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Our Victorian approach to HCAs puts patients at risk


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

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    Our Victorian approach to HCAs puts patients at risk


Readers' comments (11)

  • I am a HCA and hope to go into nursing but would like to see every clinical setting adhering to the rules as the HCA role is getting a lot of negative attention. I do venepuncture and had to go on an extensive training course for this, ditto for ecg, wound care, spirometry, etc. My role is clearly defined within my practice as I will do all of the all the above and do it correctly before passing the results to clinicians to proceed with. Everything I have done is evidence based and regulated and the same can be said for every HCA at the practices within my area as we all attend the same PCT training, so perhaps people should actually name the places that make HCA's carry out work beyond their competency so they can be dealt with. Every HCA I know does not consider themselves to be a nurse and we all ensure that the patients are aware of this as it does come under informed consent. So perhaps masquerading as nurses should be made a disciplinerary offense after all people who pretend to be doctors are usually given a jail term!

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  • The trouble here seems too be that the work being undertaken by HCAs are in fact the roles carried out by qualified nurses. I dont see how HCAs can carry these roles safely unless there is consistency in training and then why are we calling then HCAs when they are doing the job of a qualified nurse. Cant have it all ways. Why not reintroduce the wonderful EN (SEN). The HCAs that really do not want to undertake specialised tasks can continue with the Aux role.

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  • HCAs with extended roles as with assistant practitioners do not equate to the old SEN/EN role. I am not saying they are not capable of training as a qualified nurse, but that was what an SEN was, a qualified nurse with just about the same responsibility as an SRN. SENs were in charge on the wards on a regular basis (whether right or wrong, but acceptable at the time), whereby assistant practitioners aren't. I can talk from experience, and when I converted in 89/90, the course mainly brought us in line with the academic world as opposed to learning new skills, we already had those. Having said that, I think the assistant practitioner role will eventually demand more recognition, but I don't see it as how the SEN role was at all. Things have moved on since then. In our trust there are some SENs that haven't converted, are Band 5, and doing exactly the same as an RN and are very capable too, more so in some cases. Regarding consistancy in training, the same applies to post-registration courses. When staff move from one trust to another, they often have to undertake the training again, in line with their policies, such a waste of resources.

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  • The structure and supply of Nursing Assistants is partly to blame for the wide variability of skill and knowledge amongst non-qualified nursing staff. This is all the more reason to alter the nursing curriculum to a higher scientific and clinical level.

    It must always be that they are doing things that are relatively simple, mastered by us a Professionals and observed to have a finite period of activity.

    Having non-qualified staff puting in cannulas and catheters proves definitively that these are not extended nursing skills by any measure or by any degree.

    These must be taught to Nurses inside and out and this simplistic view of Nurse education where basic nursing care trumps everything else routed.

    On the other hand NA/HCA's must be trained better to pass on vital information and to be comprehensively trained in basic care.

    Some NA's on my ward take obs but forget/don't measure catheters; others might look at the oen to three IVAC's going and write in those numbers but most don't.

    Obviously it would actually help if trusts and agencies put i place a more comprehensive way of ensuring a minimum of theoretical and practical aspects above simple moving and handling and BSL (which is totally inadequate for modern day hospital nursing).

    Luckily it is clear that many if not most NA/HCA's feel linked enough to the profession to want to assist us as well as possibleand on my own ward we all work so well together.

    I think at a minimum there should be training in

    How to take clinical obs including manual BP and a rough guide to what good and bad 'looking' blood pressure is. i.e. too tall or too small.

    what are acceptable levels of SpO2 and resps. By a stopclock to put on the obs trolley if they lack a fob watch. It's all terribly easy if you think about it.

    Keep as many things like aspirating an NG four hourly or emptying a stoma local and if they are permanent or regular bank put them through a local competency if you have them.

    I don't know about the legality of ensuring comptencies but we must consider that as we develop we can't leave them behind nor can we assume or pretend that dithering about whether we are losing touch is the central theme in the argument.

    All this proves is we have to be more skilled than them.

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  • No no No - we should definately NOT have HCAs joining the NMC register. Do legal secretaries join the Law Society as assistant Lawyers?? No. I dont think it should EVER happen.

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  • I agree, I dont think HCA's should join the register. If they want more responsibility then why don't they do the training and become registered? they will soon realise that there is more to being an RN than taking bloods and catherisation. I have every respect for HCA's and without them the healthcare system would not function. But their roles needs to be more defined and I am a bit fed up with meeting HCA's who think they can do the job of an RN without doing the training. Sorry guys you cant! And if you did do the training you would soon realise why.

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  • I am a Nursing Student and I am really bewildered by the roll-over attitude we seem to have in the Nursing Profession. HCA's/AP's - whatever you want to call them - are not nurses, they have not trained as nurses and do not have the knowledge and thinking processes that nurses have. They should not join our register and I am sad they are allowed to join the RCN. Training to be a nurse is hard going, as it should be, and we should be proud to have completed that training and should fight to protect our status and profession. I am fed up with meeting HCA's who think they are equal to us, better than us or some who even think they do a better job than us. Would our Doctor colleagues put up with this? No way. And neither should we. I don't see Doctors even accepting assistants let alone them joining their register and professional bodies!!!

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  • As a newly qualified Assistant Practitioner I feel most disheartened by the comments in this article. I work on a very busy respiratory ward with a separate NIV unit, and I whole heartedly disagree that I work outside the remit of my post. As a HCA Band 3 I was trained in peg and ng feeds and ECG's. After completing a 2 year postgrad degree I feel more than happy with my level of knowledge, and my capability of completing these tasks as do the team I work with or I am sure I would not be allowed to undertake the work in the first place. Nursing at all levels is about learning, we all constantly learn new things whether it be in nursing or in every day life. I have been a HCA for 7 years and a TAP for 2years. So please do not tell me that I am incapable of my role. We have a lot of life skills as well educational skills to offer. it is not the AP's fault that there are so many inconsistencies with job descriptions but in the North West there is a generic job description. The Government with its many cutbacks are also to blame, but again not our fault that qualified nurses are not being replaced as they retire or the fact that university placements have been cut due to extortionate fees. The tides have to turn and lets face it the HCA is the one that does a lot of hands on patient care compared to staff who are bogged down with more administration duties.

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  • Anonymous's comment is just incredulous!! As medical secretaries do not have to perform law duties!! Unlike HCA's who have to perform Nursing duties!! I think we should be registered as should all who work in health. We have been given this extended role so it only fair that we should have some sort of backing by a regulatory body!!

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  • Yes But

    'The type and quality of training depended on the individual teachers, supervisors and role models on the wards of the training hospital' - the quality of training still depends on who the teacher is, and

    '(HCAs) 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.'

    Isn't the idea, to have people being good at what they actually do ?

    That isn't just related to your title - surgical teams which carry out lots of the same operation, are known to get better outcomes than when a team performs a particular type of operation infrequently.

    It isn't necessarily true, that some type of across the board qualification for HCAs would be enough to make an individual HCA excel in her/his regularly undertaken tasks - and if excellence in everything which might reasonably be undertaken were required, HCAs would be well on the path to being trained very similarly to nurses.

    It can be argued that training specific to the actual job, but with some sort of statutory duty on employing organisations to provide and monitor that training, would be better than a registration scheme - IF the mechanism to ensure compliance with that duty to train and assess, can be made strong enough.

    There would, then, also need to be some way of recording the new skills acquired, for transferability between employers - but I can't help but believe, that any regulation or national minimum qualifications of HCAs which could be achieved in the current straitened financial situation, would set the bar too low to be useful.

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