VOL: 102, ISSUE: 30, PAGE NO: 34
Joyce Smith, PGCE, BSc, RGN, is practice educator for pre-registration nursing students
Rachel Roberts, PGCE, BSc, RGN, is critical care nurse and practice-based educator; Sonia Fahy, RGN, N53, is acute pain nurse; all at The Pennine Acute Hospitals NHS Trust
Strategies to redesign nursing roles (Department of Health, 2000a; 1999) have now started to focus on the delivery of patient care by healthcare assistants. Currently there are no nationally agreed guidelines for developing the role of the HCA. This has resulted in a continuing grey area in professional accountability for qualified nursing staff and fragmented training for HCAs. However, plans for the regulation of the HCA role will be formalised in 2007.
In 2003 the increasing number of patients being admitted to critical areas within The Pennine Acute Hospitals NHS Trust compounded the pressures that already existed as a result of low bed availability and staff shortages. This situation reflected continuing problems across the UK in the recruitment of appropriately skilled staff.
It has been clearly demonstrated that early indicators of patient deterioration are not acted upon in the ward settings (McQuillan et al, 1998). This has been recognised as a national problem and was described in Comprehensive Critical Care (DH, 2000b). More recently, a report from the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD, 2005) concluded that 66% of patients had prolonged physiological instability for more than 12 hours before admission to intensive care units.
The trust set up an advisory group to develop a training programme to support registered nurses within the clinical setting with a two-day workshop. Feedback from this highlighted the fact that although nurses now recognise the importance of monitoring and responding to clinical trends on the wards, much of this work is devolved to HCAs. As a result all HCAs need to understand the importance of communicating clinical changes in the patient’s observations. However, it became apparent to the advisory group that there were no further educational opportunities for HCAs apart from mandatory training or the National Vocational Qualification (NVQ).
An ‘Empowering Clinical Practice’ workshop was devised by the advisory group to address gaps in the clinical training of HCAs. The three key components of the workshop were clinical observations, pain assessment and nutritional assessment.
Clinical observations are part of the Skills for Health qualification structure that is accessed by HCAs who undertake level 2/3 NVQs. The trust provides workshops based on the training and development of HCAs’ clinical skills in taking and recording the patient’s observations.
HCAs play a pivotal role in care delivery. However, Kenward et al (2001) suggest that HCAs are not always confident that they can detect changes in the patient’s physiological parameters and reiterate that if we devolve this task to HCAs we need to be confident that they have the knowledge and skills.
The Empowering Clinical Practice workshop is focused on the underpinning knowledge base of the HCAs. Clinical observations recorded and documented by HCAs are discussed and explored. Anecdotal evidence from HCAs suggested that respiratory rate was not always included in the patient’s baseline observations on admission.
It became clear during the workshop that the rationale for not documenting respiratory rate was partly due to HCAs using the Dynamap and their lack of understanding of the importance of documenting respiratory rate (Kenward et al, 2001). Respiratory rate is often the most neglected observation (NCEPOD, 2005; Goldhill and McNarry, 2004; McQuillan et al, 1998). At the workshop the importance of recording respiratory rate is reiterated as a sensitive indicator in detecting a patient’s potential deterioration.
Clinical trends displayed on the observation chart are also discussed to highlight and recognise the need to seek help from a qualified member of the team. Failure to seek help and interpret clinical urgency have been identified as two of the main causes of patients receiving suboptimal care before admission to ICUs (McQuillan et al, 1998). The Early Warning Scoring system (EWS) has been incorporated into the trust’s clinical observation chart and is a key tool alerting practitioners that the patient’s vital signs are deteriorating. The clinical observation chart also includes a pain assessment tool.
Managing pain is the responsibility of all healthcare professionals. Recording pain intensity as ‘the fifth vital sign’ is intended to increase awareness and utilisation of pain assessment (Joint Commission on Accreditation of Healthcare Organisations and National Pharmaceutical Council, 2001). Using a pain-assessment tool:
- Provides patients with an opportunity to express their pain;
- Shows concern and interest about the person in pain;
- Gives the patient ownership of her or his own pain and pain-management strategies;
- Documents the effect of the intervention plan for that patient, in other words the efficacy or failure of any analgesic or therapy implemented;
- Helps to reveal trends in the patient’s pain relief;
- Helps to provide information for other healthcare professionals.
Assessing pain is a skill that is not taught routinely to registered nurses, let alone healthcare workers. Acute pain nurses regard this as an important part of their educational role because assessment is the foundation for pain management intervention.
The role of HCAs is to give direct access to patients and allow them to communicate their pain needs during the performance of clinical observations. They also act as an advocate for patients who for various reasons are unable to communicate verbally their pain. It is therefore essential to provide HCAs with the underpinning knowledge and training in order to be able to identify non-verbal signs of pain (Farrar et al, 2000). The recognition of pain and its profound effects on the body’s physiological responses are necessary in order to report any clinical changes to the registered nurse (Ballantyne et al, 1998).
The advisory group agreed that a nutritional component to the study day was essential because up to 60% of all admissions into secondary care and up to 40% of emergency admissions are malnourished (British Association of Parenteral and Enteral Nutrition, 2003). The role of the HCA in nutritional assessment (using the MUST tool) and monitoring of nutritional intake by the three routes available (oral, enteral and parenteral) were discussed at the session. The importance of fluid intake as well as calorie intake was emphasised. The HCA role in relation to protected mealtimes was discussed through the DH’s protected mealtimes video. The trust advocates protected mealtimes as good practice in clinical areas.
The workshops are evaluated and reviewed by the course facilitators, namely the acute pain nurse, practice-based educator from intensive care and the practice educator for pre-registration nursing students.
From July 2004 to October 2005 three study days were run with 37 HCAs attending from primary care and the acute trust. Each study day was evaluated using a numerical rating scale.
All the study days scored positively. The evaluation also included a section for the learners to identify key issues related to the knowledge gained from attending the study day. This exercise identified four main emerging themes of learning (Box 1).
The HCAs further stated that the study days fulfilled their expectations and covered the content they thought would be included.
Anecdotal evidence from discussion with the HCAs highlighted that following completion of the NVQ they had no further structured development opportunities to maintain their skills and knowledge. This made it clear to the course facilitators how essential the workshop was, especially in ensuring that patients continued to receive the right care, from the right people, at the right time (DH, 1999).
The expanding role of registered nurses has consequences for HCAs because tasks previously undertaken by practitioners are devolved downwards. As the future regulation of HCAs continues to be debated and discussed, registered nurses need to ensure that in delegating care delivery to HCAs they are equipped to maintain skills and knowledge in practice.
The Empowering Clinical Practice day addressed not only the learning needs of HCAs but also the trust’s objectives and ultimately effective patient care. By building on the feedback received from the HCAs attending the day, the course facilitators will continue to explore ways to audit the effects of the workshop in improving standards of practice.
- This article has been double-blind peer-reviewed.
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