VOL: 102, ISSUE: 04, PAGE NO: 36
Irene Anderson, PGCE, BSc, DPSN, RGN, is senior lecturer, tissue viability, University of Hertfordshire. She has written this article in her capacity as a member of the National Leg Ulcer Forum Executive CommitteeIn 2004 the Leg Ulcer Forum produced a consensus statement (Box 1) following a debate at its 10th anniversary conference that health care assistants (HCAs) do not have a role in the application of compression bandages. The statement was made on the basis that a venous leg ulcer can be considered a complex wound (Leg Ulcer Forum, 2004).
In 2004 the Leg Ulcer Forum produced a consensus statement (Box 1) following a debate at its 10th anniversary conference that health care assistants (HCAs) do not have a role in the application of compression bandages. The statement was made on the basis that a venous leg ulcer can be considered a complex wound (Leg Ulcer Forum, 2004).
It has been suggested both in the literature (Thornley, 2000) and anecdotally that HCAs believe they do a similar job to registered nurses, although there is no doubt that the role has a low status and the job is poorly paid. It follows therefore that patient care is cheaper when carried out by an HCA than by a nurse.
The motivation and dedication of HCAs must be recognised but so must the impact of increasingly blurred boundaries in nursing. However, the RCN (2004) states that delegation of tasks to HCAs must not be based on staffing levels and who is available.
During a debate at the Leg Ulcer Forum Conference in 2004 some delegates suggested HCAs could apply compression bandages. However, it was only in answer to a direct question that it became clear they were referring to care delivered in a clinic under the close supervision of an experienced nurse.
This episode illustrated that the perceptions and definitions of appropriate and inappropriate delegation were ill-defined and confusing.
Since the conference it has become apparent that in some settings HCAs apply compression bandages and carry out other tissue viability-related procedures in patients' homes without supervision. However, compression therapy needs to be responsive to changes in patients' well-being, wounds and the shape and condition of their leg. Thus ongoing assessment is vital for effective therapy and patient safety (Anderson, 2004).
Some would argue that because many nurses have difficulty with bandaging skills, having a specifically trained HCA to apply bandages is an advantage (Hampton, 2004). However, in order to delegate and supervise this activity, the registered practitioner must be competent. Bypassing nurses and training HCAs means bandaging becomes a task; money is saved but patients are put at risk because professional accountability for their care is not clearly defined.
Many HCAs undertake vocational qualifications, for which success is measured in terms of competence. Dunn et al (2000) define competence as the overlap of knowledge, performance, psychomotor skills and clinical problem-solving. Nurses must also demonstrate competence but being qualified does not mean they are automatically competent in everything they are called upon to do.
There is a blurring of boundaries between professional and competent practice. Professional practice encompasses assessment, clinical decision-making and professional accountability. If HCAs are to assume this responsibility they should be registered as professionals and rewarded accordingly. It is unfair to put them and patients at risk by not defining practice boundaries, and it is also unfair to allow them to take on a registered nurse's role.
General wound care
The same concerns apply in general wound care. Some wounds are relatively straightforward and will heal provided good practice principles are adhered to. However, a significant number do not heal and cause considerable disruption to patients' lives. These wounds are complex and dynamic, requiring ongoing assessment and proactive management. While HCAs have a role to play in the care of patients with such wounds, if they change dressings without supervision they become responsible for the assessment of these wounds and for making clinical decisions about them.
The Skills for Health Framework (www.skillsforhealth.org.uk) sets out the competence components of wound care for HCAs. In the section on the removal of wound-closure materials, for example, it states that removal can be undertaken in various settings such as hospitals, surgeries, care homes or patients' homes. Removal involves assessing the contraindications to carrying out the procedure, including the risk of dehiscence (in this event it advises stopping the procedure and using the emergency alarm, which would not apply in the patient's home). It entails professional risk and risks to the patient and, it could be argued, should be carried out by qualified professionals.
Castledine (2005) discusses the 'unattractive' aspects of nursing and argues that the fundamental elements of nursing care are being eroded. There is a need to refocus on nursing - to use the talents of nurses and HCAs to focus on patient care. This includes appropriate delegation and ensuring the value of direct care is acknowledged.
Fullbrook (2004) discusses role confusion, arguing that people should have the title for the job they are doing (and be paid accordingly). Therefore, nurses who take on doctors' roles should be trained as doctors, and HCAs who undertake nurses' work, should be qualified and called nurses. She concludes that current changes in role boundaries are a response to financial constraints.
Thornley (2000) investigated the role of 1,893 HCAs and found they undertook the same or similar work as nurses either 'sometimes' or 'frequently', and over half reported that none or little of their work was supervised. It became clear at the Leg Ulcer Forum debate that 'supervision' is ill-defined, ranging from the HCA and nurse working together, through to occasional checks and periodic review.
Who should apply compression bandages?
The Department of Health is reviewing the role of HCAs. According to the RCN, because procedures undertaken by nurses are being delegated to HCAs, there is a need for training and regulation of HCAs (Pearce, 2004). Nurses, doctors and other health professionals are strictly regulated and can be struck off for breaches of professional conduct.
The Code of Professional Conduct (NMC, 2002) states that registrants are responsible for supervising all nursing procedures delegated to HCAs, and that they are accountable for any errors that may arise.
All nursing staff must value nursing care and actively engage in it, but those with a professional qualification take on the added responsibility of professional accountability and must therefore be prepared to take on additional procedures. The application of compression bandages falls into this category. It is a complex skill, with nuances based on assessment, patient concordance and changes throughout the treatment period (Anderson, 2003).
If leg ulcer management is broken down into its component parts it can be viewed as a series of tasks. In some areas HCAs remove compression bandages and dressings, wash the leg and prepare patients for a nurse to apply the bandage. This means the nurse misses vital elements of the assessment and clinical decision-making components of care. If the HCA carried out the whole procedure this would facilitate more complete care but would take the HCA into the realm of assessor and manager of the patient, which is a nursing role.
Accountability lies with the registered practitioner (NMC, 2002). While NVQ standards allow HCAs to apply 'simple dressings', assessment and compression bandaging are specialist skills. The Skills for Health Framework document outlines dressings and other wound care activities that are far from 'simple'.
HCAs must not be used to fill a skill shortage; they should be encouraged to engage in fundamental aspects of patient care and to be assistants to, and under the direct supervision of, registered nurses. In view of recent discussions about the role of the HCA in compression bandaging, the views of the executive committee of the Leg Ulcer Forum that HCAs should not apply compression bandages still stands (Box 2).
- This article has been double-blind peer-reviewed.
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