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Changing Practice

Developing a workbook to support healthcare assistants in delivering competent care

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An initiative to use a workbook to help HCAs develop their competencies


Rees, J. et al (2009) Developing a workbook to support healthcare assistants in delivering competent care. Nursing Times; 105: 14, early online publication.

Ensuring that healthcare assistants are competent to perform tasks delegated to them is essential. The Newcastle upon Tyne Hospitals NHS Foundation Trust has developed a workbook that addresses competencies in continence (catheter care), nutrition and pressure ulcer prevention. The workbook aims to accompany clinical-based learning and help HCAs to progress through the NHS Knowledge and Skills Framework. This article outlines issues around competence, and the three clinical areas covered in the workbook.

Keywords: Healthcare assistant, Workbook, Continence, Nutrition, Pressure ulcer


Jacqueline Rees, MSc, PGDip, DipN, RGN, is nurse consultant (continence); Fania Pagnamenta, MA, BSc, DipN, RGN, is clinical nurse specialist (tissue viability); Valerie Hogg, RGN, is professional development coordinator; all at Newcastle upon Tyne Hospitals NHS Foundation Trust.

Practice points

  • A new workbook has been compiled to lead HCAs on an educational journey, which includes learning skills to benefit patient care, with an emphasis on maintaining patients’ privacy and dignity in all aspects of care. 
  • It pulls together all the elements of care for a particular healthcare intervention.
  • The workbook contains frameworks to support competency development and clinical assessment in continence care, nutrition and pressure ulcer prevention.
  • It is intended that the workbook will accompany clinical-based learning and help HCAs in the trust to progress through the gateways of the NHS Knowledge and Skills Framework.
  • The book and the frameworks can be adopted within other specialist areas of care. 


  • HCAs work in various settings and represent 17% of the 1.3 million people who make up the NHS workforce (Department of Health, 2005).
  • As the NHS has expanded and output has increased, tasks that were previously restricted to doctors are now performed by nurses, and tasks that were previously restricted to nurses are now undertaken by HCAs.
  • Views on the desirability of such changes have been questioned. Supporters have based their views on anecdotal evidence (Walters, 2005; O’Dowd, 2004) while sceptical authors have drawn on more robust findings (McKenna et al, 2004; Sutton et al, 2004).


HCAs are now required to perform a wide range of skills so ensuring that they are competent is essential. The Newcastle upon Tyne Hospitals NHS Foundation Trust highlighted three areas of competency that required intervention: catheter care; nutrition; and pressure ulcer prevention. The trust developed a workbook to offer a more robust approach to education to complement existing study events.

Implementing the workbook

The initial aim was to implement a workbook incorporating the NHS Knowledge and Skills Framework standard list of competencies (Department of Health, 2004) and HCA vocational training standards, as well as best-practice standards for catheter care, nutrition and pressure ulcer prevention. Competency frameworks provide a structured approach to knowledge and skills acquisition (Myers, 2008). This fundamental principle supported the workbook’s development.

The framework used for each clinical aspect varies in teaching and evaluation style. Each area of practice has been published as a chapter, which can be removed from the workbook while HCAs work through the information, linking clinical theory and practical skills. Each HCA has a mentor responsible for signing them off and the HCA receives a certificate of achievement.

HCAs deliver much day-to-day, essential care and have become important in the wider context of the NHS workforce, including in areas such as catheter care, nutritional care and pressure ulcer prevention. In our trust, HCAs have a selection of training opportunities to attend, including formal and informal education sessions.

In acute trusts, there are several difficulties in establishing a robust competency framework that incorporates integrating theory and practice, and in determining which tasks are appropriate for HCAs.

While best practice is advocated in the HCA training opportunities, their competency following a training event in these three elements of care was unknown. However, the general view was that an opportunity remained to bring theory and practical skills together. Accessing and appraising best-practice evidence is becoming a core clinical competency for HCAs. The consensus was that clinical care must be based on best practice and assigned clinical skills must include assessing clinical competency.

The issue of competence

While HCAs are conscientious, they are often pressurised to go beyond their level of competence to perform duties for which they are unqualified (Hasson et al, 2007).

The issue of competence is a crucial one, and the question of ‘how competent’ HCAs have to be to perform their role safely had to be answered before an educational programme such as the workbook could be set up.

Marshall and Luffingham (1998) argued that greater role definition is achieved through introducing core competencies. Competence is job related, being a description of an action, behaviour or outcome that a person should demonstrate in their performance.

On the other hand, competency and competencies are person orientated, referring to the person’s underlying characteristics and qualities that lead to an effective and/or superior performance in a job. According to Woodruffe (1993), competence concerns an aspect of a job that an individual can perform, while competency concerns an individual’s behaviours underpinning competent performance.

In other words, competence covers something a person is or should be able to do. Its focus is more on performance than on knowledge and it is concerned more with what people can do than what they know.

Performance criteria provide assessors with statements by which judgements about a person’s ability to perform a specified activity to an acceptable level can be made (Manley and Garbett, 2000).

Wolf (1989) pointed out that competence cannot be observed directly and can only be inferred from performance. Hence, under a performance-based assessment system, assessors will judge from evidence based on performance whether a person meets criteria specified in competence standards. The benefits of this approach are the ability to identify learning needs, provide insight into areas of professional practice and allocate educational resources for training.

A list of pre-specified skills that have to be ticked off to show that competence has been achieved does not solve the difficulty of ensuring consistency of interpretation, but it is a relatively easy way to ensure that a basic level of competency is achieved.

Therefore, the assessment of HCAs’ competency had to be holistic; it had to contain a mixture of different types of assessment.

The workbook uses a list to assess HCAs, which can be ticked for certain competencies, such as changing a urine drainage bag or taking a urine sample. It also contains self-assessment strategies such as a questionnaire for pressure ulcer prevention as well as workshop-based questions on nutrition.

It is expected that HCAs’ knowledge, values, attitudes on privacy and dignity and general nutrition skills will be assessed within the yearly context of the performance appraisal and personal development plan by their managers. This will provide evidence of their developmental needs and support and continuing education needs. On completing the workbook, HCAs can progress through the KSF.

The workbook’s three areas of practice

Urinary catheter care

Urinary catheterisation is essential in both medical and nursing care, but carries the risk of serious complications such as urinary tract infections, trauma, stricture formation, encrustation, bladder calculi, urethral perforation and carcinoma of the bladder (Pomfret, 2000).

Healthcare professionals’ primary clinical considerations in daily practice are patients’ care requirements and the intended function of the urinary catheter and drainage system. Urethral catheterisation is a common clinical intervention in acute care settings and a recent survey identified that the urinary tract is the most common source of nosocomial infection, particularly when the bladder is catheterised (Tenke et al, 2007).

Pratt et al (2007) reported that urinary tract infections are the second largest single group of healthcare-associated infections in the UK, accounting for 20% of all hospital-acquired infections. The presence of a urinary catheter and its duration are risk factors for the development of a UTI.

HCAs need to gain an understanding and develop competence in the clinical practice of caring for a urethral catheter. The workbook’s section on catheter care focuses on attaching and disconnecting an overnight drainage bag, changing a drainage leg bag, the procedure for emptying a drainage leg bag and collecting a catheter specimen of urine.

Nutrition and hydration

Good nutrition is essential to maintaining physical and mental well-being, including growth and tissue repair and energy to function in daily activity. Food not only influences health but also provides structure and social interaction to the day in hospital settings, in the community or at home.

The DH (2001) raised awareness on the issue of poor nutrition in all areas of health care. Evidence from more recent government documents (DH, 2007) suggests that there is still some way to go to meet patients’ needs.

Age Concern’s (2003) Hungry to be Heard campaign identified some important evidence (see Box 1). The charity also highlighted some of the concerns raised by older people and their carers/relatives and friends, especially inappropriate food and lack of assistance with eating at mealtimes in hospital.

In our trust, HCAs are trained and involved in the initial screening process of patients’ nutritional status on admission, using the malnutrition universal screening tool (MUST), which incorporates weight, height and body mass index. They report any adverse scores to the relevant healthcare professional in the team who uses the information when planning and implementing the patient’s care.

HCAs are in an ideal position to observe patients at mealtimes, while preparing and positioning them for meals (NICE, 2006) and are able to observe their level of independence. In addition, they can observe how much patients eat and drink, complete food and fluid charts appropriately and ensure that any changes in appetite or thirst or oral/dental problems are reported to the relevant practitioner.

HCAs can complete the section on nutrition and hydration in the workbook by attending the trust’s regular nutrition workshops.

Box 1. Evidence on malnutrition
  • Four out of 10 older patients are already malnourished on admission to hospital.
  • Six out of 10 are at risk of becoming malnourished or their situation worsening.
  • Patients who are malnourished stay in hospital longer, need further treatment and medicines and are more likely to suffer infections.
  • The cost to the NHS is £7.3bn per year.
Source: Age Concern (2003)

Pressure ulcer prevention

Pressure ulcers can cause pain and suffering, delay rehabilitation and result in a longer hospital stay.

Treating pressure ulcers requires a multifaceted approach to care such as positioning, ensuring the appropriate therapy bed has been provided, nutrition (Anderson, 2005; Gray, 2003) and moving and handling. Wound care is only one small component in pressure ulcer management.

Educating HCAs in the prevention of pressure ulcers is key to quality patient care. HCAs are ideally placed to be able to observe patients’ skin and it is important they are able to note and report subtle changes in pressure areas (Morris, 2007). During personal hygiene, moving and handling, helping patients to use the toilet and other procedures, the skin over pressure areas must be checked regularly. This will enable early identification of pressure damage and will help in determining the frequency of turning/repositioning needed and the effectiveness of the prevention plan.

Pressure ulcers are a common and costly problem. With the information provided in the workbook, HCAs can make an informed inspection of the skin and be involved in the early identification of pressure damage.

The workbook covers areas such as:

  • Identifying patients who are vulnerable to or at higher risk of developing pressure ulcers;
  • Using risk assessment tools;
  • Explanation of intrinsic and extrinsic risk factors in the development of pressure ulcers;
  • How to inspect skin for pressure ulcers;
  • How to grade them;
  • Basic skincare;
  • The different therapy beds available in the trust.


The workbook is the initial foundation of developing HCA knowledge and skills, linking to a competency-based style of learning. The workbook’s success will be evaluated and there is scope to include other dimensions of healthcare.

With the continual changes in the NHS and the demands of the HCA’s role, it is essential to provide support using a process of structured learning, offering the opportunity for an educational journey. We acknowledge that this workbook is only one method in achieving best-practice competencies.

Quality of care must be embedded in everyday clinical practice. This can be achieved through numerous methods, but the principles of ensuring HCAs have the knowledge and practical skills to deliver safe and effective practice remain the same. The workbook ensures that HCAs provide competent care for patients in any of the three clinical dimensions described.


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Readers' comments (1)

  • Sounds like this will assit in teaching and training HCA's and ensure that we meet our goverance targets well done what a great project to promote

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