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Health care assistants: developing their role to include nursing tasks

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VOL: 99, ISSUE: 36, PAGE NO: 34

Vanessa Fowler, MSc, BSc, is HCA project manager, South West London Workforce Development Confederation, St George’s Hospital NHS Trust, London

Divisions between health care assistants and nurses are gradually breaking down (Mulholland, 2001) as health care assistants increasingly take on traditional nursing tasks (Duffin, 2001; Gould, 1999). In order to address this development in acute care settings (Artley and Mehennet, 2002), St George’s Healthcare NHS Trust and the South West London Workforce Development Confederation (SWLWDC) applied to the Department of Health for funding to develop an advanced training programme for health care assistants across four acute trusts. In September 2002, a steering group was formed and a project manager appointed.

The need for an advanced training programme for health care assistants is well supported (Department of Health, 2000a; 2000b; 1999). Such a programme can benefit health care assistants who demonstrate the motivation and ability to develop further skills but who do not wish to undertake preregistration training. 


Although there is evidence from academic literature to support the need for an advanced training programme (Ramprogus and O’Brien, 2002; Barczak and Spunt, 1999), little is known about the specific needs of the health care assistant workforce within south-west London. To address this knowledge gap (O’Dowd, 2003), an empirical study was undertaken and a report produced that incorporated:

- A scoping exercise across four acute trusts;

- An analysis of questionnaires completed by health care assistants; 

- A thematic analysis of a workshop conducted for health care assistants.

Data collection involved both qualitative and quantitative methodologies and incorporated the views of both the subject group (the health care assistants) and the service planners.

The scoping exercise involved the project manager gathering information from the workforce, and the human resources and training departments in each trust.

The health care assistants’ questionnaires were statistically analysed using the Statistical Package for Social Sciences computer software. Descriptive statistics were used to interpret the data (percentiles and means) and parametric tests (one-sample t-tests, one way ANOVAs [analysis of variance between groups] and Pearson’s correlations) were used to analyse the significance of the findings.

Nineteen representatives from across the four acute trusts attended a workshop for health care assistants. This included a group discussion about the aims and objectives of the project. Participants then worked in three small groups to identify the skills that were considered either essential or desirable to fulfil the role of an advanced health care assistant. During the feedback process the group also identified the need for basic skills training. Data was collected from flip chart notes and records of the group discussion.


Scoping exercise

Although generic A-grade job descriptions were available at three of the trusts, no such job description existed across all four trusts. A-grade job descriptions for different service areas varied both within and among trusts. No generic B-grade job descriptions had been devised in any of the trusts. There was disparity between local pay scales for both A and B-grade health care assistant posts across all four trusts. The results showed that 10 per cent of the total health care assistant workforce were employed at B-grade.

Two of the four trusts recruited health care assistants in cohorts and carried out literacy and numeracy tests. However, their validity and reliability have not been tested and their origins are unknown. In all trusts health care assistants were asked to identify which service area they would prefer to work in, even though they had little knowledge of the work tasks and service delivery needs in these different areas.

Within one trust, a random sample of recruited health care assistants identified that 30 per cent had achieved the academic requirements necessary to gain entry into nurse training and 10 per cent possessed degrees in nonrelated disciplines.

Where recorded, the rate of absence due to sickness for health care assistants was higher than in any other workforce group. The average annual staff turnover rate for health care assistants was 21 per cent across the trusts, ranging from 14 to 25 per cent.

Two of the trusts held specific health care assistant induction programmes and the other two held corporate induction programmes. The content and duration of both the ward-based and classroom-based induction for health care assistants varied greatly both within and among the trusts.

Vocational training

Each of the four trusts offered NVQ level 2 and 3 training, although the availability and accessibility of this training varied. Three of the four trusts employed peripatetic assessors to carry out NVQ practice skills assessments. Gathering detailed information about the service location and the number of health care assistants currently undertaking, having completed or waiting to begin NVQ training was a difficult and lengthy process. Only one trust ran the Cadet Nursing Scheme.

All four trusts had study leave policies and corporate training manuals for health care assistants. Differences in the quantity, accessibility, frequency and recording of non-corporate or non-qualification training were apparent among trusts and across the different service areas. Practice educators at two trusts allowed health care assistants increased access to study days.

There was disparity both within and among trusts when recognising further training for health care assistants. Only one trust allowed health care assistants to progress to the maximum A-grade pay scale after completing NVQ level 2. 

Questionnaire analysis

When leaving the job, very few health care assistants completed and returned their exit questionnaires. However, providing stamped addressed envelopes increased the response rate. A lack of financial recognition for continued learning was repeatedly cited as a factor when choosing to leave an employer. 

Questionnaires and explanatory letters were randomly distributed to 305 health care assistants across the four acute trusts. The questionnaire was piloted and proven to demonstrate sound face validity, content and construct validity and test-retest reliability (p<0.001). The overall response rate was 28 per cent and was demographically representative of the age, sex, duration in post and service area location of the total population of the health care assistants across the trusts (Box 2). 

Of the health care assistants who completed a questionnaire, 40 per cent had worked as health or social care assistants prior to working for their current employer. Of these 50 per cent had worked in an inpatient ward and 50 per cent in a residential care home.

A Pearson’s correlation test indicated a positive relationship (r=0.581 at the 0.01 level of significance) between the length of induction in the classroom setting and how ‘useful’ it was perceived to be. Half of the health care assistants reported not having had any formal ward-based induction programme. Of the 50 per cent who had received the induction, 65 per cent found it ‘very useful’.

Analysis showed that 51 per cent of health care assistants had a personal development plan, appraisal or review and 72 per cent ‘agreed’ or ‘strongly agreed’ that the personal development plan, appraisal or review had been used to identify and action their training and career development needs.

When asked about any perceived potential barriers to further training, 46 per cent indicated ‘financial impact’ and 39 per cent specified ‘lack of knowledge about available opportunities’.

When questioned about recognition for further training:

- 66 per cent of health care assistants did not agree that those who undertake further training were ‘adequately recognised’;

- A ‘pay increase’ (73 per cent) and ‘increased responsibility and challenge at work’ (72 per cent) were perceived as the most valued means of recognition for completing further training; 

- Up to 74 per cent of health care assistants responded ‘no’ when asked: ‘Is there a clear career pathway for gaining B-grade status?’

In response to questions about their aspirations, health care assistants showed that: 

- 53 per cent ‘would like to become a trained nurse’, and of this group, 47 per cent (n=21) were undertaking further training;

- 86 per cent of health care assistants either ‘agreed’ or ‘strongly agreed’ with the statement: ‘I think that there are other skills and competencies that I could formally learn that could help me to become even more useful on the ward.’


When interpreting the questionnaire results it is important to be aware that, despite random sample selection, those who chose to participate in the study may constitute a self-selecting group, presenting a bias in opinion.

An individual’s experiences of training and career development may well have influenced his or her motivation to participate in the study. Therefore, interpreters cannot conclude that the questionnaire results express a true reflection of the aspirations and experiences of health care assistants across the four acute trusts, although the findings are a good indicator.

Notably, many health care assistants returned their completed questionnaires after the closing date, reflecting the fact that they rarely received mail at work, were unaware that there was any waiting for them, and were unsure where to collect it.

Health care assistant workshop

Nineteen representatives from four acute trusts and the SWLWDC attended the workshop. The group quickly decided that core (or essential) skills must be taught to health care assistants before advanced skills.

Workshop members recommended the development of a cross-confederation health care assistant induction programme for acute care settings to ensure that minimum standards of care are taught to all new health care assistants. It was also suggested that this programme should be followed by an advanced training programme.

Data from the workshop was written up and a number of central themes emerged for the development of the induction programme.

Quality of care theme:

- To place patient care at the centre of induction for health care assistants;

- To enable the development of a competent workforce;

- To ensure compliance with clinical governance and documents such as The NHS Plan (DoH, 2002b), Essence of Care (DoH, 2001) and Agenda for Change (DoH, 2003).

Human resources theme:

- To reduce the current turnover of and sickness absence rate among health care assistants working in acute care settings across the south-west London region; 

- To value the health care assistant workforce;

- To increase the likelihood of achieving consensus across the four acute trusts on pay scale for those who have completed the initial award;

- To optionally inform job descriptions and the health care assistant recruitment process.

Promotion of the health care assistant skills escalator and career pathway theme: 

- To encourage career development and access to NVQs or related vocational or preregistration training;

- To enable and support new starters to re-enter the learning environments from which they may have been absent for some time;

- To demonstrate a commitment to ongoing learning and the continuing development of the health care assistant workforce;

- To equip health care assistants with a qualification that is transferable and recognised among trusts in the south-west London region.

Induction standards theme: 

- To match mandatory induction standards in social care settings;

- To ensure new starters (health care assistants working in acute care settings) achieve minimum standards of understanding about the essence of care delivery; 

- To inform registered nurses about the clinical skills that new starters already possess and those that they are working towards within the first six months of their recruitment;

- To ensure greater equity within and among trusts and service areas concerning the quality and content of ward-based and classroom-based induction training for health care assistants.



The methodologies used during this study allowed for broad consultation across four acute trusts in discussing the educational experiences and aspirations of health care assistants working in acute care settings. Gathering information from the four organisations during the scoping exercise allowed the presentation of a regional perspective of the current conditions and career environment for health care assistants.

The low response rate (28 per cent) of returned questionnaires may be indicative of the low motivation of some health care assistants with regards to training issues. However, it may equally represent the existence of poor internal mechanisms for the distribution of mail to this workforce group.

Holding focus groups with randomly assigned health care assistants may have ensured a wider group of health care assistants were consulted. Focus groups held with registered nurses may also have added weight to the understanding of the future role of the advanced health care assistant. In spite of some of the methodological developments required to repeat a similar study, the current findings have closed gaps in workforce knowledge and helped inform the project planning process.

Professional development

The study supports the claim by McCready and Macdonald (2002) that there is a growing consensus that health care assistants need to have access to professional development, education and support. The questionnaire results clearly indicate a workforce group that is highly motivated to pursue further training, skill-building and career development: 

- 86 per cent recognised that they could formally learn other ‘more advanced skills and competencies’;

- 72 per cent reported wanting ‘increased responsibility and challenge at work’. 

The health care assistant workforce group came to post with up to 30 per cent having acquired the necessary qualifications to enter preregistration training. Over half of the participants expressed a desire to enter nurse training and this finding is supported by a survey conducted by Unison in 1998 (Mangan, 1998). The potential of non-registered carers to progress into registration training is also identified by Thornley (2000).

Although the findings from this study confirm that many health care assistants want to progress into nurse training, it also indicates that many health care assistants do not want to progress further.

This study helps to support both the growing number of gateways into preregistration nurse training for health care assistants and the development of more advanced training options for those individuals who do not wish to enter preregistration training.

It must also be highlighted that some health care assistants may have unrealistic expectations of their ability to gain a registered nursing qualification and that an advanced health care assistant training programme may be more suitable for their abilities.

Improving staff retention

This study revealed an average 21 per cent annual turnover rate of health care assistants across the four trusts. This finding is greater than the average 14 per cent turnover rate that was found across 91 trusts by the Pay and Workforce Research Unit (1998). De Ruiter (2001) showed that improving the skill-mix between the two groups could reduce the turnover rate of nurses and nursing auxiliaries. Encouragingly, a group of health care assistants with NVQ level 3 had improved levels of job satisfaction (Warr, 2002). 

In order to capitalise on the motivations expressed by this study’s sample group, it is vital that any future training course acknowledges the barriers to further training and education identified by health care assistants. Future courses will also need to acknowledge and take into account the average age of many health care assistants and how this may impact on their specific training needs.

Equity of access to learning opportunities across trusts and meaningful recognition of the completion of further training and the use of assessed competencies in the workplace is being called for by health care assistants. A structured, standardised approach to the provision of training opportunities and the active promotion of a skills escalator for this workforce group should be encouraged. This is essential to complement the developing roles of the registered nurse.

The future’Increasing demands on the skills of qualified nurses and a recognised shortage of personnel in the NHS emphasise the need to maximise scarce resources and realise the full potential of the nursing contribution’ (Warr, 2002). This project aimed to address this need by developing higher-level support roles for health care assistants working in acute care settings.

As a result of this study, the project steering group was able to make informed, evidence-based decisions when planning the processes and objectives for the training project for advanced health care assistants.

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