The Contribution of Assistants to Nursing

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The contribution of assistants to nursing

Report commissioned by the RCN

July, 2006

Dr Wendy Knibb*

Professor Pam Smith

Carin Magnusson

Professor Karen Bryan

Healthcare Workforce Research Centre

Centre for Research in Nursing and Midwifery Education

University of Surrey

Guildford, Surrey,GU2 7TE

*Email:

*Telephone: 01483 684631

ACKNOWLEDGEMENTS

We would like to thank the RCN for the opportunity to engage in research of such interest and timely importance to the nursing community. We also acknowledge the involvement and assistance from the Trusts and the continued support of their Directors of Nursing. The Personal Assistants of the Directors of Nursing are to be thanked for their contribution to the administration of the survey which ran so smoothly.

We would like to acknowledge the assistance of the transcribers of the focus group data. Our thanks must also go to the Research Administrator from the European Institute of Health and Medical Sciences.

Finally, we would like to offer our sincere thanks to all the participants, without their participation the research would not be possible.

CONTENTS Page

Executive Summary...... 4

1. Introduction...... 8

1.1 Relevant literature...... 8

1.2 Aims and objectives...... 13

1. Methodology...... 14

2.1 Research Design and Methodology...... 14

2.2 Ethical considerations...... 18

2.3 Analysis...... 18

1. Quantitative Results...... 20
2. Response to the survey...... 20
3. The profile of the NA sample...... 21
4. Working conditions / deployment of NAs...... 23
5. Delegated duties including the accountability and

responsibility of tasks...... 26

3.5NA training and development...... 29

3.6Tasks that NAs perform ...... 33

3.7Job satisfaction...... 44

3.8Requested support from the RCN ...... 45

3.9Summary ...... 46

4Qualitative Results...... 47

4.1Participant overview...... 47

4.2Tasks and responsibilities...... 47

4.3Responsibilities / duties and delegation...... 51

4.4Role Boundaries...... 52

4.5Accountability...... 55

4.6Perceptions and experience of Training, Courses

and NVQs...... 56

4.7Changing role...... 62

4.8Assistants’ relationship with RNs, managers

and students...... 64

4.9RCN support...... 65

4.10Summary...... 67

5Discussion...... 68

6Conclusions and Recommendations...... 76

7References...... 78

Appendices

AQuestionnaire and information sheet – Ward Manager...... 81

BQuestionnaire and information sheet – Nursing Assistant.....93

CClassification of Clinical Areas...... 106

DFocus Group Schedules ...... 107

Tables

1. Participant NAs...... 17
2. Participant Ward Managers...... 17
3. Population of NAs and response from NAs...... 20
4. Numbers (headcount) of current and ideal staff on wards...... 24
5. Extra hours worked by NAs per week...... 25
6. Accountability and responsibility for NA tasks undertaken...... 27
7. Distribution of NAs holding NVQ qualifications across

the Trusts...... 30

1. Distribution of NAs holding NVQ qualifications across clinical areas 30
2. Type of tasks NAs perform...... 34
3. Ward managers’ views on NA tasks...... 35
4. Percentage of NAs performing tasks ...... 37
5. NAs’ responses to question relating to job satisfaction ...... 44

Charts

1. The profile of NAs’ length of service in their Trust...... 22
2. The age profile of the sample of NAs...... 22
3. Nursing assistants are valued by the RNs that I manage...... 28
4. Number of NAs holding NVQ in care...... 29
5. Aspirations of NAs to become RNs...... 33
6. Support requested by NAs from the RCN...... 45

EXECUTIVE SUMMARY

The role of nursing assistants (NAs) has been brought to the forefront by two policy reforms: a change in the education process for registered nurses (RNs) (Project 2000) and a major injection of resources into the NHS (DH, 2002). The NA post continues to grow in significance within the healthcare workforce with year-on-year increases in NA numbers.

The main aim of the study was to explore the work (including the boundaries and limitations) of samples of NAs (with National Vocational Qualification level 3, with NVQ2, and without formal certificated training) who are employed in acute settings within the NHS.

Following pilot work, a survey was sent to 570 NAs and 51 ward managers. This represented all the NAs working in all the clinical wards that employed four or more NAs that were either permanent members of staff or hospital bank staff (not agency staff). Two members of the research team visited each ward and were able to speak either with the ward manager or the staff nurse in charge. The research team explained the purpose of the project in order to gain the involvement and support of the managers. In each case, the ward managers undertook to distribute the questionnaires to their NAs, through the use of named pigeon holes.

Response rates were 69% for ward managers and 34% for NAs. These rates were higher than response rates for comparable studies. The responses came from a range of wards and units giving a representative profile of the areas where NAs were deployed.

Information sought from NAs included: demographic profile (age, gender, nationality, overseas nurse, prior experience, length of service, dependents, main/second income etc); training opportunities and rewards for training; tasks undertaken (categories such as making beds, communication tasks, helping to feed patients, administration, taking blood samples and other invasive procedures) and built on the work undertaken by Thornley (2001, 1997); the terms and conditions of the working environment of NAs; levels of job satisfaction, issues surrounding delegated duties; aspirations to become an RN and how the RCN can support NAs.

Data from the ward managers included: proportions (actual and ideal) of NAs to RNs on their wards, the value of NAs, relationships between RNs and NAs, numbers of NVQ trainees, training capacity and rewards for training, NA tasks undertaken and how the RCN can support ward managers to deploy NAs efficiently and effectively. The information obtained from ward managers and NAs was similar for some areas of enquiry, such as the questions relating to tasks undertaken and training opportunities.

Focus groups for NAs were facilitated to provide more in-depth information on interesting areas such as: delegated duties; accountability and responsibility for tasks performed; perceptions of the relationships within the nursing team; and the boundaries and limitations of the NA role.

Four focus groups of 2-4 NAs each were held, two at each research site comprising NAs trained to NVQ2/3 and NAs with no formal certificated training. In addition, nine semi-structured interviews with ward managers were undertaken, spread across the two sites.

The survey results were analysed using quantitative analysis and the focus group/interview data was analysed using qualitative techniques.

The findings suggest that NAs are widely deployed and are much valued members of nursing and ward or unit teams. NAs reported high levels of job satisfaction.

Two routes to career progression for NAs were evident. These were progression to qualified NA usually via the NVQ2 and NVQ3 system, and training to become an RN.

There was evidence that NAs who opted for the NVQ route were likely to progress to NVQ level 3 and were much valued at this level. There appeared to be a need to develop a career progression framework with incentives to train and suitable remuneration for NAs who do not aspire to RN training. NAs who wish to remain as NAs would also benefit from an agreed approach to lifelong learning to ensure that their Continuing Professional Development continues within the NA role. The link between the Knowledge Sills Framework (KSF) and Agenda for Change (AfC) may not be well known or implemented as yet.

35% of NAs reported aspirations to train as an RN. Access to such training appeared to depend primarily on encouragement from the ward manager and, to a lesser extent, determination on the part of the NA. The findings suggest that there should be a guideline for both NAs aspiring to RN status and for managers who are advising staff on career development matters on aptitude and criteria for RN training.

There was a need for a robust NA induction in essential care as well as Trust specific information that should be undertaken by NAs prior to contact with patients on the wards. A common syllabus for such induction courses for NAs without qualifications should be developed,to include such areas as health and safety and training on confidentiality and codes of conduct.

The role of NAs was found to show variation across different clinical areas and across the two Trusts in some areas. Deployment of tasks involved a complex set of issues, but did not always reflect levels of experience evidenced by certificated training. Knowledge and age of the NA also influenced deployment. Ward managers felt more confident about deploying staff that they knew and were aware that RNs often lacked information on whether the NA had adequate skills for a task. NAs often took responsibility for informing RNs and ward managers about whether they were competent to perform certain tasks. Again this involved qualification levels, but also included experience ‘on the job’ and self-imposed boundaries, particularly in relation to invasive procedures.

There is an urgent need to clarify NA roles within a competency framework that involves certificated aspects of training (such as NVQs) as well as short course and specific task training which will feed into the NHS careers framework, AfC and the KSF.

While essential areas of care such as bed making and feeding were common to most NAs, expanded roles involving more technical aspects of patient care were identified. These involved taking blood samples, removal of equipment during invasive procedures eg catheter removal, dressing and wound care and liaising with doctors. Ward managers also expressed concern about NAs being involved in relating medical information to relatives, assisting with developing and updating care plans, and drug rounds involving preparation of medications and administration to patients. These tasks appeared to represent areas where the role of the NA is particularly unclear and where there are boundary issues in relation to NAs and RNs. Further research is needed to explore and define appropriate role boundaries between NAs at different levels and between NAs and RNs.

Further research is also needed to define the complexities of invasive tasks where NA roles might include assisting with preparation and clearing away, but where there is already evidence of roles extending, for example to removing catheters. Ward managers expressed cautious approaches to deploying NAs in such invasive procedures and there was a tendency towards trained NAs being involved, although there was also evidence of non-NVQ (or equivalent) level NAs performing such tasks.

There appeared to be scope for extended NA roles, although ward managers were more cautious than the NAs on this point. Ward managers expressed a view that NA roles had already expanded. The findings suggest that until there is a framework for NA deployment based on competencies in place (as outlined above) further extension of NA roles should be approached with caution.

Responsibility and accountability of delegated tasks are not universally understood. There was a tendency for both NAs and ward managers to take responsibility for tasks. Understanding of responsibility and accountability also needs to extend to RNs. There is a need for the RCN to communicate with members on the legal framework surrounding the issues of accountability and responsibility of tasks.

NAs and ward managers would welcome the RCN taking a lead role in clarifying NA roles and competencies.

The RCN was also requested to act as a professional body for NAs, providing support on pensions and pay and conditions, and education and support. The RCN should clarify with members the role that the RCN plays with respect to NAs

Further research is needed to explore NA deployment in other geographical settings and in medical training hospitals, community hospitals and primary care.

Further research is also needed to explore the boundary between NA and RN roles paying particular attention to the NAs’ expanded roles involving potentially invasive clinical procedures and the necessary educational and supervisory support required to perform them to the required level of competence.

1. INTRODUCTION

With policy encouraging workforce redesign within service provision and a predicted growth in numbers of nursing assistants (NAs) (DH, 2003a; DH, 2002), the deployment of these workers within NHS teams is of consequence to the patients (West, Rafferty and Lankshear,2003), the worker (Adams et al, 2000) and workforce planning (Doyal and Cameron, 2000). New positions and the remoulding of workforce boundaries generate a variety of jobs for the non-registered workforce from important roles providing reassurance and continuity of care directly to patients to newly researched, more specialist assistant roles.

1.1 Relevant literature

This short literature review provides the background and rationale for the research and is divided into three sections: the recent evolution of the NA, what is currently known on the profile of the NA including their training, and the interface between NAs and RNs.

Recent evolution of the NA

The role of NAs has been brought to the forefront by two policy reforms: a change in the education process for RNs (Project 2000) and a major injection of resources into the NHS (DH, 2002). The NA post continues to grow in significance within the healthcare workforce. A mean year-on-year percentage point increase of 3.4 is estimated in comparison with 2.7 for RNs over the period 1995-2004 (DH, 2004). ‘Making a difference’ (DH 1999) spelt out a clear pathway for the NA to climb to RN status and beyond. However it was not until the NHS Plan in 2000 that a dedicated training budget was secured for the non-registered workforce that facilitated that progression. Little is known about the consequences of this policy, although the Audit Commission (2001) attested to training, particularly for NAs, as being variable over the NHS Trusts. Their report showed differences across 22 Trusts in expenditure on education, training and development per worker. It also showed that the non-registered workforce was consistently more likely to have training needs unmet and were less likely to have a Personal Development Plan. In a more recent survey of 108 Trusts in England a lack of standardisation around training provision was confirmed (Knibb, 2005).

Wanless (DH, 2002) in his report outlined the significance that NAs would make to the success of the NHS and highlighted a need, under the ‘solid progress’ scenario, for the recruitment of 74,000 (whole time equivalent - wte) extra NAs and in addition a review of skill-mix suggested that 12.5% of RN duties may be delegated to these workers. From this substitution, a requirement for a further 70,000 (wte) NAs was computed. It was acknowledged that recruitment to this extent over two decades would prove a challenge. The emphasis on the role of the NA is a testament to the importance that the government is increasingly affording to the non-registered workforce. In an attempt to deliver the target by stages, ‘Delivering the HR in the NHS Plan’ (DH, 2003a) stated that 27,000 extra NAs (headcount) should be in post by 2005 (over the 2002 baseline).

The announcement of the ‘skills escalator’ concept in 2002, together with the New Ways of Working initiative in 2003 (DH, 2003b) that incorporated the Changing Workforce Programme, added further confirmation that NAs could expect not only to be trained via the NVQ system but that their roles could and would be developed to meet local workforce needs. In addition, lifelong learning was an opportunity to develop skills, irrespective of age or career to date.

The policy trend therefore has been to emphasise the role of NAs. Nevertheless audits (Knibb, 2005; Audit Commission, 2001) have mentioned a lack of data and evidence pertaining to the non-registered workforce, varied and poor access to training across the Trusts and barriers to successful completion of vocational training.

The profile of the NA

The NA workforce is suggested as predominantly female and characterised by relatively high proportions (approximately 33%) of part-time workers and is a maturing workforce with 40% 40 years or older (Thornley, 1999, 1997). Union density is high, possibly reflecting the absence of any professional body or registered trade union such as the RCN that is dedicated to the non-registered healthcare workforce. Of a representative sample, over 80% were self-reported as UNISON members, 1% belonged to other unions whilst 15% stated that they had no union membership (Thornley, 1997). The levels of job satisfaction are generally found to be high although low pay is an issue (Kessler, 2005).

Traditionally, the role of the NA was to undertake domestic duties, the maintenance of supplies and equipment, and answer telephones (McKenna et al, 2004). Thornley’s (1997) survey demonstrated that the vast majority of NAs were involved in communication tasks and manual work associated with patients, for example bathing patients and making beds. Equally, high proportions were asked to monitor/record patient observations, dress wounds and help with catheters. Only slightly less than half the sample handled syringes/equipment. In addition, approximately 20% carried out invasive procedures and 10% undertook venepuncture. To this list Duffin (2001) added helping to train student nurses, liaising with doctors and supervising staff.

Persistent calls have been made for the regulation of NAs (Johnson et al, 2002). Key reasons for regulation stemmed from patient safety and a lack of a code of conduct for NAs. For example,there was increasing concern that RNs who were ‘struck off’ the register may gain access to direct patient contact through employment via the less rigorously screened inflow of NAs (Davies, 2004). Also, anecdotal evidence points to an accumulated backlog on checks with the Criminal Records Bureau that could impact on thescreening processes of NAs. These issues become significant particularly as NAs undertake intimate one-to-one care with patients. Possibilities of regulating NAs were explored as far back as 1995 but no outright decision was made. The subject was raised again in 1997 as more traditional nursing duties were performed by NAs (Adams et al, 2000) and the question of liability grew. The government commissioned a feasibility study which reported and led to a further consultation in 2004. Latterly, the Department of Health (DH, 2006) has referred to the consultation in 2004 citing that the majority of respondents were in favour of statutory regulation for some NAs but that more debate was required. The paper concludes that the results of a Scottish pilot on regulation will be studied to gain factual information on possible organisational procedures and that decisions on future arrangements for the regulation of NAs will be made in 2007.