Support Workers in Secondary Healthcare: Four Case Study Reports

Transcription

1 Support Workers in Secondary Healthcare: Four Case Study Reports Ian Kessler 1, Paul Heron 2, Sue Dopson 1 & Helen Magee 2 1 Saïd Business School, University of Oxford, OX1 5NY 2 Picker Institute Europe, King s Mead House, Oxpens Road, Oxford, OX1 1RX EXECUTIVE SUMMARIES January 2010 Research funded by the National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO) programme: 08/1619/155 Sponsored by the University of Oxford

2 Contents Contents Executive Summary: South Case Study...3 Executive Summary: Midland Case Study...8 Executive Summary: North Case Study...12 Executive Summary: London Case Study...16 Page 2 Support Workers in Secondary Healthcare: Four Case Study Executive Summaries

3 South Case Study Executive Summary: South Case Study The report sets out research findings on the role of support workers (healthcare assistants and senior ward housekeepers) at a NHS Hospital Trust in the South of England (South). The research concentrated on these roles in two clinical areas acute general medicine (AGM) and general surgery (GS) at two hospital sites. Approach The research work at South was carried out at the end of 2007 and comprised the following elements: Interviews (15) with senior Trust managers and clinicians. Interviews (81) with matrons, sisters, nurses, HCAs and SWHKs from selected GS and AGM wards and clinical areas on the respective sites. All interviewees also filled-in a pro forma providing personal background details. Observation (16 shifts) of HCAs, SWHKs and nurses on morning and late shifts. Focus groups and interviews involving (25) former patients on the relevant wards. Background Recruitment There were difficulties in recruiting HCAs. These recruitment difficulties combined with other sources of staff absence sickness, study days, maternity leave to produce some fluctuation in and uncertainty about HCA staffing levels on any given shift. There were concerns that Trust wide procedures slowed down the recruitment of HCAs, in some cases leading to the loss of successful candidates as they took up other jobs before their appointments were confirmed by the Trust. The recruitment difficulties were less acute at one site with advertisements for HCAs usually attracting a significant number of applicants, although not always with the right backgrounds for the role. On the other site HCA recruitment difficulties were more ubiquitous and long standing, linked to a tighter local labour market and perceptions of the job as unglamorous, menial and poorly paid. Background characteristics Pro forma data revealed that: On average HCAs were in their mid forties, somewhat older than nurses. There was a marked difference in the ethnic mix of HCAs between the sites. Around three quarters of HCAs had spouses or other partners. There were site differences with HCAs at one site more likely to have children suggesting a noteworthy number of single mothers in HCA roles at this site. Support Workers in Secondary Healthcare: Four Case Study Executive Summaries Page 3

4 South Case Study A considerable proportion of HCAs had attended a local school (73%), much higher than amongst nurses (57%), suggesting that HCAs were more embedded in the local community. Again there were site differences. Union membership was low in absolute terms (20%) and relative to membership amongst nurses (71%). Average length of service amongst HCAs was seven and a half years, lower than amongst nurses. At the same time, around a quarter of HCAs had ten years or more service. HCA journeys Three routes to the HCA role were distinguished; a pure health/social care route where past jobs and experience had been confined to caring sectors; a mixed route where HCAs had previously worked both within and outside of health/social care; and a non- health/social care route where there was no formal experience of working in a caring capacity. The majority of HCAs had taken the mixed route, although substantial minorities had arrived via the pure and non health/social care routes. Individuals were motivated to become an HCA by an immediate need disliking their current job, being attracted to the HCA role or changing of personal circumstances; by a stimulus, which converted this need into action, typically in the form of encouragement from a family member or friend; and by the ability to justify the decision in terms of a broader life narrative, which often revolved around a longstanding desire to enter nursing or an affecting care experience usually involving a dependent relative. The Support Worker Role General perceptions While overlapping in important respects, general views about the nature of the HCA role coalesced into different patterns. These placed a slightly different emphasis on particular aspects of the role and especially on who HCAs were supporting. Thus, the role was seen as: a nurse support; a patient support; a basic care provider; and a team support. The good HCA Asked what makes a good HCA, there was considerable consensus amongst HCAs, nurses, sisters and former patients with an emphasis on caring and compassion. HCAs, nurses and sisters also attached importance, for example, to stamina, communication, common sense, a sense of humour and listening. Nurses and HCAs highlighted a number of similar characteristics such as patience and accountability. Some characteristics were mentioned by sisters alone: such as motivation and conscientiousness; by nurses alone, including organisation skills and time management; and HCAs alone, such as being happy, humility and empathy. Page 4 Support Workers in Secondary Healthcare: Four Case Study Executive Summaries

5 South Case Study Tasks and responsibilities The HCA role was seen to comprise a wide range of tasks, classified as clerical, patient-centred, care management, team-centred, technical and specialist. These were bundled in very different ways suggesting that the shape of the HCA role was contingent and took many different forms. This bundling was sensitive to, and influenced by, the following factors: The trust. HCAs were found in Bands 2 and 3 of the Agenda for Change grading structure. However, the link between Band 3 and NVQ 3 or equivalent qualifications, particularly given the under developed nature of NVQ accreditation at the Trust, had resulted in many HCAs who were performing extended roles being found in Band 2. The clinical area. In general, HCAs in GS were performing slightly more extended roles than those in AGM related to differences in the nature of patient conditions and age profiles. The ward. Firstly, by ward shift where the HCA role varied according to whether it was being performed on the morning, late or night shift. Secondly, by speciality where the HCA role was somewhat more extended in specialist areas like the Surgical Emergency Unit and Medical Assessment Unit than on the general wards. Thirdly, by management style where some ward sisters were more proactive in developing the HCA role than others. The individual. The more experienced and trained the HCA, often the more extended the role. HCAs who aspired to a career in nursing were also more likely to push the boundaries of the role; while individual domestic circumstances often shaped working patterns and, in turn, the shape of the role. The Management of Healthcare Assistants Integration. At ward level HCAs were seen by sisters, senior nurses and nurses as well integrated into the ward team, while HCAs saw themselves as full team members. This was reflected in their opportunity to participate in: ward meetings; handover meetings; and (management) team-based activities such as away-days. HCAs were not involved in multidisciplinary team meetings, to the dismay of some. Voice. The distinctive collective voice of HCAs was weak. This was reflected in low union membership and the absence of opportunity for HCAs to meet as a group at any level within the Trust. Preparation. While standard induction at the Trust was seen to provide a sound grounding for undertaking the HCA role, preparation for the following appeared less robust: HCAs changing shifts; dealing with death and bereavement; delivering soft skills; and helping confused patients. Performance management. The administration of performance appraisal was extremely patchy. This was in part attributed to the introduction of the new Knowledge and Skills framework, but given that some HCAs had not been appraised for many years, this could not be the sole reason. Support Workers in Secondary Healthcare: Four Case Study Executive Summaries Page 5

6 South Case Study Consequences Consequences for the HCA Likes and dislikes. Asked unprompted what they most liked and disliked about the role, the most common likes highlighted by HCAs included: patient contact and making a difference. The most common dislike was dealing with bodily fluid although most HCAs had come to terms with this aspect of the job; other dislikes included staff shortages and workload pressures (the two often being linked). The future. Asked where HCAs felt they would be in five years time, just over a quarter saw themselves as nurses, with around 60% indicating that they would still be in the HCA role. Few HCAs saw themselves as leaving healthcare. To some of those seeing themselves as still in the HCA role five years hence, the stayers, nursing was seen as unappealing. In part this was related to the nature of the nurse role, although for others this lack of appeal related to personal circumstances which prevented them moving into nursing. Yet others lacked the confidence or means to take on nurse training. Amongst the stayers, there was also a distinction between those who were keen to develop in the HCA role and those happy to tread water in it. Relationship with nurses and other professionals. Contact with doctors was fleeting and rare. There were odd instances where HCAs were upset about junior doctors attitudes toward them. In the main, HCA views on their relationship with nurses were very positive. However they raised a few concerns, sometimes seeing themselves as: Not recognised. The work-horse of the ward. Having to deal with a disproportionate amount of the dirty work. Unevenly used by nurses. Cheap labour. Consequences for nurses In general, nurses viewed HCAs in extremely positive terms. Nurses were most likely to value HCAs when they trusted them, which, in turn, was associated with the HCAs experience, training, motivation, self awareness and communicative skills. In addition, the use of HCAs was contingent on the background and orientation of the nurses themselves: the training (or lack of it) they had in dealing with HCAs; their age, experience and national backgrounds. Nurses valued HCAs as: A relief, taking certain routine task off them, although there was a perceived danger that this could distance nurses from key aspects of direct care. A co-worker, working alongside nurses on the same task. A complement, taking on tasks in parallel to the nurse. An extension, acting as the nurses eyes and ears. An added value, contributing something new and distinctive to healthcare. Page 6 Support Workers in Secondary Healthcare: Four Case Study Executive Summaries

7 South Case Study Consequences for patients There were attempts across the Trust to help patients distinguish between HCAs, nurses and other members of staff. However, these were unevenly applied: while uniforms were coded amongst different staff groups, amongst HCAs there was still some variation in the uniforms worn; moreover, name badges carried different designations including nursing auxiliary alongside HCA ; some wards had posted pictures, names and job titles on a corridor notice board but this was rare; and while HCAs sometimes introduced themselves to patients, this was far from standard practice. A number of HCAs and nurses felt that patients could not and did not distinguish between them. This was confirmed by former patients who found it easier to identify domestics than to distinguish between HCAs and nurses. For some former patients making this distinction was not particularly important; they trusted in the system to deliver good care. Others, however, felt that directing questions and concerns to an inappropriate member of staff had affected the quality of their care experience. Whether acknowledged or not, HCAs and nurses felt that HCAs did develop a different type of relationship with patients than nurses. In providing basic care, HCAs spent more time with patients and were more likely to meet personal needs. This often allowed HCAs to build a closer, more friendly relationship with patients, which in turn allowed HCAs to develop useful insights into the patient s general condition and situation. However, this closer relationship was not greatly in evidence during observation. Once prompted, former patients also highlighted the significant contribution made by HCAs to the quality of their hospital stay, although in providing basic care HCAs could at times find themselves in the firing line when patient concerns were raised about care quality. Support Workers in Secondary Healthcare: Four Case Study Executive Summaries Page 7

8 Midland Case Study Executive Summary: Midland Case Study This report sets out the research findings on the role of support workers, in particular nursing auxiliaries (NAs), at an English NHS Hospital Trust in the Midlands (Midland). The research concentrated on NAs in two clinical areas: acute general medicine and general surgery. Approach The research work at this Trust was carried out during the Spring and Summer of 2008 and comprised the following elements: Interviews with 23 executive directors, senior managers and matrons; Interviews with 35 ward sisters, nurses, NAs and ward assistants/hostesses in six wards (four medical and two surgical); Observation of 10 shifts across two wards, 6 of these observation sessions covering NAs, and two each respectively covering nurses and hostesses; A focus group for ward assistants; Four focus groups involving former patients on the relevant wards. Context Over recent years a new executive director team had been seeking to turn around a failing Trust; a Trust which some three or four years ago had been facing major financial and performance challenges. In responding to these challenges the executive team had to confront a traditional organisational culture founded on the Trust as a key and high profile employer in the city. The culture was characterised by an intimacy within the workforce or a family-like closeness, which bred a strong loyalty and commitment to the Trust, but at the same time had encouraged a general complacency and indulgence encouraged by weak corporate centre and exacerbated by an adversarial pattern of industrial relations. The response to these challenges by the executive team took the form of four main initiatives: Seeking to shift from an adversarial to a partnership form of industrial relations; Re-designing the organisation both in terms of rationalising the divisional and directorate structure and re-configuring wards; A programme of workforce reductions; A nursing skill mix review driven in part by the pursuit of cost saving, but also by an attempt to balance nurse resources across the different clinical areas. The review introduced a shared staffing template across the Trust which inter alia created a largely Band 2 NA workforce. In outcome terms, these initiatives had effectively addressed the most pressing financial and performance challenges confronting the Trust. A shift in senior management style was certainly perceived by staff, although views varied as to whether this was for the better. There was Page 8 Support Workers in Secondary Healthcare: Four Case Study Executive Summaries

9 Midland Case Study general agreement that these initiatives had generated uncertainty and stress across the workforce reflected in low staff morale. Nursing Auxiliary Backgrounds The recruitment freeze imposed during the skill mix review had created a cumulative and pent up demand for NAs, largely addressed at the time of the research albeit with some residual vacancies in evidence on some of the wards. While the high demand for NAs in this context placed some pressure on recruitment, in general there was a plentiful supply of applicants for NA jobs with the Trust therefore the Trust was in a position to introduce some quite stringent entry requirements typically in the form of previous care experience. Drawing upon pro forma data collected during the interviews, it was clear the NA workforce was fairly experienced, principally made up of those with partners and children and with a strong connections to the local community. In terms of career journeys, NAs had been employed in a diverse range of work domains, but direct entry into the NA role was mainly through employment in some aspect of care. Movement into the NA role usually comprised three elements: priming, i.e. frustrations with a current job or the lure of the NA role; a stimulus converting the disposition to move into an actual job change, such as encouragement from a friend or relative; and alignment with a life narrative which rationalised the move such as past aspirations to become a nurse or previous personal care experience. The Nursing Auxiliary Role There was some difference in emphasis as to whether the NA was seen as supporting the nurse, patient or team, although most felt the NA was supporting the nurse by providing direct patient care. There was considerable consensus amongst nurses and NAs that a caring approach was essential to being a good NA with NAs also placing considerable emphasis on the need for communication skills and a commitment to the role. The shape of the NA role, and particularly the extent to which it had been extended, were seen as contingent on Trust policies, ward systems, clinical area, and the crafting of individual postholder. There were indications that Trust policies which had led to the creation of a predominantly Band 2 NA workforce had fostered some retrenchment around core basic care activities. However, the needs of patients in certain clinical areas saw the development of Band 3 posts and NAs in extended roles. Ward routines also encouraged differences in the shape of the NA role with tasks and responsibilities varying by shift, ways of organising work, ward management style and the presence or not of bank or student nurses. Individual crafting of the NA role to reflect personal needs and circumstances was not greatly in evidence, although aspirations and motivations had some residual impact on tasks performed. Support Workers in Secondary Healthcare: Four Case Study Executive Summaries Page 9

10 Midland Case Study The Management of Nursing Auxiliaries Nurse auxiliaries were well integrated into ward teams, although at the margins there was some discontent at not being directly involved in handover on some wards. NAs had a distinct voice in two of the six wards, reflected in separate NA meetings. While most NAs were in a union, only a minority knew their local union representative or had been to the union with an issue. While most NAs felt well inducted into the role, there were indications that preparation for aspects of the job were under developed; in relation, for example, to working on different shifts and dealing with unexpected ward events. The NA workforce appeared well trained as apparent in the number with NVQ 2 and 3 qualifications. A few difficulties with training provision for NAs were highlighted including difficulties in finding time to leave the ward and the absence of discrete NA programmes. In general, performance appraisal was seen as a worthwhile process by NAs. Consequences of the NA Role For the NAs themselves When asked about the most attractive aspect of the role, many of the NAs highlighted patient caring and contact as their main like. A greater variety of dislikes were noted including physical abuse from patients and hostile relatives. While most NAs were able to maintain an appropriate emotional distance from patients, there were examples of the NA role placing considerable emotional stress on post holders. In terms of aspirations, exactly a quarter of NAs interviewed saw themselves as professionals in five years, two-thirds as still being in the support role. NA contact with doctors was extremely limited. In general, relations with nurses were positive although at the margins NAs viewed themselves as being treated as the ward work horse and the dirty worker as well as in an under valued way. For nurses In general NAs were highly valued by nurses as a relief, complement, co-producer, catalyst, another pair of eyes, and occasionally on-the-job teacher. Nurse orientation towards and the use of NAs was, however, heavily contingent on their own background, experience and disposition as well as on how they perceived the quality of the NAs and whether they could trust them to carry out tasks. For patients Views varied on whether patients could distinguish between nurses and NAs, patients themselves suggesting that they did have initial difficulty on entering the ward on picking up the difference albeit in time being able to do so. In general NAs were perceived to have a different type of relationship with patients, being able to get closer to them and act more as a confidant and friend than nurses. Page 10 Support Workers in Secondary Healthcare: Four Case Study Executive Summaries

11 Midland Case Study Views differed, however, as to why NAs were better able to develop such a relationship than nurses. For some, there was nothing intrinsic to the NA role which led to this special relationship: NAs simply had more time to spend with patients and were more likely to provide direct personal care; if nurses had more time and provide the same direct care they would also be able develop such a relationship. Others were more inclined to view the nature of the NA role along with the type of individual it attracted as creating a more accessible and less intimidating point of service contact, a view which found some support from patient views. The Ward Assistant Role Multiple Band 1 roles exist in the Trust: Hostess; Ward Assistant (WA); and Housekeeper Auxiliary. There appears to be some confusion about titles, duties and the budget holder for these roles. The role is shaped by the nature of the ward and type of patients: the operation of a tray or dishing up of food system; the staffing on the ward; ward managers use of the role, individual style adapted to the distribution of food; and the quality of the cleaning staff. The WA role is valued by all occupational groups we spoke to. The view was expressed that these roles could be extended. Ward assistants reported that NAs have taken on many tasks that used to be done by nurses and that following the skill mix review they are working noticeably harder. This observation has not encouraged them to want to make the NA role a career choice. Support Workers in Secondary Healthcare: Four Case Study Executive Summaries Page 11

12 North Case Study Executive Summary: North Case Study This report sets out the findings from research into the role of support workers at a NHS Hospital Trust in the North of England (North). The work was carried out by researchers from the Saїd Business School, University of Oxford and the Picker Institute Europe during Autumn, Funded by the NHS Service and Development Organisation (SDO), it forms part of a larger project being undertaken by the researchers into support roles in secondary healthcare, with North representing the third of four acute Trust case studies. As in the other case studies, the focus at North was on two main support roles: Healthcare Assistants (HCAs), or Clinical Support Workers, and Ward Housekeepers (WHs). Approach The research focused on HCAs and ward housekeepers at two of the Trust s main sites and in three general medical and three surgical wards A total of fifty interviews were conducted covering senior managers at the Trust but mainly focusing on HCAs and nurses at ward level. A total of ten observations were undertaken covering HCAs, nurses and housekeepers on a medical and a surgical ward; each observation corresponded to the first six hours of an early shift. Four focus group involving former patients on the six wards were conducted. Context A relatively new divisional structure at the Trust had been established and designed to create a better balance between corporate and operational management. Steps were being taken to develop a stronger organisational culture. The Trust was moving onto a more even financial keel after a period of some uncertainty which had effectively led inter alia to a recruitment freeze. New strategic priorities were emerging related to patient choice, access and safety. The issues of new workforce roles and ways of working were beginning to emerge on this strategic agenda but remained largely aspirational rather than being active and ongoing. Backgrounds In general the Trust operated on 70/30 skill mix but was undergoing a skill mix review at the time of the research. Some flexibility around skills mix issues was noted at ward level. Although there were some Band 3 HCAs in the Trust, almost all HCA in the wards studied were in Band 2. Page 12 Support Workers in Secondary Healthcare: Four Case Study Executive Summaries

13 North Case Study Most HCAs on the wards covered worked full time and this included working long days. There were mixed views on the costs and benefits of long days for the employees working them and patients. Recruitment of HCAs was mainly handled at ward level. Entry requirements for the role were minimal, although some wards were keen to recruit those with some healthcare experience. Despite or more likely because of low entry requirements, there were few problems in attracting a considerable number of applicants to HCA posts, although the quality of applicants was seen as questionable. In terms of personal background, the HCAs covered were relatively young, embedded in the local community, as likely to have a partners and children as not and with limited service in the Trust. This was a profile which did not differ dramatically from that of the nurse interviewees but in general HCAs were younger, had a shorter length of service, and were more likely to have a partner and children than nurses. Those entering the HCA role had held a diverse range of jobs in a number of sectors although a significant majority had some work experience in health or social care. The Role HCAs and nurses placed different degrees of emphasis on whether the HCA was mainly a support to the nurse, patient or the team, although there was a general consensus that the core of the HCA role revolved around the delivery of personal patient care. A range of qualities were highlighted as characterising the good HCA with caring and communication skills being most commonly cited. While the core of the HCA role remained direct patient care, and despite the fact that all HCAs were in Band 2, the precise sets of tasks undertaken varied considerably and the role was found to be more or less extended. The shape of the role was related to various factors: the presence or not of other workers like physicians assistants whose role overlapped with the HCAs ; the clinical area, with direct care taking up a higher proportion of time for HCAs on medical than on surgical wards; the style of the ward manager in encouraging or not an extension of the role; individual post holders themselves in terms of their disposition and willingness to push the boundaries of the role. Management of the HCA Role A short corporate induction is held, along with mandatory training; however induction mainly took place at ward level, typically involving a two week supernumerary shadowing period. Consequently there was a considerable amount of training on the job, with views varying about the adequacy of preparation for the HCA role. NVQ training was patchy and not always closely related to band level. Performance appraisal tended to be conducted in the wards covered with HCAs finding the process useful. HCAs were invariably seen as part of the ward. They were included in handovers and ward team meetings, although the latter were often held on an irregular basis. There were no opportunities at any level in the Trust for HCAs to meet as a group and with union membership low, the collective HCA voice was weak in the Trust. Support Workers in Secondary Healthcare: Four Case Study Executive Summaries Page 13

14 North Case Study Consequences of the HCA Role For the HCAs themselves Most HCA enjoyed their job with patient contact being viewed as the most commonly cited like. Some dislikes were raised including lack of recognition, patient distress, staff shortages and aggressive patient behaviour. The role was seen by some as emotionally intense with various coping strategies adopted. A high proportion of HCAs saw themselves as nurses in five years time although they did raise personal and work related barriers which might inhibit progress. HCAs saw their relations with nurses as generally positive, although some concerns were raised by HCAs such as being dumped on and being patronised by other staff members. For nurses In general nurses valued HCAs, suggesting that a good relationship needed to be based on trust and communication. The nurses saw the value of the HCA as lying in them acting as a relief, a partner and as complement in providing distinctive qualities. At the same time, the use made by nurses of HCAs was contingent upon how the nurse perceived the HCA, whether the HCA was seen by the nurse as capable, committed and enthusiastically engaged in the role. Nurses were conscious of their accountability for delegating tasks to HCAs and tensions could arise, for example where experienced HCAs might intimidate newer and younger nurses. For patients The Trust and wards made efforts to distinguish between different types of staff through uniform colour and name badges. However patients still often had difficulty differentiating nurses and HCAs. In general HCAs were seen to have a different relationship with patients than nurses. The longer and intense contact between HCAs and patients was seen as fostering a closer relationship. The Ward Housekeeper Role Context The housekeeping role is performed in-house and falls within the Facilities Directorate Three recent policy decision have impacted on the organisation and functioning of the role within the Trust: the introduction of a credits for cleaning system allowing central planning of staffing; the establishment of rapid response cleaning teams; the splitting to cleaning and food duties on wards to guard against cross contamination. Page 14 Support Workers in Secondary Healthcare: Four Case Study Executive Summaries

15 North Case Study The Housekeeping Role Housekeeping (HK) is a Band 1 role. The HK role is a no patient contact role, sometimes a cause of frustration amongst HKs. HK tasks do not overlap with HCA tasks accept occasionally in relation to bed making. The HK role is highly routinised and centres on cleaning and the provision of drinks and food. HK s have no involvement in dealing with equipment or stocking. Differences in the organisation of tasks were noted at ward level. Concerns were raised about rapid response cleaning. The HK enjoyed working with others and patient contact. They raised concerns about the quality of communication and confused lines of accountability. The role has become increasingly pressurised and more intensely monitored. Management of HK The quality of relations with team leaders from Estates was uneven. Induction was not viewed positively. Some concerns were raised about appraisal. The HK role was viewed both formally and informally as a possible route into the HCA role. Relationships Relations with nurses and HCAs did not emerge as an issue. Despite the absence of formal contact with patients, HKs often chatted with patients who were sometimes prepared to confide in them. Support Workers in Secondary Healthcare: Four Case Study Executive Summaries Page 15

16 London Case Study Executive Summary: London Case Study This report sets out the findings from research into the role of support workers at a NHS Hospital Trust in the greater London area (London). The work was carried out by researchers from the Saїd Business School, University of Oxford and the Picker Institute Europe during the Spring and Summer of Funded by the NHS Service and Development Organisation (SDO), it forms part of a larger project being undertaken by the researchers into support roles in secondary healthcare, with London representing the last of four acute Trust case studies. Approach This report explores the background, nature and consequences of the HCA role. A total of 65 interviews were conducted covering mainly nurses and HCAs, as well as senior managers, on five surgical and medical wards on one hospital site and a medical and a surgical ward on another site. These interviews were supplemented by observation of HCAs and nurses on 10 separate morning shifts on three wards and by patient focus groups. Context This is a high performing Trust, reflected in its application for Foundation Trust status. Its culture was characterised as: Allowing personal responsibility; Open and accessible; Friendly; Supportive; Engaging; Locally embedded. The Trust was facing challenges; the issues on the senior management agenda relating to: The London Factor in the context, for example, of service reconfiguration; Competition; Relationships with purchasers; The Trust s estate; The Trust s performance. Workforce issues did not figure prominently at the Board level; the most pressing workforce issues emerging at this level related to: (Nurse) vacancies; E-Rostering; Skill mix. Page 16 Support Workers in Secondary Healthcare: Four Case Study Executive Summaries

17 London Case Study Issues of workforce structure linked to new roles and ways of working were mentioned in the recently published Nursing and Midwifery Strategy, and some tangible steps had been taken with development of a new Band 3 role and some work at Band 4 level. Healthcare Assistant Backgrounds Skills: The number of HCAs required by the Trust was linked to skill mix which, while varying by clinical area, was generally around 60/40. The recruitment process: Recruitment of HCAs was essentially handled at ward level. While there was a generic HCA job description and some broad entry criteria, including the expectation of NVQ 2 at or soon after appointment, a variety of ward level criteria were used including: growth potential; work experience; impressions; interview performance; personality. Personal backgrounds Drawing upon pro forma data, it emerged that: Most HCAs worked full time; The overwhelming majority of HCAs had four or more years experience at the Trust; Close to half were over 45 years old; around three quarters had partners and children; The HCAs were strongly embedded in the local community reflected in the fact that two thirds had been to a local school; HCAs had a diverse range of work and life experiences, arriving at the role from a range of jobs in a variety of different sectors. Their motivations also varied, although often HCAs had had a care experience in their personal lives or were attracted to the role by aspirations related to nursing. The HCA Role General perceptions Respondents varied in terms of the weight they placed on the HCA role as regards team, nurse or patient support. There was some consensus amongst HCAs, nurses and ward managers on what constitutes a good HCA, communication skills being seen by all three groups as crucial. Being caring and compassionate was seen as the most important quality required by the good HCA. Patients who discussed the HCA role during focus groups listed a good sense of humour, listening skills and working well in a team as desirable qualities. HCAs who had stood out on the ward exhibited a reassuring manner and a willingness to go that extra mile. Support Workers in Secondary Healthcare: Four Case Study Executive Summaries Page 17

18 London Case Study Task and responsibilities There was much debate within the Trust about whether and how the HCA role was being and might be extended. While the core of the HCA role remained bedside, basic patient care, some HCAs were working beyond this core. The suggestion that HCAs rather than nurses were delivering this basic care was reflected in our observation data, which suggested that over 60% of HCA time on shift was spent delivering direct and indirect patient care, the figure for nurses standing at barely over a third of their time. At the same time it was also suggested that the shape of the HCA role was related to contingent factors associated with the Trust, clinical area, ward and individual. The Trust regime was fairly permissive in the way that the constraints or standardising influences on the HCA role were applied. There was some broad guidance on what HCAs could and could not do but within these limits there was considerable scope for the role to develop in response to other factors. The HCA role was found to differ somewhat between the surgical and medical areas, reflected in observation data which indicated that those in surgery were slightly more likely to engage in more complex, technical tasks. At ward level, the shape of the HCA role was affected by the extent to which ward managers supported its extension as well as the nature of the ward workforce; in particular, whether or not other types of workers, such as student physicians assistants, were active or not. The individual was seen as having an important influence on the HCA role, disposition, aspiration and personal circumstances all impinging on its form. For example, those HCAs with ambitions to become nurses tended to push the boundaries, while those with heavy domestic responsibilities did not. The link between extended working, band level and NVQ qualifications was not consistent, generating concerns amongst HCAs and others. Management of HCAs Training Induction of HCAs was thorough, with almost all HCAs feeling well prepared to take on the role. The set up for NVQ training was robust: the Trust had a dedicated team working on HCA NVQs; the Trust was an accredited NVQ centre; and much NVQ material was accessible online. The proportion of HCAs with NVQ 3 was put at only around one quarter. There were a range of systemic, institutional factors and constraints facing HCAs in pursuing NVQ qualifications despite the impressive NVQ infrastructure and hard working staff operating the programme. Performance appraisal HCAs viewed PDR positively, but its application was at best uneven. Page 18 Support Workers in Secondary Healthcare: Four Case Study Executive Summaries

19 London Case Study Voice There were no dedicated forums or channels available within the Trust for HCAs to express their views. HCAs however routinely attend handover and (irregular) ward meetings. Union membership was relatively low amongst HCAs and union organisation at the Trust was fragile. Consequences of the HCA Role For the HCAs themselves HCAs enjoyed their jobs, valuing in particular contact with patients. There were however a number of dislikes raised by HCAs including: Difficult relatives and patients; Poor pay and lack of recognition; Being dumped on. Working as an HCA can be an emotionally intense experience, particularly in the context of dealing with death and last offices. The emotional consequences of the role were significantly influenced by the circumstances of death and the coping strategies developed by HCAs. In terms of the future, around one half of HCAs indicated that they aspired to become nurses. However, other HCAs highlighted the barriers to this form of career development in terms of their age (too old) and domestic responsibilities (too many). In general HCAs indicated that they had a positive relationship with the nurses on their ward, working well with them. A few concerns with this relationship were highlighted: Being dumped on ; Lack of recognition; Invading the nurse space. For nurses Nurses valued the HCA. They saw them contributing positively to their working lives in a number of ways: A team player; A relief; Reservoir of knowledge; Additional set of eyes and ears ; Adding value; A mentor. There were some tensions in this relationship including: HCAs over-stepping boundaries; Clarity (or lack of) on HCA accountability; Support Workers in Secondary Healthcare: Four Case Study Executive Summaries Page 19

20 London Case Study Clarity (or lack of) nurse accountability for the work of HCAs. For patients Various means for distinguishing HCAs from other members of the ward team were in place: different coloured uniforms, badges and the scope for formal introduction. The effectiveness of these mechanisms was at best uneven. Nevertheless, HCAs were generally seen to develop a closer relationship with patients than nurses, a function of the greater time HCAs spent at the bedside with patients and the kind of comfort tasks they performed for patients. Page 20 Support Workers in Secondary Healthcare: Four Case Study Executive Summaries