art&science clinical research education A training programme for healthcare support workers 33-37 Care map 7: Extrapyramidal side effects 39-41 Continuing professional development Self-harm and suicide: care, interventions and policy 43-52 Multiple-choice self-assessment 54 Practice profile assessment 56 Author guidelines If you want to write for Nursing Standard s art&science section, visit the website at www.nursing-standard.co.uk A training programme for healthcare support workers Arblaster G et al (2004) A training programme for healthcare support workers. Nursing Standard. 18, 43, 33-37. Date of acceptance: March 16 2004. Summary Healthcare support workers (HCSWs) are at the front line of patient care delivery. It is essential that they are appropriately trained and competent in the skills required to deliver the fundamentals of care. There is also a need for HCSWs to have access to continuing professional development that offers a career pathway. The University Hospitals Coventry and Warwickshire NHS Trust has developed a framework for career progression that incorporates three phases of continuing professional development. These are organised and co-ordinated by a dedicated support worker training team comprising four registered nurses plus senior support workers in the role of peripatetic NVQ Care assessors. THE TRADITIONAL grade of nursing auxiliary or nursing assistant achieved formal recognition in 1955 (Dingwall et al 1988), and expanded rapidly thereafter, particularly when there is a shortage of trainee nurses. Following implementation of the NHS and Community Care Act 1990, a new grade of worker materialised, for whom a variety of titles emerged, including support worker, health care assistant and healthcare support worker (HCSW). The role of the HCSW has evolved partly as a result of the change in pre-registration student nurse training to diploma level education in 1997 and the introduction of supernumerary status during clinical placements. This resulted in skills gaps in the delivery of care. The role of the HCSW has developed to bridge these gaps (Nazarko 1999). HCSWs now play a major role in the delivery of basic care, but historically their contribution has not always been recognised, as Edwards (1997) points out: Popular images of nursing, largely based on Victorian ideals, have tended to ignore the role played by the unqualified nurse. Yet nurses aides have been described as providing the backbone of health services and in many clinical areas have traditionally performed the greater part of basic nursing care. It is important to safeguard patients, and hence to provide HCSWs with the training and development opportunities needed to ensure that they are competent to deliver the care required and are recognised for their contribution. In addition, registered nurses remain accountable for delegation and for ensuring that the person who does the work is competent to do it (NMC 2002). Completion of a formal structured training and assessment process goes some way to providing evidence of competence. HCSWs are dedicated to delivering a high standard of care, but this needs to be nurtured. They need to be valued for their dedication and knowledge (Marick 2000). The University Hospitals Coventry and Warwickshire NHS Trust recognised that HCSWs were an essential and valued part of the workforce, providing excellent support to registered nurses, but needed to ensure that they were competent and that there was consistency in the care delivered to patients. Although the opportunity to undertake a National Vocational Qualification in Care (NVQ Care) was offered within the trust, the employment of increasing numbers of HCSWs meant that there was a waiting list. Consequently, not all HCSWs were able to access this course at the start of their employment. Many had to learn their role and acquire skills through on-the-job training, with the quality of training and the level of support varying across the trust. In addition, there were limited development Gillian Arblaster RGN, MSc, PG Dip, BSc(Hons), DPSN, is associate director of nursing, Chris Streather SEN, RGN, DSPP, Cert Ed, is support worker training manager and NVQ Care manager, Lesley Hugill RGN, DPSN, BSc(Hons), is support worker and NVQ Care facilitator, Melvina McKenzie RGN, is training adviser, and Judith Missenden RGN, ONC, is internal verifier at the University Hospitals Coventry and Warwickshire NHS Trust, Coventry. Online archive For related articles and author guidelines visit our online archive at: www.nursing-standard.co.uk and search using the key words below. Key words Healthcare support workers National vocational qualifications Peripatetic assessors These key words are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. july 7/vol18/no43/2004 nursing standard 33
opportunities for staff who wanted to progress. It is within this context that the trust developed a framework for training and career progression (Figure 1). The training and development pathway incorporates three phases of continuing professional development: the Essence of Care programme, and NVQ Care levels 2 and 3. These enable HCSWs to develop skills and achieve recognition of these skills, with the opportunity to progress to nurse training. The pathway was presented as a progressive flow chart that indicated the development of HCSWs from induction through to the exit point for nurse training. Phase 1: Essence of Care programme For the first phase of training, the authors sought to develop a programme that could be accessed by all HCSWs on induction to the trust and would provide them with a foundation to deliver basic care. The initial programme evolved over time and is known as the Essence of Care programme. The Essence of Care model This model has developed to complement the standards of care identified in the Department of Health (2001) Essence of Care (toolkit), which aims to raise the quality of care by getting the basics right and improving the patient experience. The key themes of the programme were informed by the eight key aspects of care initially identified in the Essence of Care (DoH 2001): 1. Principles of self-care. 2. Food and nutrition. 3. Personal and oral hygiene. 4. Continence and bladder and bowel care. 5. Pressure ulcers. 6. Record keeping. 7. Safety of patients with mental health needs in acute mental health and general hospital settings. 8. Privacy and dignity. Although these are not the only aspects of care Figure 1. Healthcare support worker training and development pathway carried out in practice, the authors considered that these reflected the national priorities and seemed a reasonable first phase in the development of the trust s HCSW training programme. Communication was evident in all elements of the programme, and its importance is reflected in the additional benchmark, namely communication between patients, carers and healthcare professionals, in the revised Essence of Care document (DoH 2003). Programme design and content The programme is of seven days duration and runs every month. It is mandatory that all HCSWs employed by the trust undertake the Essence of Care programme. It provides the underpinning knowledge, and the opportunity for experiential learning through practical demonstrations, practice and assessment of competency in basic care. It also incorporates: the trust s induction day; mandatory training for handling and moving; cardiopulmonary resuscitation; infection control; and child/adult protection. The support worker training team recognises that it is crucial for knowledge and practice to be up to date and evidence based. Therefore, the programme is delivered in partnership with practice facilitators, specialist nurses and external agencies. Assessment of competency The development of a training programme alone would not ensure that HCSWs were competent to practise. Generic competency assessment workbooks were developed to provide a framework for evaluating individual learning and recognising the development of competency in practice. These built on existing packages that were being used in clinical practice, and were designed to complement the Essence of Care programme. The HCSWs are issued with the competency workbooks on completion of the seven-day training programme. They are required to complete the workbooks successfully within six months by working with mentors in practice. The assessment workbook also enables the HCSWs to develop the skills and knowledge required to commence the next development phase. Essence of Care programme Phase 1 Pre-NVQ study skills course Competencies Phase 2 NVQ level 2 Phase 3 NVQ level 3 Vocational Assessors Award C25 Coaching Award Diploma in Nurse Training Generic basic care competencies Care Care Phase 2: NVQ Care level 2 All newly appointed HCSWs are required to undertake the NVQ Care level 2. On successful completion of the competency workbooks, the HCSWs are nominated by their line manager for access to to the NVQ Care programme. There are three NVQ intakes a year, with 20 candidates in each intake. The NVQ Care is a work-based qualification using the National Occupational Standards for Professional Activity in Health Promotion and Care (CSC 1997). As part of the NVQ Care assessment process, candidates performance is assessed through observation in their clinical areas against the National Occupational Care Standards (CSC 1997). When they perform consistently to the 34 nursing standard july 7/vol18/no43/2004
National Occupational Care Standards they are deemed competent. The NVQ Care is delivered as a structured programme of nine study days (one per month), which delivers the knowledge required to meet the National Occupational Care Standards (CSC 1997). For example, the content of the study day for Unit CL2 focuses on communication differences and includes a session on sign language. Before commencing phase 2, HCSWs attend a pre-nvq study skills day (Box 1), which is delivered on a monthly basis. The aim is to help the HCSWs identify their own learning style and the importance of time management. The NVQ Care programme commences with an induction day, during which each candidate is issued with a learning contract (Box 2) which must be discussed with, and signed by, the respective line manager. The purpose of the learning contract is to formally recognise the support given to the candidate by his or her line manager, and to confirm that the line manager is supporting the candidate s attendance on the programme. When undertaking an NVQ in Care, candidates have to register with the awarding body (City and Guilds). All relevant registration forms, documentation and support mechanisms are discussed to ensure that candidates understand the course processes and requirements before the first study day. In addition, candidates are informed who their assessor will be, which gives them the opportunity to meet the assessor before commencing the full programme. Phase 3: NVQ Care level 3 The next phase in the developmental programme provides HCSWs who have completed their NVQ Care level 2 with the opportunity to access NVQ Care level 3, provided that they meet the criteria set by the trust (Box 3). Candidates are nominated by their line manager and are interviewed to ensure that they meet the criteria (Box 3). Achievement of the NVQ Care level 3 enables the support worker to apply for senior HCSW roles, nurse training or NVQ assessor training. Nurse training HCSWs with an NVQ Care level 3 can apply to the university for nurse training either as bursary students or via the trust s secondment places. HCSWs who access nurse training as bursary students leave their permanent positions as support workers in the trust. However, those who apply for secondment and are successful will commence nurse training, and are paid a percentage of the HCSW wage (which is higher than the bursary). Seconded students are also given a position as a trained nurse on completion of their training. As part of the developmental pathway for HCSWs, they are offered a study skills module before commencing nurse training to prepare them for university studies. This was developed after discussions with student nurses who had accessed nurse training through the NVQ route. They found the transitional stage from NVQ Care level 3 to university difficult. This prompted the authors to address the academic gap. The module has been developed in collaboration with Coventry University. It comprises two study days and includes topics such as critical appraisal skills, presentation skills, writing and formatting essays and referencing. Healthcare support workers as NVQ assessors One of the difficulties in delivering competencybased training and NVQs for HCSWs is the provision of assessors. Traditionally, registered nurses have been expected to fulfil this role, but pressure of work meant that they were having difficulty in finding the time to act as assessors. It was apparent from discussion with HCSWs that much of their support in practice came from successful NVQ Care candidates who had experienced the process first hand. This suggested that there was the potential for HCSWs to train as NVQ Care assessors. Before further steps could be taken, approval from senior management needed to be obtained. This reduced the potential risks associated with devolving responsibility for assessment of competency in the skills required to deliver fundamental care from registered nurses to unqualified staff. The key issues related to gaining assurances that assessors would be clinically competent, competent in the assessment process and receive supervision from a registered nurse, and that the process would be evaluated. It was agreed that the role of the HCSW as NVQ assessor would be developed. The role of peripatetic assessor has evolved from here. Criteria were developed for the peripatetic role (Table 1). Initially six HCSWs undertook the Assessor Award and began actively assessing NVQ Care candidates in their workplace. However, although keen, the assessors experienced the same difficulty as registered nurses in finding the time to undertake the assessment element of their role. Because of the constraints experienced by wardbased assessors, support was given by senior management to implement peripatetic assessors and the authors took this opportunity to pilot HCSWs in peripatetic positions. Following interview and a selection process, three HCSWs who met the criteria (Table 1), and possessed experience in a senior position in clinical practice, were appointed. The results of piloting HCSWs as NVQ Care assessors have led to a dramatic increase in the number of candidates completing the NVQ Care Awards. Before implementation of this role, 12 candidates Box 1. Content of pre-nvq study skills day Introductions, course outline and individual expectations from the day Self-awareness and values activity Time management, individual activity and group discussion Setting personal objectives Support systems using the library Preferred learning style Learning cycle Introduction to reflective practice activity Introducing NVQs and evaluation july 7/vol18/no43/2004 nursing standard 35
completed the NVQ Care Award each year. This figure has now risen to 45 annually. These HCSWs have proved that peripatetic assessors are effective in clinical practice and that HCSW NVQ assessors have the ability, experience, knowledge and understanding of the NVQ process to perform the role adequately. They have become an effective and much-valued resource within the trust. Quality assurance As an NVQ centre, it is paramount that quality assurance processes are followed to ensure continued maintenance of the highest standards. Within the NVQ framework, an internal verifier ensures that internal quality processes and systems are in place. The internal verifier ensures that the NVQ Box 2. Learning contract issued to candidates on the NVQ Care programme It is a requirement at the start of training or on accepting candidates for training that all concerned with their training read and sign this agreement Under the terms of this contract the candidate will: Attend the study days as directed by the Training and Development Department on the required dates. Candidates reporting sick must inform the ward and the Training and Development Department. All absence from study days will be recorded and placed in the candidate s training file, and copies are sent to the internal verifiers and the ward or department manager. Please note, any study day not attended without notification will be taken off the NVQ programme Be responsible for his or her own portfolios, including assessment and unit documentation. To enable candidates to receive appropriate and current advice, candidates are required to produce their portfolios at every study day to the internal verifiers on request. External verifiers will require candidates portfolios for final verification, and as a requirement of the awarding body can make one request to see a portfolio, once completed, up to three years from completion Not plagiarise or misuse another person s evidence as this may result in the termination of his or her NVQ by the Training and Development Department Not falsify his or her portfolio of evidence, as this will result in the termination of the NVQ by the Training and Development Department In the case of being suspended from duty, be discontinued from the programme by the approved centre Be expected to conduct himself or herself in an appropriate manner at all times and be expected to abide by the appropriate nursing policies, guidelines and personnel Be made aware that the Training and Development Department will not tolerate any verbal or aggressive behaviour towards staff or those appointed to act in the assessment process Have a named assessor, before commencement of the NVQ programme, identified in the area of employment who has agreed to support him or her throughout the NVQ Care Award Take responsibility for his or her own assessments and documentation Expect to be directly observed by the assessor for a timely period to ensure that competence for performance criteria and range has been comprehensively met Report any difficulty in obtaining access to assessment, or if not satisfied with any aspect of the assessment process, should, in the first instance, try to resolve it at ward level via the assessor concerned. If the difficulty persists, candidates should contact the Training and Development Department. (They will be made aware of the appeals process and can resort to this procedure in the event that agreement cannot be reached at ward level) Comply with the above and if not will be deemed to have breached the terms of this agreement. As a result, the Training and Development Department, in negotiation with the ward or department manager, may discontinue his or her training I have read and understand the NVQ process, relative policies and guidelines Training and Development staff member s name... Signature... Candidate s name... Signature... 36 nursing standard july 7/vol18/no43/2004
Table 1. Criteria for the role of peripatetic NVQ Care assessor Factors Essential Desirable How identified Qualifications and NVQ Care level 3 Certificate and interview training D32/D33 or near completion of Vocational Assessors Award Experience Minimum of two years working in the Two years experience At interview plus references care environment and is vocationally in a level 3 support competent worker role Special skills, Able to prioritise own workload to Has supported At interview knowledge and meet deadlines candidates in the work experience Demonstrates knowledge of NVQ environment framework Personal qualities Reliable, with good attendance Has supported At interview plus references Approachable candidates with special Patient assessment needs Willing to be flexible to support candidates Understands importance of confidentiality Understands equal opportunities and special assessment needs Interest and motivation Able to motivate self and candidates At interview to do the job Demonstrates listening skills Other job requirements At interview centre is fulfilling the awarding body requirements with regard to quality audits and documentation. In addition, centres are graded by an external verifier from the awarding body (who visits every six months) as part of external quality monitoring and audit. The gradings are from A (top grade) to E, with two grades at each level. The University Hospitals Coventry and Warwickshire NHS Trust has been awarded A star status by the awarding body for its NVQ Care. Conclusion Historically, the role of the HCSW has not been developed through training, and the HCSW s contribution has not always been recognised. Implementing a structured approach to the training and development of HCSWs ensures gradual development in both theory and practice. It also enables HCSWs to plan their professional development and identify a career pathway. The University Hospitals Coventry and Warwickshire NHS Trust has developed Box 3. Criteria for accessing NVQ Care level 3 Support workers who meet one of the following criteria: Are in a senior support worker role or applying for a senior support worker position Are selected to train as a vocational assessor Wish to apply for a secondment or bursary to commence nurse training Exceptions apply to specialist areas, for example, renal, critical care and endoscopy and implemented a training structure that has enabled, and continues to enable, HCSWs to develop personally and professionally REFERENCES Care Sector Consortium (1997) National Occupational Standards for Professional Activity in Health Promotion and Care. London, Local Government Management Board. Department of Health (2003) Essence of Care: Patient-focused Benchmarks for Clinical Governance. London, The Stationery Office. Department of Health (2001) Essence of Care (Toolkit): Patient-focused Benchmarking for Healthcare Practitioners. London, The Stationery Office. Dingwall R et al (1988) An Introduction to the Social History of Nursing. London, Routledge. Edwards M (1997) The nurses aide: past and future necessity. Journal of Advanced Nursing. 26, 2, 237-245. Marick M (2000) Give support workers a chance for better training. Nursing Standard. 4, 25, 29. Nazarko L (1999) Delegation dilemmas. Nursing Standard. 14, 13-15, 59. Nursing and Midwifery Council (2002) Code of Professional Conduct. London, NMC. july 7/vol18/no43/2004 nursing standard 37