Unregulated dogsbodies or essential members of the clinical team – either way, health care assistants are increasingly having a stronger presence in our hospital wards. FIONA CASSIE provides a beginner’s guide to HCAs and shares some nurse leaders’ thoughts – positive and negative – on the role and some recent HCA training innovations.

An unregulated, low-cost workforce potentially putting patient safety at risk? Or an essential and inevitable addition to the health workforce that frees up valuable nurse time?

Whichever way you view them, health care assistants (HCAs) – in their many forms and titles – are a growing sector of the health workforce and are likely to keep doing so as nursing shortages loom ominously in the future.

While there was much debate amongst the nursing profession over rebuilding an enrolled nurse workforce, there has been much less debate about setting standards and training for the growing role that health care assistants play in acute patient care.

In the last four or so years, more than 500 enrolled nurse graduates have emerged from the 18-month, Level 5 diploma but many have struggled to find nursing work – particularly in the public hospital sector.

Meanwhile, the 20 district health boards in the past six years have taken on an additional 920 HCAs and hospital aides across a wide variety of DHB settings, with training levels of most of those HCAs a great unknown.

New Zealand Nurses Organisation researcher Dr Jill Clendon says she worries about the lack of accountability for an unregulated HCA workforce. The greatly varying training and qualification standards for HCAs makes it “really, really difficult for a nurse to trust an HCA unless they know them really, really well.”

“I’m not saying we shouldn’t go down that route in terms of HCAs and practice assistants, but I think we need to be very cautious,” says Clendon, who has been working on a major project looking at future models of nursing care.

“I say that because if you look at the UK experience, they disestablished their ENS and totally went to an HCA model, and now they are talking about regulating HCAs because the risks to patients were so great.”

Professor Jenny Carryer, executive director of the College of Nurses, acknowledges nurses don’t always know what to expect of an HCA on their ward.

“In the rush and craziness of the average ward, you don’t tend to have time to sit down and say have you done six-week training, three-month training, or no training at all,” says Carryer. “Or have you been there 10 years or 10 minutes.”

“My argument has always been that we should have nationally agreed employment standards for HCAs and nationally standardised training and not to employ HCAs until they’ve been trained. Then you deal with the confusion and any uncertainty (over what tasks you can or cannot delegate to them).”

Carryer is not only in favour of HCAs being able to ease the workload of nurses on the ward but also of practice nurses.

“Any RN in general practice who feels threatened by the employment of a practice assistant is probably not being fully utilised as a registered nurse,” believes Carryer.

Clendon questions setting up a new practice assistant training programme (some of it at Level Five) when graduating enrolled nurses can’t get jobs.

“Why is it that we’re not using a resource we already have? The great thing about ENs is that we know what skills and knowledge they hold and therefore we know what tasks and responsibilities they can take.”

Carryer has never been in favour of an enrolled nurse workforce and believes any advantage of being able to delegate tasks to a regulated enrolled nurse rather than an unregulated HCA is countered by the potential for employers to blur boundaries between the registered and enrolled nurse scopes.

Meanwhile, Robyn Hewlett, chair of NZNO’s enrolled nurse section, is frustrated to see new graduate ENs unemployed while unregulated HCAs are employed to do tasks that some DHBs won’t even allow qualified enrolled nurses to do.

“My firm belief is that nursing is being devalued if HCAs are increasingly employed to replace the regulated nursing workforce,” says Hewlett.

She also believes a better answer to projected nursing shortages is for every EN and RN nursing graduate to have a nursing job rather HCAs taking on duties that used to be the domain of the regulated nursing workforce.

“New Zealand could end up like the UK, where HCAs are doing the patient care and also taking on other tasks such as cannulation, bloods, etc. and the RNs are doing the paperwork,” says Hewlett.

“Eventually, the powers that be are going to say ‘well, we don’t need regulated nurses as HCAs are doing the work of the nurse’.”

She believes a team nursing model of RNs and ENs is not being explored enough or enough research being undertaken into what ENs can contribute to patient care and outcomes.

The Nursing Council is “very mindful” of the whole area of unregulated health workers, says chief executive Carolyn Reed.

“Council has on numerous occasions touched on it but quickly realised it’s not within their brief under the current legislation.”

She personally believes, like Carryer, that there needs to some form of standardisation of training and skills for HCA. She also believes that regulation is not required but would like to see considered a code of conduct for HCAs and a system for managing those who breach that code.

Maybe it is time for the benefit of all parties – the HCA, nurse, and their patients – that clear, national parameters about training, qualifications and accountability of HCAs (and delegating RNs) are given serious consideration to show patient safety is always foremost in everybody’s mind?