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"Role drift"
“Role drift” to unlicensed assistants: risks to quality and safety
  1. H P McKenna
  1. Correspondence to:
 Professor H P McKenna
 Faculty of Life and Health Sciences, School of Health Sciences Nursing, School of Health Sciences, University of Ulster, Jordanstown BT37 0QB, UK;

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Health care assistants are increasingly filling the gaps in patient care

Earlier this week I went to my local health centre for a routine blood test. I noticed that the uniformed woman approaching me with the needle drawn had the words “Health Care Assistant” on her badge. This is the first time I have had a sample of blood taken by a person who had no formally recognised training and whose role was unlicensed, unregulated and unsupervised. I proffered my arm—not without a little trepidation. The experience led me to wonder how many other health care assistants were practising in the health service, how many other invasive and non-invasive duties were they routinely undertaking, and how many members of the public were unaware that they were receiving care and treatment from such personnel. The answers to these questions raise further questions concerning quality and safety.

Modern health care is complex and hospitalised patients are often in the acute stage of their illness. Patient throughput has increased and new treatments and technologies have brought with them their own hazards. This is also true within the community where nurses are undertaking home based interventions which were recently only practised in the safety of a hi-tech clinical setting. From various countries there is evidence to indicate that better patient processes and outcomes can be achieved by having a high ratio of registered nurses in the clinical setting.1,2 More recently there have been reports that patient safety is positively linked to the presence of registered nurses.3 Contemporaneously, the literature is replete with percentage estimates of the amount of time nurses spend on low level basic tasks. It is believed that increasing the number of health care assistants would free nurses up to spend more time in direct patient care with the concomitant improvements in quality and safety. It is ironic therefore that, due to inducting, training and supervising the increasing number of health care assistants, the role that has been introduced to free up nursing time is actually consuming nursing time.

The junior doctors’ hours initiative and the European Working Time Directive mean that nurses are being asked to take on roles that were once the remit of doctors. Wanless4 also recognised that workload might be shifted from doctors to nurses, and from nurses to health care assistants. This “role drift” is not new and not unique to nursing; allied health professionals, pharmacists and dentists are delegating what were previous core duties to assistants or technicians. Unfortunately “role drift” often occurs in an ad hoc fashion and may exceed its original scope.

Health care assistants undertake a number of duties previously carried out by nurses. A sample from a very long list includes catheter care, wound dressing, venepuncture, formulating patient care plans, setting up and monitoring diagnostic machines, setting up infusion feeds, giving injections, taking charge of shifts, monitoring use of cardiotocograph machines, providing advice on parenting skills and breast feeding. According to the literature, much of this work is unsupervised. Because of their increasing numbers (estimated to be over half a million in the UK), and hence visibility in the clinical setting, health care assistants are also involved more in student learning.

Despite the fact that they are at the front line in providing care, there is no statutory duty for health care assistants to have any training. Invariably, such training is considered to be the responsibility of their employing organisation and this has led to informal and non-standardised training programmes. While national vocational qualifications (NVQs) were introduced in the UK in an attempt to standardise the training of health care assistants, their introduction has not been widespread. This means that their role often varies depending upon the country and the clinical area in which the person is employed. This lack of standardisation of their role is a potential threat to safety and quality.

Attempts have been made to develop skills, experience, and career ladders for health care assistants. While such recognition is laudable, it is still the case that many remain unlicensed and unregulated. There is no system in place whereby a health care assistant’s criminal record or level of competence can be checked. There have been some well publicised cases where patients have been subjected to abuse at the hands of health care assistants who were dismissed from their work and started employment in another setting shortly afterwards. Unlike most health professionals, there are no mechanisms in place to alert the new employer to past offences. There have also been reports that some nurses were removed from the nursing register and began working as health care assistants, particularly in the nursing home sector.

There are proposals for extending regulation to those staff who have a direct impact on patients. Meanwhile, within this climate of regulation uncertainty, many nurses depend vicariously on health care assistants to deliver unsupervised direct patient care without being certain of the safety or quality of such care. According to their Code of Professional Conduct, nurses should not delegate duties to health care assistants if they are concerned that the care undertaken will not be up to the standard expected by a nurse who would normally undertake the task. However, it is impossible to ensure delegation is appropriate if roles are not clearly defined and training is ad hoc. If nurses are under pressure, they may allow health care assistants to carry out unsupervised tasks they would not otherwise consider, which could result in patients being put at risk.

In a climate of a global shortage of registered nurses and demands for them to embrace a “role drift” to medical duties, there is an increasing reliance on health care assistants to fill the gaps in care. The majority of health care assistants are caring and conscientious individuals who are often pressurised to go beyond their level of competence to perform duties for which they are not qualified—potentially endangering patients. The health care assistants themselves are powerless, waiting on policymakers to sort out the mess while they do their best in an unenviable situation.

Health care assistants are increasingly filling the gaps in patient care


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