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Healthcare assistants take over bulk of bedside care


A healthcare assistant does twice as much direct patient care on the wards as a nurse, a pioneering study shared exclusively with Nursing Times has found.

A healthcare assistant does twice as much direct patient care on the wards as a nurse, a pioneering study shared exclusively with Nursing Times has found.

What I do now is what a nurse did three, four years ago, and everybody gave them respect for what they did and paid them for what they did

The three year Department of Health-funded research says the extent to which HCAs have replaced nurses in delivering the majority of bedside care implies it is now HCAs, not nurses, who are at the heart of patient care.

The researchers, based at the University of Oxford, used ward observations to measure how much time HCAs and nurses spent on direct patient care such as feeding, bathing and helping with going to the toilet.

They found that, while nurses spent 15 per cent of their time giving direct care at the patient’s bedside, HCAs spent 30 per cent.

While overall HCAs spent the majority of their time on a typical early shift carrying out direct and indirect care, nurses spent the largest proportion of their time on organisational tasks such as answering the phone and handovers (see chart).

The researchers said the findings suggested the “core” of patient care had shifted from tasks performed by nurses to those performed by HCAs as nurses had “vacated that space”.

The study is the biggest ever examination of healthcare assistants’ role based on face to face interviews with and surveys of more than 1,000 nurses, HCAs, managers and patients.

Managers at nine trusts were also interviewed and 275 hours of observation time was recorded by researchers.

The finding come as NHS employers are looking to substitute nurses with cheaper HCAs. Nurses have expressed concerns about this, but the researchers said the close relationships HCAs develop with patients could help drive up trust performance scores because they make a “vital” contribution to the elements of care upon which hospitals are judged.

They said the “encroachment” of HCAs on the nursing role had created a split and “disconnect” in the nursing profession.

Coauthor Ian Kessler told Nursing Times: “There’s the nurse who is moving up the food chain and is leaving behind some of the direct care relationship.

“But, on the other side are those that say ‘We are the only workers that provide holistic care and if we give away some of our responsibilities there would be a gap’.”

Researchers found that half of HCAs enter the role with ambitions of becoming a nurse and many do complex procedures such as female catheterisation, taking bloods and ECGs.

The ambition of many HCAs is underlined by survey results showing that while fewer than one third of nurses thought observations were among an HCAs’ three core duties, it was the assistants’ second most relished task, with 46 per cent ranking it in their top three favoured tasks (see chart).

The report suggests tensions could occur between HCAs and nurses where assistants undertook more technical tasks. At the other end of the spectrum it says: “HCA dominance might be seen as a challenge to nurse claims to the provision of holistic care.”

There are roughly three nurses for every HCA. Interviews with managers suggest this could narrow as trusts look to cut costs.

The report said: “Any consideration of the HCA role at corporate level was usually within the context of a skill-mix review. While such reviews could be linked to broader, forward looking trust goals… they were typically guided by more pressing issues associated with cost efficiency.”

The report also reveals massive inconsistencies in HCA pay, training, duties and opportunities for advancement, with some HCAs feeling they are the victims of considerable injustice.

An interviewee in London told the researchers: “What I do now is what a nurse did three, four years ago, and everybody gave them respect for what they did and paid them for what they did. So now three, four years on I’m doing exactly the same role, why am I in a band 2 and getting no respect for it?”

The research was hailed as “groundbreaking” by Unison, which represents 100,000 HCAs across the country.

Unison head of nursing Gail Adams said: “It reinforces many of the concerns that have been raised by Unison members and reflects their concern about how the role is perceived by some in the health service.”

To see the report click here.


Readers' comments (66)

  • The reason why Healthcare Assistants are doing what Nurses did 3-4 years ago now is because NHS Bosses insist on all this beuracracy and red tape namely being paperwork has to be filled in by Nurses only and the more forms or assessments is introduced the further away from patient care a nurse actually gets.

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  • Sadly this will get worse when nurses become degree only as more will be expected of them away from the bedside.
    Bedside care is where the most can be learnt about a patient and trust and respect can be built up between nurse and patient.
    Bedside care is invaluable.
    I have a degree by the way just in case people may think I am bearing a grudge, but I attained mine after I qualified with a diploma having trained under Project 2000.
    It was felt by the nurses trained before Project 2000 that hands on nurse care would be diminished by making the training more academic and they have been proved right.

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  • Im an assistant practitioner and we are in the same situation - we still do the same as the RGNs irrelavant of the banding - many trusts have various do's and don'ts so ive spoke to many AP's from other trusts who feel they are doing above and beyond there role - but still for the same banding!

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  • Surely we have gone back to the two tier nurse system of 30+ years ago! I trained as a State Enrolled Nurse (SEN) where we gave all the care at the bedside. the SRN's filled in paperwork and did drug and ward rounds. I am now an RN Child and am getting further away from the bedside nursing which I miss. it is good that there are HCSW looking after the patients needs.

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  • This is so true! I have many nurse colleagues who wish they worked as HCA`s so that they could do `proper nursing`. And it is like the old days of the SEN/SRN - which is what it will no doubt return to as we all know the NHS goes round in complete circles!!

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  • Well said Anonymous | 22-Jun-2010 7:36 am.

    As a Nurse, the level of paperwork is ridiculous, especially as the majority is repeated information over and over and over again!

    I notice how the headline isn't stating the obvious 'Nurses spend more time giving specialist/clinical care'!!

    Look, we all have a role to play here, health care ASSISTANTS (notice that distinction) are by definition there to perform the basic tasks, therefore allowing Nurses to concentrate on clinical tasks.

    The tasks that HCA's perform do ensure that they spend more time 'at the bedside'. Making beds, doing rounds, doing 'the turns', etc. All these are by definition 'at the bedside', so of course they are often more visible.

    But it isn't as if the Nurse is off skiving here. Our work does often keep us 'away from the bedside', but that does not mean we do not want to, or indeed do not spend as much time with our patients as possible.

    Lets just get this into perspective.

    And Anonymous | 22-Jun-2010 8:43 am, I'm sorry but the argument that this will get worse with degrees is absolutely ridiculous. Degree band 5's and Diploma band 5's do a different job? No, they don't.

    Personally I think the fact Nurses have to spend less time with patients is down to problems with the profession and management, such as too much paperwork, poor/unsafe staffing levels, too many patients, etc etc etc.

    Lets get away from this 'proper Nursing' and 'back to basics' rubbish.

    We all have a role to play, we are all there to provide care for our patients. Yes our profession isn't perfect, let's sort out the problems first that will free up more time for us to spend with our patients, rather than splitting into warring factions again.

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  • Hold on a mo...... just how many nurses really 'signed up' to spend the bulk of their (ward based) shift on paper handling tasks? ALL the nurses I know actually wanted to be hands on nurses and the vast majority of these say they are actively looking to move away from the NHS because of the direct lack of hands on time and the amount of paperwork they now do.
    Of course things progress, no one is doubting this, and the inevitability of audit trails means nurses need to pay far more attention to the paper tasks. But lets us not get away from the findings of this research....... HCAs now absolutely do do the job of the SEN, so why on earth are they paid insulting rates of band 2 or if they are very lucky in their trust, at a band 3. I only know of a handful of Band 4 A. Practitioners, yet all the HCAs I know ALL undertake ALL obs including Neuro, they ALL do ECGs, and ALL the Band 3's catheterise and do bloods, trach care etc.
    What a huge responsibility for HCAs!
    I do not think HCAs are trying to undermine nurses, but I do feel that some nurses definately undermine HCAs.
    I also believe that the degree only program will most certainly marginalise those HCAs who, under the Diploma program would have entered the profession with years of hands on experience to bring to the role. Now most will not get onto the program at all. How utterly ridiculous - what a waste.

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  • mike shut up yr on again about you are worked to death with paper work everyone has to document?
    i hold my hat off to the entry at 11:08 that is a real person and is not in goo goo land for godsake tell the primeminister and the dog that follows him?
    Q,what would happen if there was no hcsw,hca's csw, ap's, nursing aux,or any body under a band 4? mike would be lost in paperwork ha!

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  • I would like to say that after working for years as a SHCA and now working as a staff nurse that I knew and performed the role for which I was paid and employed to do. I get mortified with HCA's moaning about how they should be paid more-they knew the job that they were employed to do when they went for the post!!! The pay in my area is over and above what an HCA or HCSW would get in the private sector. If HCA's feel they should be on a higher payband then they should train to be a qualified nurse-if the HCA was paid at band 4 and the RGN was paid on a band 5 what the hell are we training for???? I value HCA's and the role that they perform but there must now be a shake up in exactly what the roles are so that all the upset is sorted out, we will soon be at the state of SEN/SRN and where will that get us???

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  • This study seems to be hospital based. I am a District Nurse and although I don't have a HCA in my current team. I have worked with them they can take twice as long to undertake patient care and then require further nursing time for support and feedback. On paper they may seem cheaper but they are not as cost effective as a trained nurse due to the restrictions on what they can do and because they bring back problems a trained nurse would have dealt with during the visit. Management want HCA's as they are paid less but they refuse to look at how cost effective this is in real terms. I am aware that this sounds as if I don't value HCA's, that is not the case I have worked with some fantastic ones but they worked at a level more consistent with a trained nurse and if they are doing that work they should be paid what a nurse is paid.

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