undertaken by a registered nurse with additional training.
This is not necessarily wrong. Skill mix has always been a feature of nursing teams, and support staff, under various names, have always made a contribution. Many of the support posts - especially assistant practitioners - offer exciting and rewarding work to individuals who are committed to their caring role, and may well go on to nurse or AHP education.
There is a lot of work going on around the country to support these roles with standards, training and supervision. Some is national, starting to provide replicable standards against which the outcomes of different training regimens can be measured. Some is local, establishing in house courses to prepare HCAs for specific tasks.
But none of it is compulsory, or consistently applied. And, like nursing 100 years ago, this means that: the individual’s skills are not necessarily transferable between areas; they depend on the quality of the local teaching and supervision; and training is likely to be an ad hoc mixture of tasks, suitable to the current post, but not a comprehensive preparation for a role.
This is unfair on the individual. They are being used to do risky, intimate and technical tasks without the knowledge and understanding about the patient’s condition, or the capacity to respond appropriately to other issues or information that may arise during the task.
Most will cope with this, and good local set ups will have protocols for dealing with such situations. But some HCAs will be stressed and alarmed by the responsibilities they carry; and, more dangerously, some will be oblivious.
It is a seductive thing, to be able to carry out important and technical procedures for a patient. I have known an HCA in the community, in uniform and with her bag of equipment proudly to the fore, assure an inquisitive neighbour that she was a district nurse. The older person she was visiting probably thought she was a nurse too.
It is in community healthcare that the bigger risks lie, for both staff and patients. Supervision of caregivers is remote; no one sees exactly what they do except patients. Patients are often left alone once the health worker leaves, and have to decide for themselves when and who to call for help or ask a question. If the worker is unsure, there is no one close at hand to call on for a check or second opinion.
The purpose of nurse regulation, standardisation of training and the register was to protect the public. With extremely tight budgets, rising levels of complex care in the community, and a variety of new organisations providing community services, it is essential that we protect vulnerable patients - as well as the low paid staff themselves - from providers’ temptation to deliver significant amounts of care via an unregulated and variably trained workforce.
This is not a theoretical risk: it is already happening. Band 5 nursing posts are being replaced by HCA posts; the ratio of HCAs to qualified nurses is reversing; and community nurses - not necessarily holding community qualifications - are being used as supervisors for teams of HCAs who provide nursing care.
For the sake of patients and our HCA colleagues, we must urgently resolve the question of whether HCAs doing nursing work are nurses; and make their education and regulation both standard and compulsory. The ad hoc approach was not good enough for nursing 100 years ago, and it is not good enough for those doing nursing work now.
Rosemary Cook CBE is director of the Queen’s Nursing Institute
Our Victorian approach to HCAs puts patients at risk