Developing a high-performance support workforce in acute care: innovation, evaluation and engagement

Focus and debates

This new public policy backdrop added particular significance and urgency to the present study. It encouraged a continuation of attempts to strengthen the evidence base on the nature and consequences of nurse support roles, and more particularly to focus on key issues highlighted in the earlier Oxford and York studies. 1,5 More specifically, this follow-up project centred on three related but distinct themes associated with the use and management of HCAs, each theme, in turn, concentrating on the pursuit of a particular objective:

• innovation: to identify and facilitate the development of innovative and sustainable management and working practice as it relates to support worker roles in an acute health-care setting

• evaluation: to evaluate various acute trust policies and practices designed to improve the efficiency and effectiveness of stakeholder interaction with support worker roles

• engagement: to secure the engagement of various stakeholders in sharing knowledge, practice and learning on support worker roles.

Clearly, these themes cover a defuse range of issues, precluding the development of a strong central narrative and reducing our capacity to draw upon a single, unifying theoretical or analytical framework. This diffusion of interest might be related to the ‘follow-on’ status of the project. Building on previous, more tightly focused research, the current study was, in a sense, ‘mopping up’ and digging deeper into often loosely connected aspects of health-care support worker roles and their consequences. The central themes – innovation, evaluation and engagement – were an important organising device, but they were typically dealing with different sorts of issues: respectively, the incidence and development of new practices, the outcome of initiatives and the sharing of ideas and approaches. The current study, therefore, remains somewhat fragmented and might, by analogy, in part be viewed as a collection of self-contained ‘short stories’ rather than an integrated ‘novel’.

This is not, however, to detract from important cross-cutting issues and shared lessons emerging from the project or from our capacity to link the study to broader theoretical debates. The project’s predominant theme related to workforce change in the NHS, and in particular the challenges and difficulties faced in bringing about and sustaining such change. This was self-evidently the case in considering innovation, with its focus on the introduction of new ways of using and managing nurse support workers. Indeed, while centring on outcomes, the evaluation theme was still exploring initiatives which changed approaches to health-care delivery, particularly in terms of the new contribution made by the support worker. Moreover, although our engagement theme sought to encourage the sharing of views, and practices, this sharing principally related to changes in approaches to the use and management of nurse support workers.

A focus on workforce change, concentrating on the use and management of nurse support workers, encouraged a connection between the current study and a number of closely related theoretical debates. The first such debate related to organisational architecture, and, more specifically, to those organisational features that might facilitate or inhibit workforce change. An extensive literature provides a variety of organisational change models,37,38 rooted in differing assumptions about the drivers, nature and outcome of change. In crude terms, a distinction is often made between rational, often top-down, strategic change and normative, typically bottom-up, incremental or organic change, with very different prescriptive implications. Taking an inductive approach, the current study did not adopt a particular model of change. It was, however, sensitive to these different models and sought to explore which more usefully characterised and explained change in the management and use of nurse support workers.

The second debate linked to the literature on interoccupational relations,27,28 and, more particularly, role boundaries and jurisdictions, which, as noted, had previously devoted only limited attention to the positioning of the nurse support role. An acknowledgement that job territories are often contested, especially by occupations seeking to professionalise, encouraged an interest in how the development of the nurse support role was viewed by adjacent groups, most obviously RNs: whether changes to the nature of the nurse support role and its contribution to health care were welcomed or resisted.

The third and closely related debate touched on by the project was associated with the institutionalisation of new ways of using and managing nurse support workers. For (neo) institutional theorists, change had traditionally been problematic and not easily accommodated; after all, institutions are viewed by such theorists as enduring and constraining. 39 More recently, however, there has been a growing emphasis within this literature on agency, reflected in the figure of the institutional entrepreneur (IE),40 well placed and motivated to pursue institutional change, and the notion of institutional work, routine activity designed to ‘create, maintain and disrupt’ institutions. 41 This interest in institutional change at the workplace has increasingly been used by institutional theorists to examine the emergence of new work roles and practices, not least in health care,42–44 but again with little inclination to embrace the development of the nurse support role. The current project provided an opportunity to explore whether or not and how new ways of using and managing nurse support workers had become legitimised and taken for granted: in other words, institutionalised.

Approach

The research on the three themes – innovation, evaluation and engagement – was overseen by an advisory group comprising national and regional employer and employee representatives, plus academics with an expertise and interest in the nursing workforce (see Appendix 1 for list of members) and key actors from the project’s case study trusts (see Chapter 3, Focus and methods and Chapter 4, Introduction). Patient representatives were also members of the advisory group (see Appendix 2 for a more detailed statement on patient/public involvement in the project). The advisory group was a virtual network for the duration of the study. It was kept informed of project developments as well as being asked to comment on draft research instruments and papers. It was also sent research findings as they emerged. The group met once, on 19 April 2012, halfway through the project, with 20 members and senior case study representatives attending. This meeting reviewed and discussed available findings from the project and commented on the plans for future work.

The project also maintained a dedicated and openly available website for the posting of project documents and findings. 45 The material on this site complemented that produced by the previous Oxford and York studies,1,5 coming to constitute a significant and accessible repository for research data on nurse support workers. Indeed, indicative of the value of this site, there have been almost 3000 visits (according to Google Analytics website data) since the project began in 2011, with recent monthly averages of almost 50 hits per month from search engines, implying that the traffic is not simply generated from our own project mailings.

The NIHR-approved research protocol was granted full NHS ethical approval (11/LO/0770). Trust research and development approval was successfully sought prior to carrying out the fieldwork in all innovation case (IC) studies and evaluation case (EC) studies. The project fulfilled all university requirements for the ethical conduct of research.

The main body of the report is structured around the three main themes: Chapters 2 and 3 focus on the innovation theme, the former considering the scoping and survey work on this theme and the latter on the related case study work; Chapter 4 concentrates on the evaluation theme; and Chapter 5 examines the engagement theme. In each of these chapters, we present the context for the work undertaken, the methods used and the findings. A final chapter provides an overview and discussion.

Focus and methods

The scoping phase, conducted during the summer and autumn of 2011, aimed at developing an appreciation of the range and nature of innovative practices emerging within trusts across England. The findings from this phase were valuable in their own right, identifying practices, examples and debates on the management and use of nurse support workers. However, they were also used to inform the design of the national survey (see National survey, below). It was crucial to build a picture of the types of innovative practices being considered and implemented by trusts as a means of exploring their take-up and use in a more structured and systematic way through a survey. Moreover, without prejudging the outcome of the survey, these scoping meetings were used to explore the possibility of case study and evaluation work with trusts.

Conducted during 2011, the scoping phase comprised face-to-face interviews and meetings with key actors at different levels of the NHS – national, regional and local. A total of 116 actors were covered during this phase including:

• national employee (RCN and UNISON) and employer representatives (NHS Employers)

• regional workforce leads (in the east of England, the south-west, the north-west, Yorkshire and Humberside, London, Scotland and Wales)

• directors and assistant directors of nursing, HR directors, education leads and practice development nurses (PDNs) from trusts

• representatives from a miscellaneous range of organisations including higher education institutions (HEIs) and the Nursing and Midwifery Council (NMC).

This total included 12 one-to-one interviews; eight meetings involving two to three participants; four meetings covering five to six participants; and two more significant events involving trust support worker education leads in different regions of the country, one covering 15 and the other covering 35 participants. As a scoping or exploratory phase, these interviews and meetings were conducted in a flexible way, using open questions encouraging participants to highlight examples of innovative practice in the use and management of nurse support workers, why and how such practices were introduced and with what perceived impact on various outcomes. In the main, full notes were taken of the interviews and meetings. These examples were then classified and coded according to the three dimensions of innovation highlighted earlier to reveal the incidence and patterns of such innovation. Participants were also asked to raise more general issues: prevailing practice, emerging developments, and areas of debate or contention. The responses to these issues were processed to establish patterns and trends. For example, the prevailing practices and emergent trends raised by the respondents were again coded against our three forms of innovation. Similarly, areas of debate or contention were coded according to the substantive issue at stake to distinguish a spectrum of concerns.

Findings

Figure 1 sets out innovative practice as it relates to the use and management of support workers along the three dimensions distinguished: new ways of working, new roles and new management practices. It is clear that most of the innovation has taken place along the new management dimension. Thus, there have been instances of trusts drafting their own codes of conduct for HCAs, establishing clearer career pathways for their HCAs, and creating champions for the role and dedicated corporate educators. Most striking, however, is the concentration of new management practice associated with the recruitment of HCAs and preparation for performing the role. In the absence of minimum entry requirements and with trusts recruiting from low-paid, low-status jobs from across the labour market,1 these new practices suggested that trusts have been seeking to develop and ensure the capabilities of starter HCAs.

FIGURE 1.

Innovative practice.

New recruitment practices have included the strengthening of entry requirements. In some cases this has been by stipulating a requisite qualification, typically National Vocational Qualification (NVQ) level 2, and in others it has been by recruiting straight on to an apprenticeship scheme. The new practices have also been apparent in numeracy and literacy tests, designed to filter out applicants deficient in these basic capabilities. Perhaps the most novel development relates to the use of values-based recruitment, which moves selection beyond capability to focus on the attitudes and beliefs of applicants: whether or not these are appropriate for care work and aligned with those of the trust. Finally, the introduction of extended induction programmes arguably reflects attempts to better prepare individuals for the HCA role, particularly before they join the ward team and begin delivering direct patient care.

The scoping phase revealed far fewer examples of new roles or ways of working, perhaps a reflection of the clinical governance issues generated by such change. New ways of working were highlighted, in particular the extension of AP roles to take on drugs administration and the greater use of maternity care support workers to perform more direct care duties. New specialist roles were being developed in clinical areas – theatres, emergency departments, endoscopy and dermatology – typically graded at pay band 4. However, changes involving the performance of new tasks, whether within an existing or in a new role, often had important implications for clinical practice, requiring revisions to trust policy and mechanisms to ensure patient safety and minimise risk. Dealing with such issues could be time-consuming, procedurally complex and sometimes contentious.

These difficulties informed broader debates among NHS policy-makers and practitioners on the management and use of nurse support roles in acute care settings. These debates were indicative of differences in approach to these roles and signalled continuing uncertainty as to how to deploy and deal with them. The debates often revolved around dilemmas or competing views along five dimensions, set out and discussed below:

1. Careers ←→ Costs

   1. Developing career pathways for nurse support workers provided new opportunities, seen as a way of retaining this valued part of the workforce. However, career progression also incurred pay bill costs as employees were upgraded, not easily met in times of financial pressure.

2. Sweating ←→ Elevating

   1. New roles and ways of working could be developed at pay band 4, but an alternative, perhaps cheaper and less difficult option was to ‘sweat’ those in band 2, in other words find ways of generating more work and effort from those in the lower band. This dilemma was deepened by the fact that trusts were sometimes uncertain about the tasks performed by their band 2s, particularly relative to those undertaken by band 3 HCAs. Such uncertainty was encouraging particular trusts to clarify and ‘sort out’ the tasks respectively undertaken by band 2 and 3 HCAs before considering the development of new roles at band 4.

3. Trained ←→ Registered

   1. Traditionally, skill-mix ratios are based upon a distinction between unregistered and registered nursing staff. However, as AP training has developed and intensified, this distinction has become increasingly problematic, especially where trusts have been seeking to replace a band 5 RN with an AP. If APs continue to be counted as unregistered, their increased use inevitably dilutes skill mix and in so doing raises trust concerns about how such dilution might be perceived.

4. Assistant practitioners ←→ Registered nurses

   1. Partly related, there is a debate on the relative worth of using band 4 APs or band 5 RNs. Some trusts question the value for the money of the former: the cost difference between the two is not great, and nurses as registered professionals are seen as a more cost-effective option.

5. ‘Growing your own’ ←→ In-role development

   1. The development of career pathways allows trusts to ‘grow their own’ nurses, but this might well be in tension with a trust’s interest in retaining those experienced staff in nurse support roles who might otherwise seek to move into RN roles. Nurse training takes support workers away from the trust, depleting workforce experience and stability.

Focus and methods

Findings from the scoping phase provided the basis for a more structured and systematic mapping of innovative practice in the management and use of nurse support workers by surveying directors of nursing and human resources (HR) in English acute trusts. A draft of the survey was developed and refined in response both to comments from the study’s advisory panel and to a pilot conducted among a national network for support worker co-ordinators.

The mapping of innovative practice comprised a number of elements, reflected in the final survey design. The first provided an overview of employment trends, with the aim of highlighting changes in the structure of the nursing workforce over the last 2 years. To this end, respondents were asked whether they had ‘increased’ or ‘decreased’ (or ‘not changed’) nursing staff at each of the pay bands from 2 to 6 inclusive. The second element centred on those factors driving trusts to innovate in the use and management of nurse support workers. The survey included a range of possible drivers such as efficiency gains and service delivery pressures, asking whether or not these had been influential, as well as directing respondents to specify ‘the most’ influential driver. The third element focused on organisational infrastructure. It had become clear during scoping that workforce innovation depended on the development of a supportive infrastructure: systems to facilitate, nurture and sustain innovation. Respondents were asked whether or not systems that constituted such an infrastructure were in place (‘yes’ or ‘no’); for example, a HCA champion at trust level or a HCA working group.

The centrepiece of the survey was three dimensions of innovation: management, new roles and new ways of working. Selectively drawing upon some of the innovations highlighted during the scoping phase, respondents were asked whether or not they had introduced a given number of such practices along each of these dimensions (‘yes’ or ‘no’), and, indeed, whether they had been introduced in ‘most’ or only ‘part of the trust’. Respondents were provided with an opportunity at the end of the questionnaire to provide additional comments on any of the issues covered in the survey (see Appendix 4 for questionnaire).

The survey was conducted online and invitations to participate were sent to the directors of nursing and of HR at all acute trusts in England during November 2011. To ensure that as many trusts as possible were covered, the final reminder sent in December asked those who had yet to complete the survey to forward it to the most appropriate person in their organisation. The survey was closed in January 2012 and the response details are available in Table 1. In total, 94 trusts took part in the survey, representing a response rate of 57%. The respondent in 90% of the trusts was the most senior nursing or HR director. This represents a very good response rate for a voluntary and independent survey among senior managers in the NHS. The original decision to cover both directors from any given trust was driven by an appreciation that the respective directorates were likely to be involved in innovations related to the nursing workforce. It was also informed by an interest in whether or not the views of the respective functional professionals on nurse support roles were aligned. It was disappointing that the response rate among HR directors was considerably lower than that among nursing directors, despite the promotion of the survey by the Healthcare People Management Association (HPMA). This limited the intended comparison of views between the two groups, although there were glimpses of how perspectives on the nurse support role might vary by function (see Miscellaneous, below).

Using data from the Department of Health, Monitor and the Audit Commission non-response analysis was carried out to ascertain if there was any bias in the type of trust that chose to respond to the survey. The analysis revealed that there was no significant difference between those trusts that responded and those that did not on background variables such as foundation trust status, regional location, trust type, nursing workforce size or financial well-being. We can, therefore, be confident that the results of the survey are likely to be representative of the wider population of English NHS acute trusts.

The survey findings are presented under the following headings:

• the workforce trends for pay bands 2 to 6 during the last 2 years

• common drivers of nurse support worker development

• managerial infrastructure for nurse support workers

• innovative practices to manage nurse support workers

• innovative nurse support worker roles or ways of working

• miscellaneous.

Where respondents provided comments on particular questions, they are referred to in the appropriate section.

Findings

Context

This case study deals with a new values-based approach to the recruitment and retention of HCAs introduced by York Teaching Hospital NHS Foundation Trust in 2010. The innovative character of this initiative was reflected in the fact that it had won the 2011 HPMA award for innovation in HR and a similar Health Service Journal (HSJ) award in 2012. The trust’s interest in such an approach was underpinned by two broad considerations. The first related to a high turnover among its 500-or-so HCAs, particularly in the first 6 months of employment, which the trust found to be associated with recruits not being fully aware of the nature of the HCA job:

So many people just came and didn’t have a clue really what they were going to be doing . . . They come and think, ‘oh I thought I was only making tea’. And you think, ‘gosh no, there’s a whole host of things, and tea isn’t one of them’.

IC1_ward staff_1

The second consideration was values based, and reflected York’s interest in aligning its values, revolving around ‘caring and ‘compassion’, with those of new HCAs:

We wanted to be able create the opportunity for the individual to demonstrate their caring disposition.

IC1_trust manager_1

The new recruitment model

York’s new approach to HCA recruitment comprised a number of elements:

• A new band 2 HCA job description placed emphasis on personal disposition rather than formal qualification. The person specification was modified to reduce the need for ‘relevant work experience’ and the need for a NVQ level 2 qualification. There was a sharper focus on an understanding of the HCA role and an ability to demonstrate a caring orientation.

• A new application process sought to address the high turnover of HCAs, stemming from the failure of candidates to fully appreciate the HCA role. The centrepiece of the change was a mandatory open day: ‘On the open day, they come and talk to other healthcare assistants, and they get a view of what the job actually entails. They can look around at the stands, and it’s a really good push into what the role is’ (IC1_trust manager_2). Only those attending were provided with a unique identification number which allowed them access to the application form. As a means of providing more detailed information about the role, the trust also produced a 10-minute film made available on DVD and online, involving HCAs talking about their role.

• A new selection process sought to ensure a better fit between applicant and clinical area, with shortlisted candidates having the opportunity to list their order of preferred wards. Moreover, the old standard list of interview questions was replaced by an open, scenarios approach, better able to assess whether or not candidates had a caring disposition.

• A new 2-week HCA induction programme was introduced, with new recruits only taking up their post on the ward on its completion. Replacing an often deferred corporate induction of a couple of days, the new programme ensured that HCAs were better prepared for their role, and so more able to deliver compassionate care and become more appreciative of what the role involved before ‘hitting the ward’.

Key processes and actors

The emergence of York’s new recruitment model rested on a number of processes and actors.

Impact

There were some organisational concerns raised about the introduction of values-based recruitment at York. For example, it was suggested that setting up the model was time consuming:

. . . probably just the time to set it up. Because there was a lot of work in, you know, producing the DVD, getting people to come and feel confident enough as a HCA to stand up and talk to a room of what can be a 100 people.

IC1_trust manager_4

More generally, however, responses to the new model were positive, with a number of benefits being highlighted.

Overview

Figure 2 provides an overview of York’s new approach to HCA recruitment. It can be seen that the initiative was embedded in two closely related but analytically distinct streams of development based on retention and on values, which fed into the design of the new recruitment model in various ways.

FIGURE 2.

Tracking the initiative.

Context

This case study explored the development of the AP role at South Devon Healthcare NHS Foundation Trust (henceforth referred to as Torbay). The AP role was first introduced at Torbay in 2006 and, with the foundation degree (FD) taking 2 years to complete, the first cohort of APs qualified in 2008. Two further cohorts have since completed their training. With three cohorts active, in the summer of 2012 there were around 30 APs in the trust, with another 14 trainees in either the first or the second year of their FD. The emergence of the AP role at Torbay some 7 or 8 years ago placed the trust at the vanguard of developments in the south-west.

This leading position was indicative of an organisational culture, which, in a more general sense, displayed a capacity to innovate. Torbay had won the HSJ Acute Healthcare Organisation of the Year Award in November 2011, with the judges commenting that ‘the trust works as a team in an integrated way to deliver best outcomes and innovations in care with high levels of clinical engagement’.

Inevitably, questions arise as to how Torbay was able to develop such an innovative culture, with suggestions that the trust’s structure played a part. As a medium-sized district general hospital, with its acute services located on a single site, Torbay was a relatively compact organisation. The workforce was relatively stable, with low turnover. These characteristics fostered an open and friendly organisational culture, encouraging the kind of direct personal interaction needed to raise, share and develop new ideas.

The culture and working environment provided the backdrop to, and fostered, Torbay’s lead role in developing APs. Initially, this lead role assumed a somewhat opportunistic form. There was money available from the Strategic Health Authority (SHA) for a pilot to develop an educational programme to support band 4 APs. In 2006, Torbay worked with a trust in Cornwall on such a programme, with an initial intake of around 20 trainee APs covering community and mental health as well as acute health care. The opportunistic nature of this involvement was further reflected in the absence of clearly articulated objectives underpinning Torbay’s development of the AP role:

It was a gamble. But we made it work and that was the impetus to do more. There were pound signs and, ‘oh we’ve got some money coming in, let’s take it, let’s see if we can do something that would actually benefit the patients’, without really understanding what the [AP] role would be.

IC2_trust manager_1

However, this initial opportunism was quickly transformed into a more strategic approach to the AP role, characterised by a number of features, each discussed below.

Objectives

A variety of aims came to inform Torbay’s interests in the AP role, some formally stated by senior management and others more informally articulated in the organisation.

Design

Torbay’s AP initiative had the following design features:

• trainee assistant practitioners (TAPs) recruited from HCAs within the trust

• a 2-year FD delivered by South Devon College (SDC), but with significant input from Torbay’s education department (ED) and other staff members

• TAPs mainly employed as band 3s

• two study days, although one of these was taken from their own time

• band 4 on qualification

• a preceptorship programme, also involving RNs.

The design of this initiative was based on a ‘virtuous triangle’, set out in Figure 3.

FIGURE 3.

A virtuous triangle at Torbay.

This ‘triangle’ rests on two key relationships. The first was between the trust’s ED and SDC as the provider of the FD taken by the TAPs. This relationship was strengthened by idiosyncratic features, particularly the fact that the key point of contact at SDC had formerly worked at Torbay, and indeed had been involved in the initial AP pilot.

The quality of the Torbay–SDC relationship ensured that the delivered FD was sensitive to the needs of discrete clinical areas:

Working with SDC was a revelation really because they were hungry for doing something that actually would link them in to us, but also it was actually sort of saying we’ve got enough people locally, we’ve got a local workforce, we need to tap in to it.

IC2_trust manager_5

This relationship also allowed Torbay to develop a cross-subsidising funding model. SDC had agreed to expand its AP programme to include self-funders, alongside those on the programme employed by and supported by the trust. These funders needed placements and, in providing them, Torbay generated an income stream which supported its internal candidates.

The second key relationship was between the trust’s ED and clinical areas interested in introducing an AP role. The most important aspect of this relationship was establishing a clear role for the AP. This was ‘hammered out’ in intense discussions between ward managers and the ED. The clinical areas brought to these discussions a full appreciation of clinical requirements, work routines and what a distinctive AP role might be able to bring to care delivery. The ED brought a capacity to clarify issues and sort out any ‘blockages’. For example, with a need to amend trust policy and develop protocols, allowing APs to undertake certain clinical procedures, the ED engaged the pharmacist in the development the AP role:

Over the years pharmacy started to teach on the AP programme, so they’re setting learning standards with me as to what they’re teaching. So they’re knowing the education they’ve given and feeling more comfortable because they know the standard of teaching.

IC2_trust manager_1

Impact

The impact of the AP role at Torbay can be considered from the perspective of different stakeholders, each discussed below.

Background

This case study focuses on the development of a role designed to provide support for the delivery of stoma care at Hillingdon NHS Foundation Trust (henceforth referred to as Hillingdon). Developed under the job title ‘colorectal support worker’, the role was based within a team of specialist coloproctology nurses. This specialist nursing team had four members: a colorectal nurse and a senior colorectal nurse, working alongside the one C-SW, and headed by a nurse consultant. Most of the patients undergoing colorectal surgery at Hillingdon were located on a single ward, although the team were responsible for patients needing stoma care help throughout the hospital.

The specialist nursing team was involved in three broad areas of activity:

• consultant- and nurse-led clinics

• on-ward work, immediately prior to and following the surgery

• community, typically post-operative, outreach work, involving home visits.

Within this set-up, the C-SW was seen as an innovative role, not only within the trust but also across the NHS:

We think it is the only one in the UK, because I haven’t come across any more.

IC3_service manager_1

The C-SW role was designed principally to engage in on-ward work dealing with those patients in need of stoma care. The number of stoma patients in the trust at any given time varied. During the research fieldwork, there were 13 patients in need of stoma care at Hillingdon. Over the year, it was estimated the trust would deal with between 80 and 100 stomas, with the C-SW likely to be involved in most of these cases.

The role had emerged 3 years ago but then developed organically, rather than in response to any clear-cut strategic initiative. More specifically, the role was a response to the confluence of two broad sets of factors: institutional and personal.

Design and implementation

This confluence of institutional need, and the availability of a person with the background and skills to meet it, was appreciated by the nurse consultant leading the team of specialist colorectal nurses, and taken forward by her, with the support of others, through various processes.

Impact

The C-SW role had a largely positive impact on a range of stakeholders. However, a few qualifications are worth noting. First, the C-SW’s capacity to impact in these ways was closely tied to the personal characteristics of the post-holder, someone known and trusted by these various actors. It was, therefore, not a contribution easily replicated by another taking on this role.

Second, there was some resistance to the C-SW role. As an expert, the C-SW might challenge the registered and higher-graded professional:

Registered practitioners maybe feel a bit intimidated because she’s [the C-SW] doing teaching on the ward and obviously teaching patients and seeing patients on her own without that direct supervision and that has caused a bit of a problem.

IC3_trust manager_2

Third, the specialist nature of the C-SW role might encourage ward staff to ‘dump on’ her all those tasks associated with the stoma care, with detrimental consequences for the quality of the C-SW’s working life and perhaps for patient care more widely:

Most ward staff, because there’s a stoma care nurse, it’s not their job to change bags, so some would be happy to leave a patient with a leaking bag until they found a stoma care nurse to come and do it.

IC3_service manager_1

Figure 4 summarises the C-SW’s various contributions.

FIGURE 4.

The C-SW’s contribution to stoma care.

Context

This case study explores the introduction of a dedicated corporate role, the HCA development nurse (HCA-DN), to support the management of HCAs at UCLH. One of the first trusts to acquire foundation status in 2004, UCLH is a large organisation comprising seven hospitals, some specialist and some general, located on different sites in central London and employing around 7000 staff in total.

The emergence of the HCA-DN role reflected an increasing focus on the unregistered component of the trust’s nursing workforce in the delivery of patient care:

The heads of nursing, corporate nursing and the trust itself has a commitment to training and development and to healthcare assistants and to that support. Otherwise we wouldn’t have I suppose the [HCA-DN] post we have.

IC4_trust manager_1

Driven by financial pressures, this focus was integral to an attempt to review the trust’s traditionally rich skill mix. Indeed, there was a growing interest not only in the balance between unregistered and registered staff, but in the distribution between HCAs at band 2 and band 3 in the trust. UCLH had a relatively high proportion of its HCA workforce at band 3: the trust’s 428 HCAs were spilt roughly half and half between band 2s and band 3s.

From a financial perspective they [HCAs] save the trust money and if we can bolster them as much as possible, then it’s fantastic not just for their self-esteem and their educational purposes but also from the trust’s financial perspective, and I think you’re foolish if you don’t utilise them to their fullest potential.

IC4_ward staff_1

The trust’s greater interest in the nurse support workforce was also influenced by perceived challenges to the future supply of RNs with implications for the nature of the nurse role:

We looked at the demographics of the nursing workforce . . . and thought that first of all we might be limited in the numbers of registered nurses and it was thought that the assistant practitioner would be assistants to some of the day to day delivery of care, the sort of routine stuff that didn’t need a more advanced assessment of the patient’s needs.

IC4_trust manager_2

The health-care assistant development nurse role

The HCA-DN post was initially supported by SHA funding. It was filled on secondment by a clinical practice facilitator (CPF) from within the trust (initially for 3 months), who had since remained in the role. In a large and complex organisation, these background characteristics were not without significance: the post-holder understood the trust’s systems and routines and had credibility in the role.

In terms of purpose and focus, the HCA-DN role was principally seen by senior nurse managers as a way of developing training standards on entry to the trust, and supporting the establishment of clearer career pathways for HCAs:

What was very frightening to us when we were first expanding the numbers was that for band 2s these are people who could be working in Woolies one day and here tomorrow. There’s not a lot of training in between and what we wanted to try and do is make sure that at least there were very clear induction standards, very clear development programmes associated with these roles, and hence the development of [the HCA-DN] role.

IC4_trust manager_2

In practice, the role’s remit was broader, covering nurse support workers at bands 2 to 4, and concentrating on a number of aspects of HCA training and development:

• assessing the capabilities (numeracy and literacy) of candidates for HCA posts

• developing and delivering corporate HCA induction

• developing and delivering in-house HCA training

• managing accredited training/education programmes, including the apprenticeships and the FD

• supporting HCA career development

• liaising with and supporting wards in the development of their more bespoke training.

Working with wards to address their particular HCA training and development needs involved the HCA-DN connecting to another key role within the trust, the CPF. Graded at band 6, typically performed by a RN and found in many of the trust’s wards, the CPF’s main purpose, according to the job description, was ‘. . . to support and develop band 5 and band 6 nursing staff and healthcare assistants through facilitation in clinical practice and promotion/implementation of relevant education and development pathways’ [emphasis added]. 50

The training and development of health-care assistants

The HCA-DN role had been responsible for developing a number of initiatives related to HCA training and development. These are set out in Figure 5.

FIGURE 5.

Training and development initiatives.

The role in practice

As a single post-holder working in a large and multi-site organisation, the HCA-DN needed considerable skill in taking these initiatives forward and in establishing wider commitment to them across the trust. A consideration of process issues suggests the importance of three organisational characteristics (Figure 6): institutions, actors and systems.

FIGURE 6.

Elements of process in developing HCA initiatives. N&M, Nursing and Midwifery.

Impact

The HCA-DN’s impact on the training and development of nurse support workers was seen as significant and beneficial. Views on the positive contribution made by the HCA-DN were often provided in an unprompted way, and suggested that the HCA-DN had made a tangible difference to improving these aspects of the HCAs’ working lives and changing the trust’s capacity in these respects:

The trust has put a lot of funds and effort into it recently, certainly the recruitment of [name of HCA-DN] . . . Giving someone of [name of HCA-DN’s] level and experience a whole-time equivalent job to spend putting together training for them, and to be fair pretty much every course that we run for qualified staff, [the HCA-DN] has adapted. So the work [HCA-DN’s name] done has been fantastic. So asking me the question now, I do think we have great learning and development opportunities for unqualified staff.

IC4_ward staff_2

For some, the HCA-DN role had provided trust focus and direction on HCA training and development:

What [HCA-DN’s name] has done is given it a bit more focus. Everybody knows [HCA-DN’s name], she’s done a lot of good work for lots of other projects within the trust and I think that now she’s sort of taken this on-board, it’s got a bit more direction.

IC4_ward staff_1

In the HCA focus group, the name of the HCA-DN was mentioned on no fewer than 18 separate occasions, providing some insight into how HCAs viewed and used the role. Thus, HCAs perceived the role and engaged with it as a channel for raising concerns, accessing opportunities and sorting out problems. Each of these areas is illustrated with a quote below.

[HCA-DN’s name] was one of the persons I said, ‘sorry, I’m not here just to do domestics, I’m here because I want to become a nurse; I give up my degree in biomedical because I want to be a nurse, I don’t want to be a domestic’.

IC4_HCA_focus group

So you have, so you have regular e-mails from [HCA-DN’s name] letting you know about things. There’s the website to check things on. And so there’s the availability of study days, courses that you can do.

IC4_HCA_focus group

I didn’t know what to do because I finished my nursing from [name of country], came here, was not able to work as a nurse because of the English exam. So then I approached [HCA-DN’s name] what to do, then she told me if you’re going to go back to nursing, do this course and then go.

IC4_HCA_focus group

Data on the scale and coverage of many of the in-house initiatives developed by the HCA-DN are presented in Table 11. Some noteworthy achievements stand out from these figures. Most striking, perhaps, is the significant number of HCAs completing the Domino and pressure care programmes. The number of HCAs who had been through the new induction programme, close to 100 over the last 2 years, was also striking.

Background

The development of the SAP role took various turns, emerging in an iterative rather than in a fully formed way. Asked if the nature of the AP role was clear from the outset, the post-holder noted:

No, it’s just evolved really.

IC5_SAP_1

Indeed, despite clinical consultant interest in it, the role initially emerged through discussion between the AP lead in the ED and a specialist nurse in the dermatology department, within the broader context of the trust’s second cohort of APs around 2008–9. These discussions, which also involved the potential AP post-holder, considered service gaps in dermatology that might be filled by an AP role. This encouraged an initial focus on how such a role might contribute to service flows in the outpatient clinic, with the aim of relieving nurses of aspects of work in this area and allowing them to concentrate more on their specialist tasks. All patients were seen in the dermatology department on an outpatient basis, with any surgery being performed as day surgery.

Against the backdrop of these discussions, a person had been selected for the AP support role in dermatology and had begun the FD. However, around 1 year into the degree, the specialist nurse who had originally sponsored the role as a support for the department’s clinics left the trust. At around the same time, the value of a role supporting the department’s day surgery work became apparent, particularly to one of the department’s consultant dermatologists, resulting in a shift in the role’s focus from the general clinics to the operating theatres.

The emergence of a support role centred on the dermatology department’s surgical activities was related to the confluence of two sets of factors: institutional need and personal circumstance. Institutionally, the need for such a role to contribute to surgical work was linked to the nature of the service provided by the dermatology department, and by the performance management regime underpinning it. Physically, and indeed clinically, the department was divided into two main parts. The upstairs section, comprising consultant-led general clinics, dealt with the full range of conditions: ‘. . . leg ulcers, anything to do with your skin, so eczema, psoriasis’ (IC5_specialist nurse_1).

A tumour clinic was also run upstairs, a ‘one-stop’ service which provided those in need of skin surgery with a same-day service. This same-day surgery was provided downstairs in the department’s operating theatres, along with elective surgery. These operating theatres were staffed by a number of clinical consultants – the department had a team of four consultants working on tumours along with two band 6 specialist nurses and the band 4 SAP.

Within the context of this set-up, a SAP role, able to undertake a wide range of tasks, many overlapping with those performed by the specialist nurses, was seen as a means of addressing service capacity and workload pressure. Such a role could undertake and finish off work, freeing up consultants and specialist nurses to see more patients:

With the one-stop service we try and do as much as we can on the same day, and we have so many referrals it’s really hard to keep on top of all the skin cancers that we need to perform surgery on. So having that supportive role, somebody to stitch up a hole while you’re doing the paperwork, it means that we can get through everything so much faster.

IC5_specialist nurse_1

More specifically, such a role provided a greater a range of options in terms of staff deployment, particularly important given variation in and uncertainty about the availability of staff on any given shift:

The way we’ve done that is that we have clinics which are designed to see, screen and recommend treatment for patients at the same time as the theatre is open downstairs, so that they can be seen and treated at a one-stop. The difficulty with that is staffing it really, and so the way we’ve staffed it is by having a consultant downstairs and a consultant upstairs and if one of the consultants is away on holiday, the other consultant comes up and then covers the clinic, and then supervises the nurses and junior doctors downstairs; which is why it’s essential that we have the flexibility we’ve got from the girls [the nursing staff in the operating theatres].

IC5_consultant_1

The personal circumstances contributing to the development of the SAP role were apparent in a potential post-holder with a profile particularly well suited to the role. In part, this profile was characterised by a work history which provided the post-holder with a firm platform to develop in an extended unregistered role. Prior to joining the trust, the post-holder had been involved in nursing work in the military. More significantly, the post-holder had some experience of the trust and the department prior to taking up the SAP role:

I worked with them beforehand anyway and they know that if I was never happy I’d always come and find them, and there is a massive amount of trust involved in this and I think that’s one thing that needs to be stressed, you know, that they have to trust me.

IC5_SAP_1

In fact, the post-holder had taken up a band 2 HCA post around 7 years before commencing the FD. This allowed her to develop an appreciation of the department’s systems, team members and ways of working. Equally significantly, it provided an opportunity for the department’s clinical and nursing staff to get to know her and to build trust in her personality and skills.

The disposition to take on more complex tasks was the final feature of the personal profile underpinning the emergence of the SAP role:

I’ve known [post-holder’s name] for I don’t know, seven or eight years now, it was very obvious early on that she had the competence to do this.

IC5_consultant_1

This approach to identifying development potential in an individual and then building upon it encouraged the view that an evolutionary, ‘grow-your-own’ process was the ‘best’ way to develop an extended support role within the department:

The problem is identifying those HCAs that will have the competence and confidence to be able to do those, it’s much more of a sort of an evolutionary ad hoc thing, it’s very difficult to find the individual right for the job, you know, we have to grow our own almost.

IC5_consultant_1

The development of the role

If institutional need and personal circumstance provided the basis for the role, these drivers still needed to be converted into a process that provided for the development and emergence of the SAP role. As played out in the dermatology department of OUH, a number of features of this process are worth highlighting. The first was the emphasis placed on competence as a means of cutting through formalities and any apparent barriers to change. It was a view summed up by the consultant in noting the range of complex tasks undertaken by the unregistered band 4 SAP:

As long as the competencies are in place to demonstrate ability and safety, then to be honest that’s far more important than a name or a label.

IC5_consultant_1

The second feature of the process was a willingness to push boundaries. Without in any way compromising patient safety, the role was developed to undertake the complex clinical tasks associated with skin surgery, and systems were found to facilitate this extension.

The third feature was the importance of the consultant’s authority and support in giving effect to the changes needed to establish the SAP role:

So long as they know that they’ve got the support of the consultant, then it gives them the confidence to proceed.

IC5_consultant_1

The importance of the consultant’s support was particularly apparent in his engagement with the post-holder; indeed, this consultant–post-holder relationship was pivotal to the development of the role. The relationship provided the basis for a shaping of the role, and more tangibly drawing out the requisite competencies. It was also a supportive relationship, with the consultant acting not only as a mentor but more actively as a trainer, facilitating on-the-job learning for the post-holder:

I do like the surgical side, and because I’ve worked down here with him very closely, he said I’d like to develop you into doing anaesthetics. And because I’d given injections and done a little bit of minor surgery in the RAF [Royal Air Force], he said let’s have a go and see where you develop. So I started off doing a little bit of suturing, then some minor procedures, and then it’s just developed and snowballed from there really.

IC5_SAP_1

The significance of the consultant–post-holder relationship should not, however, detract from the importance of other relationships to the development of the role, in particular that between the trust’s AP lead and the post-holder. The AP lead was another key support for the post-holder, particularly during the FD. More specifically, the AP lead was able to give effect to the consultant’s aspirations for the role by developing appropriate specialist competencies to be built into the second year of the FD. The development of the role also required an education provider able and willing to provide bespoke programmes sensitive to the needs of the trust and the role it was seeking to develop.

Issues of clinical governance needed to be addressed. They were dealt with by putting in place thorough systems, demonstrably ensuring that the post-holder had acquired the requisite competencies without any risk to patient safety. Certainly, staff trust in the post-holder’s sensitivity to these safety issues underpinned this approach. There was a confidence in the SAP’s awareness of her limits and boundaries.

However, formal and comprehensive guarantees of competence were in place, for example reflected in the number of times a procedure had to be practiced and witnessed before the competence was signed off:

We ensured that her competencies were such that they were kind of unassailable, they were better than had been done for the junior doctors, better than I’d had as a trainee.

IC5_consultant_1

There were specific clinical governance issues to be addressed, in particular related to prescribing and the administration of local anaesthetic. These took time to sort out. Indeed, it was suggested that ‘. . . we worked around it rather than work through it. And then did it properly afterwards’ (IC5_consultant_1).

The final aspect of the process relates to the involvement of the nursing directorate or nurse management in the development of the role. This involvement was limited. As a consultant-driven initiative, the role had a particular credibility and legitimacy, with responsibility at the end of the day presented as lying with the consultant:

As long as they know that they’ve got the support of the consultant, then it gives them the confidence to proceed. I would always ultimately be responsible for what goes on surgically and if there are issues with the nurses.

IC5_consultant_1

The post-holder formally took up the SAP role on the completion of the 2-year FD. During the period of the FD, the post-holder was working at band 3, with 2 days per week off for study (one of these in her own time). On completion, she moved on to pay band 4. The role developed during the period of the FD, with the support of the AP lead, the consultant and other colleagues. On completion of the FD, the SAP role was striking in terms both of the range and complexity of the tasks performed.

Unable to secure patient consent for a surgical procedure, the SAP was not in a position to run lists, and therefore concentrated on providing assistance to the specialist nurses and the consultants with their lists. However, with the exception of the issue of acquiring patient consent, there was very little to distinguish the SAP role from that of the specialist nurse. Thus, the SAP tasks included administering local anaesthetic; conducting shave and puncture biopsies; removing moles; undertaking suturing; applying dressing; and dealing with after-care.

Impact

The consequences of the SAP role can mainly be seen in terms of positive service outcomes. At the outset, it was suggested that, given staffing and workload pressures, particularly associated with a same-day surgical service, an extended support role contributed to departmental capacity and flexibility:

From an efficiency perspective, it just means that we can ride the peaks and troughs of a busy clinical service, you know, more or less able to deal with whatever comes at us. So it means that we’re pretty rock solid.

IC5_consultant_1

A more detailed consideration of the role highlights how it contributed to these ends and, arguably, also to improvements in service quality. Thus, the impact of the role can be seen to lie in a number of areas, each discussed below.

Summary

A summary of the features and issues associated with the development of the SAP role is presented in Figure 7.

FIGURE 7.

The development of the SAP role.

Context and objectives

The CSW trainer was designed as a corporate role, working in a small team positioned in the nursing directorate and responsible for the training and development of the trust’s CSWs at bands 1 to 4. The emergence of the CSW trainer role was related to two sets of factors. The first was strategically driven, being tied to a broader initiative on the management and development of CSWs at the trust. OUH had decided to set up what it labelled as a CSW academy, with the CSW trainer role long envisaged as an integral part of it.

The rationale for the CSW trainer role within the CSW academy was associated with a perceived need to improve the trust’s approach to the training of CSWs, particularly at bands 2 and 3. Much of this training had been centred on the acquisition of NVQs (levels 2 and 3), although at the time the CSW trainer post took effect, the national training regime was underpinned by the QCF providing level 1 and 2 diplomas, and, when linked to functional skills, an apprenticeship. The trust was seen as ‘lagging’ in the number of CSWs seeking such accredited qualifications and in the pace and scale of completion.

The problem was seen to lie in the limited support available to CSWs undertaking this programme. In large part, this limited support derived from a lack of assessors in the trust. Indeed, it was the need for a dedicated corporate assessor for trainee CSWs across the trust that underpinned the introduction of the CSW role. The job description for the post noted one of the overall objectives: ‘[t]o effectively assess NVQ/QCF learners’ performance, knowledge and understanding against the national occupational standards’. 51

In more general terms, the CSW trainer role was a means of providing support to trainees during diploma and apprenticeship programmes. Formal training for CSWs was a far from straightforward process: not only had many trainees been away from formal learning for some time, but typically the requisite training involved juggling ongoing work and domestic responsibilities. In this context, support from a dedicated CSW trainer role was seen as assuming different forms. In part, it was related to ongoing advice, particularly on time management. Indeed, the CSW trainer’s contribution in this respect was reflected in another job description objective: ‘[t]o support a cohort of learners to achieve key performance targets relating to achievement and timely success rates’. 51

In addition, such support had a more personal dimension, with the CSW trainer available to deal with the stresses and strains likely to emerge during the training period. As the job description notes, the trainer role seeks ‘to provide pastoral support’ for trainees.

A significant dimension of this support was accessibility: the CSW trainer needed to be someone CSWs could relate to and readily approach in seeking support. The job description explicitly presented the CSW trainer’s post as a ‘role model’, and suggested the need to appoint an individual with a personal and professional background compatible with such a requirement. 51

The second set of factors driving the introduction of the trainer role was more opportunistic, reflecting immediate needs and pressures. Other initiatives associated with the CSW academy, particularly a new recruitment system and induction programme, were generating unexpected demands on other team members. The academy team was small, comprising only three other staff members, with the intensity of work exacerbated by the lack of replacement cover while the academy lead took 1 year’s sabbatical leave. In such circumstances, the CSW trainer role was perceived as crucial in relieving other team members of certain duties in relation to supporting CSW trainees, freeing the team up to concentrate on these other initiatives and activities:

[We] weren’t doing a good enough job really in supporting, there was just too much to do in terms of launching the academy, trying to support that initiative and also trying to run apprenticeships and trying to make them effective, trying to meet targets from [college name] who have the overall managerial responsibility for the apprenticeships. So really we felt that we needed someone dedicated to [QCF] assessment and to support apprenticeships.

IC6_trust manager_1

Implementation and operation

The CSW trainer took up her post in September 2012. Graded at pay band 4, the post was internally funded and due to last until May 2013. This period of employment was subsequently extended until the end of 2013. The appointee came from outside the trust but had experience as a qualified nurse. As a new role to the trust, issues arose as to how it would establish itself and operate in practice. These processes unfolded iteratively: ‘I don’t think any of us really knew what was going to happen’ (IC6_CSW trainer_1).

In the event, the role developed along three activity tracks: assessor, champion and team. Each of these is discussed below.

Impact

Responses to the CSW trainer role from various stakeholders were extremely positive. In general, the role was seen as having taken on more than envisaged:

She’s taken on a lot more than we’d first anticipated, she’s sort of taken on organising key skill sessions and booking rooms for that and liaising with the key skills tutor and liaising with the students, even [when] they’re not her students.

IC6_trust manager_1

At corporate level and in terms of impact on the trust’s CSW academy, the consequences of the role included:

• Freeing up other teams members to concentrate on other tasks:

  • ‘[It’s] freed them up to do other things. I’m always willing to put my hand to whatever’s happening if I can help’ (IC6_CSW trainer_1).

• Increasing the CSW academy’s capacity, with a tangible impact on the number of CSW trainees it could manage:

  • ‘With our capacity we couldn’t have considered taking on another cohort of apprentices or people just wanting to do standalone QCF awards, but her [the CSW trainer] coming in that September time for when they started, she helped with their recruitment and the interviewing and taking them on, with their induction taking them through their programme’ (IC6_trust manager_1).

• Providing a contact point, not least through the drop-in sessions for CSWs, allowing them find out more and seek advice on training opportunities:

  • ‘There was certainly a gap in the market: they all knew about NVQs, and they all wanted to do them, but up till now there’d never been any way of them accessing it, they didn’t know who to go to or where to go’ (IC6_CSW trainer_1).

At an interpersonal level, the role impacted by providing various forms of support to trainees, again with meaningful corporate consequences such as improved and quicker completion rates. The CSW trainer noted that 18 of her 19 trainees were on schedule with their training. Asked to reflect on the various ways in which the CSW trainer had impacted on their learning and helped to keep them on schedule, CSWs noted:

I see her as a mentor that helps me with . . . [as] a lot of stuff is written in such a way that you don’t understand it. She helps you break it down.

IC6_CSW_1

If I’ve got some question I can always phone to her or e-mail to her that I’ve got problem, ‘can we just meet?’ And it’s not a problem at all.

IC6_CSW_2

More generally, the CSW interviewees highlighted the trainer’s role in:

• reassuring

• problem solving

• mentoring

• planning

• witnessing

• clarifying.

The capacity of the CSW trainer to contribute in these different ways can be related to the structure of the role and to three associated factors: personality, background and skills. In terms of role structure, the post was designed as a dedicated trainer role with a core focus on the direct relationship with the CSWs, and as a consequence the post-holder had more time to devote to the CSWs:

I can give all my time to it now really, whereas they’re [other members of the CSW academy] constantly having to deal with the AP course, that takes a lot of time up.

IC6_CSW trainer_1

It will also be recalled that, as a band 4 role, the post was designed to be more accessible to CSWs than the other, higher-graded members of the CSW academy. There were signs of such accessibility:

I suppose they just feel a bit more comfortable; sometimes I think they’re aware [that other members of the CSW academy] are quite high up nurses and, you know, a little bit wary of them. Whereas with me they’re, especially after they’ve known me for a few weeks, because we do have a little bit of a laugh and coffee together and so it’s quite informal.

IC6_CSW trainer_1

Most of the CSWs were unaware of the CSW trainer’s work background, and placed greater weight on her personality and style:

She’s [the CSW trainer] just got really positive body language; she’s not in your face; she’s quite calm; she never raises her voice and if I was struggling to get words out like on a piece of paper, she’s like, ‘I can see like you’re struggling, let’s just look at it a different way’. Like she’s just more relaxed about it and I never walk out thinking that made no entire sense.

IC6_CSW_1

In terms of skills, it was clear that the post-holder was extremely well organised: she was juggling a range of tasks, including meeting all 19 trainees at least every other week. For one CSW, the regular meetings provided a structure and regularity of contact which had been absent in her previous assessor relationship. Indeed, this CSW asserted that without the CSW trainer she would have given up her training:

[Without the CSW trainer] I’d probably be looking at stopping it, to be honest; because [before] I wasn’t doing much with it at all . . . The structure wasn’t there and I know she’s very busy, I wasn’t seeing her that often, to be honest, I’d have probably looked at giving up if, if I’m honest.

IC6_CSW_1

Summary

Figure 8 summarises the form assumed, and objectives achieved, by the CSW trainer role.

FIGURE 8.

Summarising the CSW trainer role.

Context

This evaluation focuses on the use of the Calderdale Framework (CF)52 in one NHS hospital trust in the north of England. This organisation had expressed concern about the nursing and support worker skill mix and was keen to find ways to support its services in developing the support worker roles in ways which would promote quality of care to patients and better support the registered nursing workforce. This was recognised as a priority given the changing context of health-care delivery, forecasts of a future reduction in the numbers of RNs and financial pressures.

At the outset, senior managers indicated that the nursing support workforce in the organisation comprised predominantly band 2 AfC workers who supported the registered nursing workforce (at band 5 and above). 18 However, despite this uniform banding for support workers, there was recognition and concern about the wide variation in roles and responsibilities of these staff at band 2 and the education and training that they had received, particularly when taking on extra responsibilities. The organisation was looking to ‘take stock’ of the nursing support workforce and consider its potential for the future through new ways of working and, potentially, new roles at bands 3 and 4 of the AfC. 18 It was anticipated that this would help the organisation develop a workforce ‘fit for purpose’.

The CF was perceived by the organisation as supporting it to gain a better understanding of their current and future nursing support workforce, as well as providing a possible infrastructure to underpin role developments for the non-registered nursing workforce. Originating in Calderdale and Huddersfield NHS Foundation Trust, the CF was first utilised to facilitate change to service delivery by the community rehabilitation teams. It had since been used by a range of other organisations and services (including housing adaptations and social care). The CF focused on engaging clinical staff through a ‘bottom-up’ approach to service and workforce change. The emphasis was on encouraging the development of competency-based training for staff taking on new roles and standardising the processes within an organisation. This had had particular value for considering the roles of support workers.

The CF comprised seven stages: (1) awareness raising; (2) service analysis; (3) task analysis; (4) competency identification; (5) supporting systems; (6) training; and (7) sustaining. Each stage encourages ownership of the process by clinical staff.

Methods

The CF was introduced to the organisation in November 2011. Following some introductory sessions with the CF facilitators, a decision was taken to implement it in one clinical area (which will be referred to as the pilot site). Concurrently, the CF facilitators trained three staff from the organisation in how to use the framework in other clinical areas. A substantial component of this training involved staff from the organisation shadowing the CF facilitators working with the pilot site. This pilot site was a ward, and this forms the focus for data collection. Organisation staff trained in using the framework went on to administer the framework in two additional clinical areas (referred to as sites A and B). The views of senior staff on how these have progressed with implementation have also been gathered.

Over the evaluation period (November 2011 to June 2013), the organisation progressed to stage 4 of the CF – competency identification. The progress of the organisation through these different stages, as well as the challenges this raised for the organisation, constitute this EC study. The case site evaluation has not been compromised by the organisation being only part way through the process: this is an evaluation of workforce change in real-world contexts. However, it has not been possible to gather before-and-after outcome data.

Data collected for the study (and up to the point of reporting in June 2013) comprised the following (summarised in Figure 9):

• observations (non-participant) of meetings associated with implementation of the CF and involving a range of staff from the organisation, including introductory meetings (n = 2, December 2011), awareness-raising meetings in the pilot site (n = 3, May/June 2012), service analysis meeting for the pilot site (n = 1, June 2012), task analysis meetings for the pilot site (n = 2, July 2012) and competency identification meeting for the two pilot sites (n = 1, April 2013)

• survey of all ward-based registered and non-registered nursing staff in the pilot site to explore their perceptions about their role and working environment at point of implementation of the CF (89% response rate; n = 23)

• interviews with ward-based registered and non-registered nursing staff in the pilot site at point of implementation of the CF (n = 10) and at 1 year (n = 6)

• interviews with senior nurses (including ward managers, matrons, workforce development lead, deputy director of nursing (workforce), director for staff development at point of implementation of the CF (n = 3) and at 1 year (n = 6)

• interviews with external partners for the implementation of the CF at point of implementation of the CF (n = 3) and at 1 year (n = 3).

FIGURE 9.

Summary of data collection points to evaluate implementation of CF.

Sampling of participants for the interviews was purposive with the aim of representing the range of staff in the organisation involved in implementing the CF, including ward-based staff, senior nurses and external partners. The survey used a census approach and was administered to all registered and non-registered nursing staff (n = 26) in the pilot site. Observation of meetings was purposive but included staff who attended the different meetings. Accounts from different participants have been compared and contrasted. Descriptive summary statistics were used to analyse quantitative survey data.

Findings

The evaluation findings presented are the processes of implementing the CF within the organisation. The findings reflect the drivers for change nationally and locally, the opportunities and challenges of implementing the approach for developing support worker roles, and consideration of the future potential for support worker roles in the organisation.

Summary

This EC study has focused on the implementation of the CF in one NHS hospital trust in the north of England. This framework provided a bottom-up, step-by-step approach for considering service delivery and workforce development.

The evaluation has highlighted the enthusiasm at both service and corporate levels for the development of support worker roles and career opportunities. However, there were a number of key lessons to be learnt, albeit within the context of an organisation still part way through the change process:

• There were risks and benefits associated with ‘opportunistic’ change. The chance of financial support for the Calderdale process was attractive to the organisation, coinciding with commitment to address nurse support roles and skill mix in pursuit of improved care quality. However, in early discussions it became apparent that the organisation needed to concentrate on getting some ‘order’ in the band 2 nursing support workforce, prior to developing new roles (at bands 3 and 4) or new ways of working which would require extra skills and training. This was noted once the process had got under way and a number of service-level staff had started to engage with the process.

• There were significant challenges facing the project teams. The merger with another NHS trust further complicated the landscape, and begged questions about the suitability of the CF in the merged trust; nurse support workers at the different organisations had been trained in different ways and there was variation in the banding of support workers across the organisation.

• Focusing on a defined clinical area, the CF was reliant on an enthusiastic ward manager, supportive of their support workers. It was, therefore, questionable whether or not the CF would be taken up in all areas. Indeed, there were concerns about how to use the framework within areas resistant to change in support worker roles.

• A significant question also related to the training packages required to support any new roles for support workers emerging from the CF. At an organisational level, there was uncertainty about how this would be funded and how the initiative might become sustainable.

In conclusion, the CF had prompted discussion within the organisation about the nursing support workforce. It provided an opportunity for considering step-by-step change revolving around complex issues associated with the redistribution of tasks between registered and non-registered staff. In looking to the future, the trust was hopeful that any obstacles would be overcome, with support workers in different clinical areas seeing their roles, banding and career opportunities develop. However, as the evaluation concluded, it remained uncertain whether or not the CF would be the vehicle for such change.

Context

This case evaluates an attempt to introduce beginner competencies for band 2 HCAs across a trust. This initiative was taken alongside the development of the new 2-week induction programme, also evaluated as part of this project (see A new health-care assistant induction programme). Indeed, these beginner competencies were embedded in the induction and integral to the trust’s broader pursuit of a more robust approach to the recruitment and development of its HCAs. The principle of a new competency framework for the trust’s band 2 to 4 HCAs was signed off by its nursing board in December 2011, and by mid-2012, beginner competencies had been formulated and disseminated to the wards. There were 19 such competencies. These included soft skills, such as communication and ensuring patient privacy, dignity and respect, and hard skills, for example monitoring fluid balance and meeting nutritional and hydration needs. To acquire these competencies, HCAs were to be assessed and signed off by an on-ward mentor and in the process were required to collect a portfolio of evidence indicative of requisite skill and knowledge.

The beginner competencies were seen by the trust to serve a number of related purposes:

• Preparation for new starters. The competencies were rooted in and represented an extension of the induction process. A booklet of competencies was handed out in the first week of the induction programme, and the teaching was aligned with these competencies. However, the induction programme was not designed to deliver ‘competent’ HCAs to the wards, with the beginner competencies being taken back to the ward for development and sign-off.

• Probation. The acquisition of these competencies was explicitly tied to successfully completing a probationary period: starter HCAs were given 6 months to acquire the competencies as a condition of confirmation in the post.

• Developing within band. As originally envisaged, there were different levels of competence in band 2 associated with the beginner, the proficient and the expert. This was designed to provide a structured within-band as well as a between-band route to individual development. At the time of the research, only the beginner competencies had been developed and rolled out. Indeed, on completion of the research the competencies at the proficient and expert levels had yet to be formulated.

• Standardising competencies. The beginner competencies were to be rolled out to all band 2 HCAs in the trust. Those HCAs already in post were also scheduled to achieve sign-off of the competencies in 6 months, a means of providing the trust with some assurance on the baseline capacity of its band 2 HCA workforce.

• Development route. In the medium and longer term, the roll-out of competencies to band 3 HCAs was seeking to provide clear achievable career development routes for the trust’s staff.

Our evaluation centred on the beginner competencies introduced on to the 2-week induction and rolled out to band 2s across the trust, with a view to assessing how they had been received and used at ward level.

Methods

The methodological approach was influenced by progress made by the trust on introducing the beginner competencies across the organisation. On the assumption that the beginner competencies would be taken up and administered both to HCA inductees and existing band 2 HCAs on the ward, the evaluation was to be conducted in two phases: collecting data just before and approximately 6 months after the beginner competencies had been introduced. The first phase was undertaken as envisaged and comprised:

• Interviews with three members of the trust’s learning and development team, plus the deputy chief nurse responsible for developing the beginner competencies and managing their roll-out.

• Interviews with nurses in three clinical areas on different trust sites undertaken in May 2012, examining whether or not the take-up of the beginner competencies might be sensitive to area needs and circumstances. Six staff members in each clinical area were interviewed, covering ward managers, nurses, HCAs and practice nurses in trauma, oncology and a general medical ward.

As planned, the beginner competencies were introduced by the trust on to the new induction programme for new starters and for existing band 2 HCAs on the wards. However, it remained uncertain whether or not the wards had taken up these competencies for their existing band 2 HCAs. The second phase, therefore, involved the following:

• Checking progress, by repeating interviews with the three members of the trust’s learning and development team.

• Tracking the take-up of the beginner competencies on the wards for new starters, by including a question on this issue in the follow-up induction survey (see A new health-care assistant induction programme). Respondents were given the options of stating that they had not received the new beginner competencies booklet; had none of their competencies signed-off; had some of their competencies signed off; or had all of their competencies signed off.

• Examining the impact of beginner competencies for existing band 2 HCAs by repeating interviews in two of the original clinical areas: trauma and the general medical ward. In the former, the ward manager and PDN were interviewed, and in the latter the matron was interviewed. However, it became clear that the beginner competencies had not been effectively implemented. In such circumstances there was seen to be little value in repeating the full phase 1 interview programme, and this aspect of the evaluation focused on how and why beginner competencies for existing band 2 HCAs had not been taken forward at ward level.

Findings

The findings are presented in three parts: the first draws upon the phase 1 data to explore views about how the beginner competencies might be received at ward level; the second examines the survey data on the sign-off of new starter competencies; and the third uses phase 2 data to consider if beginner competencies were taken up, and, if not, what barriers inhibited roll-out.

Summary

The introduction of band 2 HCA beginner competencies at this trust was designed to pursue a number of objectives. Embedded in a new induction programme and tied to the successful completion of the probationary period, the trust was seeking to strengthen HCA preparation for the performance of their role and provide a clear basis for confirmation in post. As applied to band 2 HCAs already in post, the initiative was aimed at establishing a clear baseline of capability among this part of the workforce, and a platform for its future development. This evaluation has cast considerable doubt on the effective fulfilment of these objectives. The phase 1 data suggested that there was some ward-level support for the initiative, seen as contributing to the more structured development of HCAs. However, concerns were raised, a number of which were borne out when the initiative was rolled-out across the trust.

The survey data cast doubt on the take up of the competencies for inductees even after at least 6 months in the post. The roll-out of the competencies to existing band 2s had also failed to materialise. In terms of our methods, this undermined the value of the planned extended phase 2 interview programme. As a consequence, the evaluation concentrated on evaluating the difficulties faced by the trust in introducing the beginner competencies.

There were general concerns of principle about the use of competencies, inevitably task centred, in developing HCAs. However, many of the difficulties were more prosaically related to process and practice. In process terms, there appeared to have been problems in clearly communicating the coverage of the initiative and its implementation. Alongside a wealth of other trust initiatives, beginner competencies also became ‘lost’, not least because of the paperwork associated with them. In practical terms, concerns about depleted supervisory capacity emerged, inhibiting sign-off of HCA competencies.

Context

This case evaluated the introduction of a new induction programme for HCAs at a large multisite trust. The new programme was part of a suite of measures adopted by the trust, which included a new approach to recruitment using numeracy and literacy tests along with an assessment centre, and apprenticeship and competency frameworks (see Beginner competencies for band 2 health-care assistants). In the words of the deputy director of nursing, presenting them to the nursing board in November 2011, these measures sought:

To develop a rigorous and comprehensive recruitment and development pathway for [HCAs] that will support our delivery of excellent patient care and uphold trust values.

The previous induction comprised a corporate day plus 3 clinically focused days specifically for HCAs. However, according to the trust’s induction handbook, this programme:

. . . no longer met the needs of the HCAs or the clinical areas and that a more robust and effective programme was required that would benefit patients, individuals and the trust.

As the handbook continued, the previous programme was:

. . . not giving HCAs the opportunity to learn practically those skills needed to fulfil their role.

In seeking to address these concerns, the new induction programme, designed principally by the trust’s support worker training and development team, had four stated aims, to:

1. produce a competency-based induction which provides a platform from which HCAs can grow into highly skilled and knowledgeable practitioners

2. provide an induction which meets the needs of the clinical areas

3. demonstrate that HCAs are valued and to improve staff retention

4. raise care standards which reflect the core values of the trust.

To be held once every 2 months, the new induction was extended to 2 weeks (10 working days including 1 day for the trust induction). It operated on the assumption that entry HCAs would complete the 2 weeks before moving on to their wards, so ensuring that they were ‘safe’ when they did so. The substance of the induction did not change greatly, but clearly participants were to spend longer on topics, with more scope to practice skills, as well as being exposed to a wider range of contributors. The new induction provided for 2 days on different forms of communication; and days respectively on maintaining patients’ hygiene needs, tissue viability, moving and handling, and safeguarding to practice.

In evaluating the new induction programme, the fieldwork mainly focused on aims 2–4, whether or not, and in what sense, they were met.

Methods

The following methods were used to evaluate the new induction programme:

• Interviews were carried out (December 2012) with three trust training and development leads responsible for design and delivery of the new programme before it started and then after it had been operating for approximately 1 year (May 2013).

• Interviews were also conducted 6 months later (May 2013) with two ward managers and PDNs on different trust sites and in different clinical areas, inter alia to gather their views on the new induction.

• A focus group was held for HCAs (n = 17) on attending the final 5-day induction in January 2012, prior to the introduction of the new 2-week programme.

• A survey was administered to four cohorts of HCA inductees. The first of these cohorts (cohort 1) comprised those participating in the final 5-day induction in January 2012. The succeeding three cohorts (cohorts 2–4) covered those HCAs involved in the new, 2-week programmes run during May, July and October 2012. Each of these four cohorts was surveyed twice: initially to generate baseline data (on the final day when they had completed their induction) and then following up at the end of 2012 (see Appendix 8 for baseline questionnaire). It was hoped that the impact of the new induction might be revealed by attitudinal and behavioural differences between the old and the new induction cohorts.

The surveys sought data on personal characteristics of the HCA inductees and on their work histories and qualifications. A number of survey measures were connected to the trust aims of the new induction (see Appendix 9 for scale mean scores). These included:

• an intention-to-leave scale (aim 3)

• an explicit evaluation of the induction programme (baseline) and its value once in post (follow-up survey) (aims 2 and 4)

• a clinical confidence scale, dealing with the confidence of the respondent to perform various clinical tasks (aims 2 and 4)

• a psychological contract scale asking respondents what they felt the trust ‘owed’ them (baseline) and whether or not the trust had delivered (follow-up) (aim 3)

• a job satisfaction scale (aim 3)

• a motivation scale (aim 3)

• a caring behaviour scale (aims 2 and 4).

Table 13 presents the survey responses by cohort and baseline/follow-up. The numbers attending induction were between 14 and 27, and, with some turnover among HCAs, the numbers responding to the follow-up survey were particularly small. For analytical purposes, the three new induction cohorts (2–4) were combined, but with only four of the old induction (cohort 1) responding to the follow-up survey, the value of comparing the new and old induction cohorts was substantially weakened.

Table 14 provides a profile of the old induction cohort (1) and the combined new induction cohorts (2–4). It is clear that the old and the new induction cohorts differ in important respects: the old induction cohort tends towards being more ethnically diverse, younger and with fewer domestic responsibilities than the new induction cohorts. Perhaps most striking is the fact that the old induction cohort comprised HCAs with a higher level of formal education than the new induction cohorts: almost three-quarters of cohort 1 were graduates or postgraduates compared with one-third of cohorts 2–4. There are grounds for arguing that cohort 1 was less typical of the HCA intake at the trust than the cohorts 3–4. Indeed, survey data on the background of HCAs from this trust, generated during an earlier research project,1 indicated that the cohort 2–4 profile was much more typical than that of cohort 1. Certainly, the distinctive character of cohort 1 suggests that the survey data should be treated with care (see Table 14).

Findings

The findings are presented in two main parts. The first concentrates on the survey results and the second draws upon the focus group and interview material to interpret and add insight to the survey data.

In general terms, the survey data suggest that the new induction had essentially failed to meet its stated aims, not least reflected in the pattern of attitudinal and behavioural responses from the old induction cohort and the new induction cohorts.

Table 15 presents the survey results on how HCAs directly viewed the induction (baseline survey) and how useful the induction proved to be once they had settled down on their wards (follow-up survey). If anything, the old induction cohort are more positive about their induction programme than the new induction cohorts are about theirs. For example, the baseline surveys indicate that despite the new induction programme being a week longer than the old, under half (41%) of the latter ‘strongly agree’ that they were given enough time to ask questions, compared with one-third of the former (65%). The follow-up surveys reveal no differences between the old and new induction in providing HCAs with requisite skills and knowledge; indeed, in both groups only around one-quarter suggested that induction is effective in these terms.

Table 16 sets out HCA confidence in performing a range of clinical tasks, immediately on completion of the induction (baseline) and after being on the ward for some time (follow-up). On some tasks the new induction cohorts (2–4) were more confident than the old cohort (1) at the conclusion of the induction programme (baseline): most of the former (89%) agree that they were confident in recording a patient’s fluid intake, while fewer than three-quarters of the latter were similarly confident. However, on other tasks, such as assessing a patient’s nutritional status, the old induction cohort was more confident than the new, and in general there were few noteworthy differences between the cohorts. Indeed, on settling into their wards (follow-up), confidence was very similar between the cohorts (with the exception of vital signs where, against expectation, the old induction cohort was more confident than the new).

Finally, the survey data cast doubt on the capacity of the new induction to improve staff retention and signal the value placed by the trust on HCAs. Turnover was much higher among the old induction cohort (1) than the new (2–4). Exactly half of cohort 1 had left the trust by the time of the follow-up survey, while most of the new induction cohorts were still in place (75% or more). However, as Table 17 indicates (follow-up survey), cohort 1 were much more likely than cohorts 2–4 to feel that the trust had delivered on what they ‘owed’ employees. Both new and old induction cohorts had similar expectations about what the trust ‘owed’ them at the outset (baseline survey) but it can be seen, for example, that while exactly half (50%) of the old induction cohort felt that the trust had delivered on ‘training to my job’ to a ‘very great extent’, the equivalent figure for the new induction cohort was under one-third (31%).

In suggesting that the new induction had not had the expected impact, the survey findings need to be treated with care. As implied, the striking differences in the background profiles between the old and new induction cohorts might have confounded the impact of any change in the design in the programme. There were, however, other indications, drawn from the qualitative data, that the new induction was not meeting trust objectives:

• Timing. The trust’s intention to ensure that HCAs attended induction before moving on to the wards was not met. Certainly, a higher proportion of those on the new induction than on the old induction had not yet been on the wards, but in two of the former cohorts half of the participants had already been working on their wards. This was seen as partly related to the timing of the inductions, held every other month; if newly appointed HCAs had just missed an induction, it was a long wait until the next one. There were also suggestions that the HR function had not always been timely in providing new HCAs with their joining instructions.

• Length. A 2-week induction took HCAs away from the ward for what was perceived, particularly by ward managers, as too long a time: this not only had staffing implications but was costly for wards already paying those HCAs attending the induction.

• Coverage. There were concerns, again expressed by ward managers, about the content of the programme and the failure to cover what they viewed as some essential aspects of care, such as life-support training. Moreover, some ward managers felt that the coverage of the programme was not sensitive enough to their specific needs:

  • ‘Trauma [manager] felt that their [HCAs] don’t do observations so they shouldn’t have to attend, but I did clarify that they didn’t have to attend that session . . . Neuro [manager] felt that they wanted information about setting up a bed space’ (EC3_trust manager_4).

These concerns were raised despite an extensive trust consultation on the design of the new induction programme. However, this consultation mainly involved matrons rather than ward managers, the workplace needs of the latter perhaps not directly informing the process. There were also some genuine dilemmas faced by the trust in developing a 2-week induction. There might well be calls for a more regular induction, but a longer induction is inevitably resource intensive and requires considerable organisational effort, not easily managed in a busy trust. Moreover, wards might well want their HCAs on the wards as soon as possible, but they also want them on the wards ‘safe’, arguably requiring a thorough induction.

Summary

A more robust induction for HCAs, better preparing them for their role before they ‘hit the ward’, has increasingly been seen by trusts as a means of ensuring and improving care quality standards, not least given considerable unevenness in the skills and experience of those taking up the post. This evaluation of a 2-week HCA induction, introduced by a trust to replace a 1-week induction, suggests the need for some sensitivity to the challenges faced in adopting such an approach. The evaluation casts some doubt on whether or not the trust aims for the new induction were met: many HCAs had started working on the wards before completing the induction; some clinical areas felt that the new induction was not meeting their needs; and, while the survey data must be treated with care, attitudinal and behavioural responses from HCAs attending the old and the new induction were not compatible with the increased efficacy of the latter. It is not being suggested that a 2-week induction is invariably problematic. However, in setting one up, organisational issues have to be managed: for example, the contributors/presenters must show ongoing commitment; HR must provide timely joining instructions; and the ‘right’ people need to be consulted on the design of the programme. Some ‘hard’ choices need to made about the purpose of the induction; if wards want ‘safe’ HCAs at the outset, a long induction might well be needed, which takes time and resources to organise and, therefore, might not be as frequent as desired and might also take HCAs away from the wards for longer than is ideal.

Context

The primary focus of this evaluation was a 9-month accelerated development programme (ADP) for MCAs at a two-site trust in the south of England. This programme, however, was embedded in a broader organisational change initiative centred on the trust’s maternity services, with implications for how the evaluation was conducted and the issues captured by it. Responsible for over 6000 births, the trust provided a hospital-based maternity service – comprising a 16-bedded central delivery suite (CDS), two postnatal wards with a total of 55 beds, an antenatal ward and a 24-hour antenatal assessment unit – and a community-wide service. The change initiative was essentially directed at the hospital’s CDS and its community service. In both service areas, the change rested on a radical shift in skill mix, MCA numbers increasing as the number of band 7 registered midwives fell. In the CDS, the number of whole-time equivalent (WTE) MCAs increased from 12 to 19, as WTE midwives dropped by three. In the community, the number of WTE band 7 midwives went down from 35 to 10, with WTE MCAs rising from 6 to 18.

In the community, this shift in skill mix was part of a major restructuring of the service. Formerly attached to GP surgeries, the trust’s community midwives had traditionally worked as lone, semiautonomous practitioners with their own caseload of between 80 and 100 pregnant women. The reorganisation created 10 area teams, with each managed by a band 7 registered midwife and staffed by four WTE band 6 midwives and two MCAs. The respective teams were designed to work in a more corporate fashion, responsible for around 400 pregnant women, dealt with and managed jointly by team members. The former band 7 community midwives were eligible to apply for one of the new band 7 team leader posts. The unsuccessful candidates and those choosing not to apply were downgraded to a band 6 post, albeit with protected pay and conditions for a period of 5 years. The reorganisation in the CDS and the community service were predicated not only on the use of a higher number of MCAs, but also on an extension of the MCA role to take on more tasks from the midwives, those so doing becoming band 3 MCAs. The accelerated MCA development programme was introduced to bring the band 2 MCAs up to a band 3 level.

The ADP was delivered on the basis of a partnership between the trust’s maternity services and HR directorate’s learning and research function. From the former, the deputy director of midwifery in post when the programme started played the lead role in the development of the programme, while from the latter a vocational team leader was centrally involved.

The ADP began in October 2011 and was characterised by the following features:

• It was an apprenticeship accredited by City and Guilds, London.

• In line with the standard apprenticeship programme, it comprised:

  • functional skills

  • generic modules (delivered by the learning and research department)

  • specialist modules (delivered by the maternity department)

  • the acquisition of relevant competencies (developed and signed off at ward and team levels).

• It was designed to be completed in 9 months, compared with the 18 months usually taken by participants.

• The intake was 15 MCAs, made up mainly of band 2s from within the trust but also of new external candidates.

• An upgrading for band 2 to 3 MCAs on completion of the programme.

• Study time of 2 or 3 days per month.

• Candidates were expected to complete in the summer of 2012.

The close relationship between the ADP and the reorganisation of maternity services impacted on our evaluation in various ways. First, it was difficult to disentangle engagement with, and perceptions of, the ADP from the changes associated with the broader reorganisation of the CDS and community service. Second, this close relationship influenced the nature of the evaluation. Ostensibly, interest remained centred on the ADP: how its delivery was viewed and experienced, and how participants fared. However, closely related was a concern with the development the MCA role – whether or not, as envisaged, it had extended to allow MCAs to take on tasks from registered midwives.

Methods

The evaluation was conducted in two phases, which involved the following:

1. Phase 1: Spring 2012 (around half way through the ADP)

   • Interviews with 14 managers, midwives and MCAs plus a focus group involving eight MCAs.

   • A department-wide survey of midwives and MCAs with an overall response rate of 55% (midwives 54%, n = 117; and MCAs 58%, n = 41; see Appendix 10 for the phase 1 questionnaire). This survey was designed to collect baseline data in relation to a number of variables, for example job satisfaction, work pressure and perceived control, with a view to assessing whether or not these had changed following the assumed completion of the ADP and the emergence of the band 3 role.

2. Phase 2: May 2013 (after the ADP was due for completion)

   • Eighteen follow-up interviews with managers, midwives and MCAs (six of the MCAs were involved in both phases of the research).

   • A follow-up survey of midwives and MCAs with an overall response rate of 56% (midwives 52%, n = 114; and MCAs 63%, n = 53). Data tracking of the progress made by the ADP cohort of MCAs.

As part of the second phase follow-up research, interviewees were asked about developments subsequent to the first phase fieldwork, which might form a backdrop to views on the ADP programme and the role of the MCAs. Two such developments were worth noting. First, the deputy of midwifery services leading the reorganisation had left the trust. Second, concerns and misunderstandings had arisen about the pay protection arrangements as part of the reorganisation. Given the stress generated by the reorganisation (see Phase 1: the reorganisation, below). The departure of the deputy chief midwife might well be seen to have diffused certain tensions. The concerns associated with pay protection might well have created new ones.

Findings

Summary

This evaluation has been complex, comprising a number of threads. Principally, the focus was on a trust’s ADP for band 2 MCAs, fast-tracking them to band 3. The programme was, however, seen as intimately related to a broader reorganisation of the trust’s maternity services, in part predicated on a shift in skill mix as band 3 MCAs increased and replaced a diminishing number of band 7 midwives, and also to a significant change in work organisation, especially on the community side. The evaluation of the ADP has, as a consequence, inevitably involved some assessment of an extended MCA role within the context of organisational change.

In seeking to deliver apprenticeship training to band 2 MCAs in a 9-month period, the ADP met with only limited success: only 4 participants out of 15 completed the programme in a timely way. The stresses faced by MCAs in undertaking the programme were flagged up during phase 1 fieldwork and, given phase 2 outcomes, these concerns were clearly well founded. MCAs faced major difficulties in completing the programme in 9 months given the need to juggle work, domestic and learning pressures. Crucially, many MCAs also had difficulties in developing a relationship with their mentor, an aspect important to the workplace learning and competency sign-off underpinning the programme.

Against the backdrop of these findings, it is intriguing to note that between phases 1 and 2 the MCA role de facto appeared to have extended and increasingly been accepted, especially by midwives. This found some support in the survey data, indicated by higher means scores on the MCA evaluation scale among both midwives and MCAs between the two surveys. Indeed, MCA perceptions of patient care quality were significantly higher between the two surveys. It might also be argued that, even if they did not complete the ADP on time, many MCA trainees were iteratively acquiring competencies and developing capabilities through workplace learning, allowing them to push role boundaries. In short, cumulative workplace learning and skills acquisition might have played a more important part in MCA role extension than formal completion of the ADP programme.

Context

This case focuses on the evaluation of a trust’s proposal to extend the administration of medicines to APs at pay band 4. The development of the AP role in this way has attracted increasing attention across the NHS. 53 There have, however, been few detailed cases exploring such an initiative: how it has been viewed by various stakeholders and taken forward within a particular organisational context. Indeed, the nature of this evaluation shifted over the period of the project in response to changing contextual circumstances. At the outset, with much of the trust preparation for implementation apparently complete, the intention was to conduct a before-and-after evaluation of a 6-month pilot involving the sign-off of relevant competencies and the administration of a specified list of drugs by APs. However, clinical governance issues arose which delayed the pilot by almost 1 year, encouraging a more detailed consideration of the design and implementation of the initiative and how various stakeholders viewed it.

The medicines management (MM) initiative can be related to the broader development of the AP role at the trust. The role had first emerged in 2005 somewhat opportunistically as the trust drew upon SHA financial support for AP training. The role was then taken up widely across the trust – with 100 APs in post and a further 70 in training by 2013 – and on the basis of a more strategic approach. Thus, the trust envisaged the AP role gradually extending over the years to take on more tasks, with the MM by post-holders being part of this planned process.

A new build on the trust’s main site gave added impetus to the development of the AP role. With 75% single-room occupancy and an absence of central ward stations, this new building had major implications for the delivery of nursing care and skill mix. RNs would be less able to take responsibility for a bay of patients, instead becoming central co-ordinators of care directly delivered by non-registered staff. The AP MM pilot was, therefore, important to the trust in preparing for the transfer of many of its services to a new building.

The MM pilot comprised the following six elements:

1. selection of a given range of drugs (n = 8):

   • oral paracetamol

   • oral codeine

   • oral ibruprofen

   • intravenous paracetamol

   • subcutaneous enoxaparin

   • intravenous venfor

   • intravenous tinzaparin

   • intraperitoneal heparin

2. administered by APs in specified clinical areas:

   • medicine: accident and emergency and acute assessment unit (AAU)

   • surgery: day surgery, recovery and urology

   • renal: dialysis unit and home team

3. identification of 12 APs from these clinical areas to take part

4. a period of training for the APs, made up of 3 days’ dedicated ‘classroom’ training on aspects of MM, completion of the online package dealing with the theoretical aspects of MM and a test of the APs’ calculative skills

5. post training, the formulation of an individual action plan for the acquisition of the relevant competencies and their sign-off at ward level

6. development of standard operating procedures (SOPs) for the administration of the relevant drugs.

As the evaluation fieldwork began, the first four elements had been completed with an expectation that the SOPs would shortly be in place. In the event, agreeing and signing off the SOPs proved difficult, delaying the start of the pilot.

Methods

The fieldwork was designed to take place in two phases. The first phase, conducted during March–May 2012, with the MM pilot still on schedule, involved:

• An AP focus group including eight of those involved in the pilot.

• Interviews with 19 staff, covering those with a stake in the initiative, including six APs, five ward managers, three RNs and five senior managers.

• A survey of band 4 to 7 nursing staff in four clinical areas (with a response rate of 43%; n = 65; see Appendix 11 for the questionnaire): renal, the AAU and a control ward not part of the pilot. The survey asked three sets of questions related to preparation for the initiative, its perceived impact on nurses and its impact on care quality.

The second phase, conducted during March–April 2013, was more limited. The pilot had not started as planned and it was therefore decided to evaluate the design and implementation of the initiative and how different stakeholders viewed it. Twelve interviews were completed: two APs, four ward managers, and six senior managers including those from nursing, HR and pharmacy (eight of these interviewees had been involved in the phase 1 fieldwork).

The findings are presented in three parts: the first (drawing mainly upon phase 1 interview data) evaluates stakeholder views about the drivers and rationale for the MM initiative; the second (based on phase 1 and 2 interview data and the phase 1 survey) evaluates the design and implementation of the pilot; and the third (mainly based on phase 1 survey and interview data) evaluates views on the nature of the initiative, and particularly its perceived impact on various stakeholders and outcomes.

Findings

Summary

In evaluating the design and implementation of a trust’s AP MM pilot, this case has highlighted the importance of contextual factors. In part, the trust was driven down this route by a new build that would radically alter care delivery systems, with implications for the structure of the nursing workforce and the richness of the skill mix. Context was also a significant influence on the way the pilot was taken forward, with the tensions between nursing and pharmacy over the form assumed by the SOPs slowing down and influencing the character of the pilot. Much of the preparation for the pilot, particularly a well-received training programme for APs, was put at risk by the failure to develop an agreed approach to the development of the essential protocols.

There are broader lessons to be drawn from these particular difficulties in terms of the potentially contested nature of an extended AP role and the consequent need to develop a partnership between functions, as well as agreed systems, at the outset of such a process.

In evaluating stakeholder perceptions of the MM initiative, it became clear that AP and nurse views differed markedly. In general, APs were much more positive than nurses about the process in terms of preparation and impact on care quality. This finding should not, however, detract from the more nuanced picture of how these actors regarded the pilot. APs retained various doubts about their future role, the levels of support provided at ward level, and how they would be used by their colleagues if they acquired responsibility for MM. Nurses expressed considerable concern about their accountability for APs administering drugs, although a significant proportion of nurses felt that they would be ‘freed up’ to focus on ‘more essential tasks’. Perhaps most telling was the ongoing uncertainty about the impact the initiative would have on patient care: some suggested risks, while others saw the initiative as improving the patient experience, allowing APs to ‘respond more immediately to patient needs’.

Context

This evaluation focuses on the introduction of an AP role across a trust. The trust in question was a single site, ‘medium-sized district general hospital’ in the east of England with 450 beds and a nursing workforce of 2000 full-time equivalent employees (including registered and unregistered workers). Initially driven by a SHA workforce group, funding a project co-ordinator’s post, the trust was at the forefront of developing the AP role in the region. Launched in June 2010, the trust’s initiative was distinctive in seeking to introduce the AP role throughout the trust, in general as well as in more specialist clinical areas. The initiative comprised the following elements:

• the appointment of a cohort of 25 TAPs embedded in nine clinical areas: emergency assessment unit (EAU); trauma and orthopaedics; respiratory medicine; gastroenterology; general medicine; general surgery; rehabilitation; endoscopy; and the stroke unit

• at least two TAPs in each of these clinical areas

• internal and external recruitment on to the TAP programme

• funding the AP through the loss of a band 5 nurse post

• TAP recruitment on to pay band 3, moving to band 4 on qualifying as an AP

• a training programme made up of:

  • a 2-year FD, with TAPs given 2 study days per week

  • a set of competencies

  • five practical assessments covering, for example, total patient care, wound care, and care of the deteriorating patient

• a 4-day preceptorship programme.

The evaluation centred on four aspects of the initiative:

• reasons for its introduction

• design and implementation

• learning and training components (FD, competencies and assessments)

• development of the (T)AP role within clinical areas.

Methods

Covering this first trust cohort of 25 TAPs, the research was carried out at two points in time:

• phase 1: March 2010, 18 months into the TAP programme – 19 interviews with various stakeholders, and a focus group covering 10 TAPs

• phase 2: December 2012, after the programme had been completed – 24 interviews with a similar range of staff.

Those covered by the fieldwork included:

• 19 (T)APs (seven at both phases)

• seven ward managers and a matron (one at both phases)

• six nurses (one at both phases)

• 10 senior managers (four at both phases).

Rapid feedback on the findings was given to the trust after each phase. In March 2013, a presentation was made at the trust, engaging stakeholders in a discussion of the full findings.

Findings

Design and implementation

The design and implementation of the AP initiative involved a range of actors and processes, presented in Figure 10.

FIGURE 10.

Design and implementation of AP initiative.

It can be seen that the initiative was managed by a trust implementation group from different directorates including nursing and HR. This group developed the TAP and AP job descriptions, which provided the basis for recruitment to the programme. The initiative was led by the head of nursing. However, the key figure, working full time on the initiative, was the project co-ordinator who:

• provided ongoing support and advice to TAPs

• worked with the FD provider

• liaised with ward managers, not least to ensure that TAPs fitted in and developed a clear role

• acted as an assessor, particularly on the practical assessments.

At the heart of the process was the development of an AP role with a given set of tasks and responsibilities designed to meet service and trust needs. In general, this process comprised two main elements:

• Covered by the upper part of the figure, the first related to the formalities of the role, particularly the training programme designed to ensure that those recruited could perform the role.

• Represented by the bottom half of the figure, the second was a less formal element, taking place within clinical areas, to shape the AP role to meet specific clinical needs and circumstances.

The findings as they relate to these two elements are presented for each phase in turn.

Summary

This initiative was seen as worthy of evaluation given its attempt to embed the AP role across a trust, in general surgical and medical wards as well as specialist clinical areas. The trust had made a strategic decision to use the AP role to restructure its nursing workforce in pursuit of a number of objectives: addressing recruitment difficulties among nurses; developing a new leader in the delivery of the fundamentals of care; making medium-term financial savings; and creating new career pathways for band 2 and band 3 HCAs.

In general terms, any evaluation needed to focus on whether or not and in what ways these objectives had been met. However, it has been argued that in examining such questions it was important to assess two aspects of the initiative: the formal training and learning aspects, and the less tangible, but equally significant, use of the AP role at ward level. In this case, the relative success of the formal learning and training component, in terms of completion rates and general perceptions of the process, has been accompanied by difficulties in ensuring the adoption and use of the AP role on wards as envisaged.

This finding derives from the views and experiences of various actors from across the trust with a stake in the initiative. The phase 1 material suggested that, in general, the TAPs were finding it difficult to move beyond caring activities, and sometimes faced resistance from team members to an extension of their role. During this period, however, they were focused on their training, which, while often stressful and intense, was generally progressing well. With only 3 days per week on the ward, their roles were always likely to be slightly uncertain and distorted. More telling was the phase 2 material which indicated that, in many clinical areas, ward use and engagement with the role remained uncertain. Indeed, if the general tenor of the phase 1 TAP interviews was upbeat and optimistic, the prevailing ‘mood’ at phase 2 was one of AP disillusionment with their role and prospects.

Certainly, the initiative had fared unevenly between clinical areas. The general roll-out across the trust provided an opportunity to compare how the role would ‘take’ in different clinical areas, and it was clear that problems were most apparent on the general wards than in the specialist areas such as endoscopy. However, the broader picture to emerge raised questions about the achievement of the trust’s objectives. There were some signs that the AP was emerging as a team leader for HCA carers, but that APs were not yet fully developed leaders of fundamental care. Most striking was the difficulties APs faced in extending their roles in an ordered and sustainable way: many claimed to be ‘glorified carers’, at ‘best’ used opportunistically by nurses to undertake more complex tasks. It was a finding that casts some doubt on the capacity of APs to address band 5 recruitment difficulties and to provide a worthwhile or meaningful career route (in terms other than a rise in pay banding).

A number of reasons emerged as possibly explaining the problems faced by the APs in gaining acceptance at ward level:

• The value and contribution of the AP was distorted by the view that they were a cost-saving measure.

• The initiative was driven by the trust senior management, and perhaps therefore seen as an imposition before an understanding and consensus on the value of the AP role had been established.

• APs expressed concern at the lack of understanding about their role, particularly among team members.

• There was a residual degree of ‘resistance in principle’ to the AP role within the trust, which proved difficult to break down. Some staff were opposed to the AP role in principle as a threat to the nursing profession and its status.

• Practical issues were raised rendering the use of APs problematic in the trust, leading to a ‘resistance in practice’. The role assumed by the AP was often crucially related to whether they were included in the trained or untrained numbers: counted in the untrained numbers, they were typically carers; counted in the trained number, they had greater scope to play an extended role. The AP’s inability to administer drugs was also seen by some as a constraint on their use.

Despite, or perhaps because of, the difficulties faced with the first cohort of APs, the trust had moved ahead with a second cohort. There had been some organisational learning from the first AP cohort, resulting in important changes to the design of the programme as summarised in Table 24. The trust’s second AP cohort, much smaller than the first, at 10, was recruited solely from internal candidates rather than also drawing upon external candidates; promotion to band 4 was to be dependent on the availability of a role at that level upon the completion of the programme, rather than being guaranteed; and the number of study days was cut by half, from 2 to 1.

Introduction

The concept of a ‘toolkit’ to support stakeholders in the development and management of support worker roles in acute care was based on a previous toolkit produced by the Working in Partnership Programme to support the development of HCAs within general practice. 54 Our vision was that a toolkit for acute care might be useful to a range of stakeholders including:

• support staff – including staff newly appointed to an assistant role as well as supporting career progression of assistant staff through the levels of the NHS Career Framework

• employers of support staff in acute care – who currently employ support workers or may be considering introducing new support workers roles (such as AP roles)

• acute trusts – who want to maximise the potential support staff resource within the organisation

• education providers – providing education and training for the development of the support workforce and

• patients – who come into contact with, and experience care delivery by, support workers.

During the research study, we have explored the potential for the development of the toolkit. In particular, we have sought opinion from a range of stakeholders on whether or not a ‘toolkit’ would be useful and to whom and, if considered useful, what form it should take and what content would be useful.

Our approach

At the respective regional workshops, an introductory presentation outlined our vision for the toolkit and broad areas for inclusion in the toolkit, including (i) role description for support workers, (ii) support worker role integration, (iii) support worker training development and progression, (iv) management of support workers, (v) recruitment and induction of support workers and (vi) support worker role impact (see Appendix 16). To explore stakeholder perspectives on the potential value of developing a toolkit, we posed the following four questions:

• Where do you go for guidance to inform management and development of support worker roles?

• Would a ‘toolkit’ be useful (and for who)?

• If you would find a toolkit useful, what form would it take and what would it include?

• Have we got the right six items (see Appendix 16, slide 4) and are they all important or are some more important than others?

This consultation has guided our considerations about the potential utility of developing a toolkit. The main findings of the consultation and our plans for taking the toolkit forward are outlined below.

Findings

Summary

The consultation with participants at the workshops, representing a range of stakeholders, was useful for exploring the potential for the development of a toolkit as part of the current research study. A key requirement of any toolkit or information repository, from the perspective of these stakeholders, was to ensure that it had ‘currency’. This raises a number of challenges in producing a toolkit or information repository that is ‘fit for purpose’ as requested through the consultation. We will, therefore, utilise the existing project website45 to provide access to information requested by participants, including signposts to useful resources, case studies and examples of ‘best’ practice and the evidence-base for support worker roles. We will not be able to manage a discussion forum and we will have to state the date of publication. However, while considering the development of the toolkit or repository, we have commenced discussions with national organisations to determine options for keeping the information up to date and adding new materials as published. This would be the most suitable option for ensuring maintenance of the resource.

Details of the web pages will be disseminated through a variety of strategies, including publications, conferences and signposting from other national and regional web sites. This is the most pragmatic way forward with this work and to ensure the longer-term engagement of stakeholders.

The nurse–support worker interface

There has been a long-standing overlap between the tasks performed by RNs and support workers, a legacy of nursing’s quasiprofessional status and its failure to achieve occupational closure on the creation of a nurse registrar at the beginning of the twentieth century. 70 Nursing has remained an activity open to ‘unqualified’ workers, with few, if any, nurse activities, beyond the dispensing of controlled drugs, protected in statute. This has created an uneasy relationship between the ‘nurse establishment’ – the RCN, the chief nurses and the nurses’ regulatory body – and support workers, particularly as RNs have sought to pursue and bolster their professional status.

The uneasiness of this relationship with support workers might be seen to partly lie in nurse uncertainty about how to take forward their professionalisation project. 29 Over the years, the nurse establishment has oscillated between two possible approaches to this project, with very different implications for the positioning of the support worker:

• Specialism–discard: the first is based on occupational closure around a discrete set of specialist tasks, with nurses discarding more ‘routine’ tasks as they move on to develop this deepening expertise. Abbott27 refers to professions passing on ‘dangerously routine tasks’, which might otherwise undermine claims to specialist expertise, to subordinate occupations, a process also stressed by Hughes71 who more specifically refers to nurses delegating such tasks to nurse aides as they move up the occupational hierarchy. It is an approach to professionalisation that views the support worker as a convenient depository of routine tasks for nurses as they acquire more expertise and take on specialist roles.

• Holism–hoard: the second approach to professionalisation is rooted in claims to professional status on the basis of the holistic provision of care. These holistic claims, often found among quasiprofessionals72 – teachers and social workers as well as nurses – are clearly at odds with the former approach to professionalisation. Rather than professional status resting upon specialist expertise, it is seen to lie in an occupation’s capacity to recognise and meet the users’ needs in the round, from the most basic to the more complex. A holistic narrative suggests that, rather than discarding or delegating tasks to the nurse support worker, the nurse needs to retain or hoard tasks. Indeed, in this context, the nurse support worker becomes less a ‘convenient depository’ and more a potential threat to nurse claims to provide all-round care.

This is not the place for a detailed discussion of the debates within nursing over the relative merits between these competing approaches, or which should be or indeed has been privileged. Briefly, there has been a secular trend towards a specialism–discard approach over recent decades as nurses have departed from the bedside to take on other, often more specialist roles and tasks. 73 In part, this has been driven by the profession itself, but it has also been steered by government policy, with its deepening emphasis on the nurses’ role in the performance management of the ward. More recently, however, such a trend has elicited a rebuke from the nursing establishment – the chief nurse and the RCN – stressing the value of a holism–hoard approach and reflected in warnings that nurses should never be too posh to wash. 74 This uncertainty, perhaps ambiguity, in the preferred approach to professionalisation was also manifest in our previous studies: the earlier Oxford1 project, in particular, revealed that while in interview nurses stressed the positive impact made by support workers on their working lives, in the questionnaire they were somewhat more qualified in their views, suggesting a more grudging acknowledgement of the HCA contribution.

The findings from the current study suggested that profession–support worker jurisdictional issues were at their most pressing and intense in relation to the band 4 AP role. Moreover, given the findings from our national innovation survey that trusts were increasing rather than decreasing their use of APs, these jurisdictional issues are likely to be increasingly to the fore. Four of our cases explored the development of APs: the roll-out of APs across a trust (the roll-out case), the MM (the MM case) by APs, the specialist use of APs at Torbay and the development of a band 4 surgical AP role in dermatology at OUH. A further two cases explored a band 3 role, which had also advanced quite deeply into professional territory: the raft of MCAs at one of our evaluation trusts (the MCA case) and the single C-SW at Hillingdon.

The results from these six cases suggest that some care is needed in generalising about the impact of extended support roles on occupational jurisdictions at the nurse interface. The one generic issue to emerge at this interface was nurse accountability for the tasks performed by nurse support workers with extended roles. Nurses often felt vulnerable, with their registration perceived as being ‘on the line’ if any mistakes were made by the unregistered workers under their supervision. These concerns were apparent despite clear NMC guidance on ‘appropriate delegation’, stressing that nurses are accountable for the decision to delegate to the nurse support workers but not for the performance of the tasks. In others words, if the nurse makes an informed and responsible decision to delegate, they cannot be held accountable if the nurse support worker then goes on to make a mistake. However, perceptions matter, with nurse uncertainty about accountability still generating concerns and influencing the propensity to delegate. It is a finding which suggests that trusts need to ensure that their nurses fully understand their accountability for nurse support workers, with assurance given that as long as they adhere to NMC guidance their registration will be safe.

Despite this generic nurse concern about accountability, the nature and consequences of the impact of extended roles are more usefully seen as related to certain contingencies, in particular why and how the support role was being extended. Thus, AP roles and the extended band 3 roles were introduced in our cases for a number of reasons, with different outcomes for nurse–support worker relations:

• meeting service needs: the specialist Torbay APs, Hillingdon C-SW and OUH SAP cases

• addressing recruitment difficulties among band 5 nurses: the roll-out case

• substituting (typically associated with the search for cost savings): the MCA, MM, roll-out cases

• creating a new leadership role at ward level: the roll-out case.

The development of AP/band 3 roles appeared less of a challenge to RN jurisdictions where they were clearly designed to meet specific service needs. Typically, this was a bespoke process, with clinical areas working through whether or not and why they needed such a role, and, if they did, how precisely it would fit into care delivery and its associated routines. Where the need for an extended AP/band 3 support role was clear and those within the clinical area were involved in its design and introduction, it was typically not seen as a threat to nurses or challenged by them. Such roles were seen as complementary to those of the RNs and with a clear added value. The Torbay case, in particular, highlights this non-threatening approach: the selective introduction of APs only into ward areas which had seen the need for such a role – cancer services and breast care – and following detailed working through of what form the role would take and its training requirements. At Torbay, the AP role was seen to provide a means of developing expertise in certain clinical procedures, which might otherwise not exist. This benefit also derived from the C-SW role at Hillingdon, with the C-SW able to work very closely with patients in managing their stomas prior to discharge. It was an approach predicated on the view that APs and extended band 3s might be needed and could fit in well in certain clinical areas, but not necessarily all.

Nurse jurisdictions appeared much more directly challenged where the AP/band 3 roles were seen as part of a broader attempt at substitution, whether as a means of saving costs and/or dealing with shortages in registered nurses. By definition, substitution dilutes skill mix and involves support workers taking on tasks previously performed by RNs. As noted, depending on how the nurses’ professionalisation project is perceived, this process is not necessarily problematic for nurses. For nurses, the real concern with APs/band 3s lies in the perception that they might be taking on core rather than marginal, routine tasks. This concern was clearly illustrated by the MM case, where the planned MM prompted nurses to question whether or not there were any tasks, other than the handling of controlled drugs, protected for them. According to the survey in this case, APs themselves appeared to be somewhat more sanguine about taking on this role, although in interview even APs voiced some concern about taking on MM. Many such APs had been keen to remain as support workers as a means of retaining direct contact with patients. The same responsibility for drugs which had contributed to nurses being driven away from the bedside was seen as likely to affect support workers at this level in the same way. Similarly, registered midwives, particularly in the community services, displayed concern at the increasing role played by band 3 MCAs in conducting home visits.

Perhaps the most striking example of nurse resistance to the AP role was in our roll-out case. The attempt to introduce the AP role across the whole of this trust provided a particularly stark contrast with Torbay’s more selective approach. Indeed, the roll-out case lends some support to the view that the AP role might be better suited to some clinical areas than to others. In certain, specialist clinical areas in the roll-out case, such as endoscopy and stroke, the AP role was broadly accepted by RNs. However, in the general medical and surgical wards, the APs’ contribution to health-care delivery was less obvious, with the post-holders finding it much harder to gain acceptance.

Interestingly, resistance at the roll-out case was not only from nurses but also from band 2 and 3 HCAs. This was a consequence of design features of the roll-out trust’s AP programme, which allowed outside applicants into TAP posts. ‘Parachuted in’ over the heads of existing HCAs who were not selected for the programme, these external TAP recruits caused resentment among HCAs. However, it was the resistance of the nurses which proved particularly significant in the roll-out case, reflected in trained APs often being restricted to the performance of basic care tasks, with little use being made of their extended skills. Indeed, the roll-out case illustrated the fact that, even where an AP training programme appears to be successful in terms of completion rates, unless the role itself is accepted at ward level by team members it runs the risk of still being marginalised.

The impact of pursuing the final objective, developing the AP role as a new leadership position, on boundaries at the nurse–support worker interface proved more difficult to assess. This objective was articulated in only one of our cases: the roll-out trust. It was underpinned by quite a strong organisational rationale. Given increasing public policy attention on direct care delivery and RNs’ drift away from the bedside, the trust felt that there was scope to develop an AP role with dedicated responsibility for direct bedside care, through co-ordinating and managing the band 2 and 3 HCAs on any given shift. Indeed, this leadership role was envisaged as broadening to take on more general line management responsibility for HCAs such as on-ward induction, mentoring and performance appraisal.

The effect of such an AP leadership role would clearly have been to reinforce or exacerbate the RN departure from the bedside. However, and in doing so, it begged a number of different questions. For example, where did accountability lie in instances where a non-registered support worker directed other support workers in care delivery? What, if any, authority would the AP have in directing nurses, not least given that nurses were still often involved in some aspects of the fundamentals of care?

In the event, this AP leadership role at the roll-out case gained limited traction, rendering it difficult to gauge nurse responses. The failure of such a leadership role to make headway at the trust might well reflect the concerns highlighted above, but more profoundly it can be linked to the dilemmas faced by a trust in using the AP role to pursue various, often conflicting, goals. Thus, it can be seen above that the roll-out case trust was seeking to use the AP role to address a range of objectives: nurse recruitment difficulties; cost reductions; and improved bedside leadership. These goals were not necessarily compatible, with the former two arguably driving out the latter. If the AP role is being used to fill nurse posts and dilute skill mix, it has to be carrying out tasks traditionally performed by nurses, such as MM. These are the very tasks likely to take the AP away from the bedside and prevent the post from being used to lead and direct bedside care. If the AP role is to be used in this leadership capacity, it has to be based on additional staffing, that is to say a new AP post, rather than as a replacement for a RN.

The bands 2 to 4 interface

Our study suggests that the RN–support worker boundary is not the only one to generate jurisdictional issues. There remains some debate on the boundaries between support roles at pay bands 2, 3 and 4. This debate was evident in the scoping phase of our innovation theme and during our four regional engagements workshops. Thus, it was clear from both sources that trusts were often unclear about whether or not there was a meaningful substantive difference between support roles at these different levels. In general, the band 4 AP role was seen as distinguishable from bands 2 and 3; it was qualitatively different in terms of the tasks performed. While unregistered, the AP role was nevertheless rooted in a robust training programme: a 2-year FD, underpinned by workplace learning and the acquisition of appropriate competencies. While residual concerns remained about the delivery and substance of this training, not least related to its sensitivity to specific trust needs and circumstances, the training provided some confidence in, and assurance about, the capabilities of APs. In the context of a much more uneven approach to the training of band 2 and 3 HCAs, and a traditionally less ordered approach to the development and use of workers at these levels, trusts were finding it much more difficult to differentiate between band 2 and 3 HCA roles and to establish sharp boundaries between them.

The blurring of the boundary between bands 2 and 3 was highlighted in our four regional engagement workshops, with views varying on the steps to be taken to address it. The ‘future nurse support role’ model, embracing emerging standard practice (see Figures 11 and 13), included the clarification of band 2 and 3 role boundaries. Indeed, at these workshops, attempts were made to hammer out differences between band 2 and 3 roles on the basis of autonomy, capacity to recognise and respond to care needs, and level of skill. In practice, some trusts were seeking to formalise and reinforce the distinction between these bands by developing distinct sets of band 2 and 3 competencies. There were, however, other trusts less convinced about the substantive difference between band 2 and 3 HCA roles, in particular whether or not any such difference was significant enough to justify fine-tuning the grade mix to reflect it. For such trusts, the band 3 support role was increasingly becoming a redundant grade, with their nurse support workforces solely comprising workers at bands 2 and 4.

The nature of change and the support worker

Institutional theorists have traditionally found organisational change problematic. Institutions are, after all, enduring systems and structures which shape behaviour on a recurring basis. More precisely, Scott defines institutions as consisting of:

. . . cultural-cognitive, normative and regulative elements that . . . provide stability and meaning to social life. . . Institutions are transmitted by various carriers, including symbolic systems, relational systems, routines and artefacts. . . They operate at multi levels. 75

p. 11

A few features of Scott’s definition are worth stressing for our purposes. First, the definition identifies various ‘elements’ as the source of stability and meaning: a regulative element, which might be viewed as formal rules, often grounded in means–ends rationality; a normative element, apparent in less formal rules, typically rooted in non-rational values and beliefs; and cultural-cognitive element allowing actors to interpret or give meaning to such rules. Second, the definition acknowledges that these elements might operate at different levels, including various organisational levels. Finally, Scott’s emphasis on ‘stability’ might be seen to reflect a traditional bias in institutionalism towards inertia: actors are deeply embedded in institutions, which constrain their behaviour and render change difficult. 39

It has long been acknowledged that acute health-care trusts are remarkably complex organisations in these institutional terms. They operate at myriad levels and display considerable vertical and horizontal differentiation, the latter reflecting the diverse clinical needs addressed by any given trust. Indeed, in dealing with a range of patient conditions, these various clinical areas have often developed their own institutional logic and set of institutional practices. Of course, the situation is even more challenging for trusts, given that such diversity is managed under a single trust governance structure, accountable for all of its activities.

Nurse support workers are particularly deeply embedded in the distinctive institutional practices at the level of the clinical area and, indeed, the individual ward. This might be seen as in part related to the unregistered status of such workers. The use and management of support workers is not subject to the standardisation of training, expected behaviours and discipline typically wrought by a national model of statutory regulation. Falling beyond this form of regulation, the treatment of nurse support worker becomes much more malleable and sensitive to the needs and circumstances not only of the trust, but of the clinical area and the ward in which they work. Less formal, normative mechanisms on the use of support workers at these levels come to complement, and sometimes subvert, more formal national and trust regulatory mechanisms on the use and management of this group of workers.

This diversity of institutional practice between clinical areas and wards in the same trust helps to account for the difficulties highlighted by a number of our case study organisations in implementing support worker initiatives, particularly top-down and across the whole of a trust. Often, such initiatives simply ‘bounced back’ and were not perceived as sensitive enough to local ward practices. This was particularly the case with the HCA beginner competencies initiative. A number of wards had already developed starters’ competencies more attuned to their needs, and felt that the trust-wide initiative was either unnecessary for them or not sensitive to their own competency frameworks. Similarly, in the AP roll-out case, the trust encountered difficulties in gaining acceptance for the AP role, especially in general wards, where it was perceived as not easily accommodated within established routines. Indeed, it might be argued that the introduction of the MCA within the context of a broader service reorganisation represented a determined senior management attempt to break through the traditional institutionalisation of workforce practices in maternity services at the trust, an attempt which elicited a strong backlash by staff and considerable demoralisation.

A more specific example of the power of ward-based institutions to shape the use and management of nurse support workers was the nurse–support worker skill-mix ratio on any given shift. In a number of our trusts, this regulative mechanism had not been modified to account for the development and presence of an AP(s) on a shift: as we have seen, APs are unregistered but often highly trained and capable of performing extended roles. In the absence of this modified approach to skill mix, the tasks performed by the AP on a shift were determined not by the capabilities of the AP but by whether or not he or she was included in the nurse or the support worker skill-mix numbers: counted in the former, clearly the AP was in a nurse ‘slot’ with the scope to perform an extended role; counted in the latter, the AP was classified as a carer and restricted to undertaking more routine tasks.

Institutional entrepreneurs

Our study has highlighted the importance of various individuals willing and able to break through institutional constraints to facilitate and drive change in the use and management of nurse support workers. The research literature has referred to these figures as institutional entrepreneurs. 40 In our innovation theme, two of the cases centred on such IEs: the HCA development nurse at UCLH and the CSW trainer at OUH. More broadly, such figures emerged in a number of our other cases: the AP project co-ordinator in the roll-out case; the consultant dermatologist involved with the SAP at OUH; the key figure in the Torbay ED; and the nurse consultant so prominent in developing the C-SW role at Hillingdon. Indeed, the ubiquity of such figures is testament to their importance in attempts to change the use and management of support workers.

Drawn from our cases, these IEs appeared to have a number of characteristics, capabilities and resources.

Institutional work

The institutional change literature has moved on from what some have viewed as an over-reliance on the ‘heroic actions’ of the IE. The notion of ‘institutional work’41 is designed to draw attention in part to the wide variety of actors working alongside, often in support of, the IEs in bringing about change. However, this notion also highlights the wide variety of techniques used by such actors, often on a sustained and routine basis, to disrupt, create and maintain institutions. 41

Attention has already been drawn to the range of actors involved in seeking to change the use and management of nurse support workers. Emphasis has been given, in particular, to the importance of partnerships between different functions. Two additional actors are worth highlighting in this context. The first such actor is the trust’s support worker education lead, often crucial in developing the training and education programmes needed to extend the nurse support role. The importance of these education leads was clearly illustrated in the case of the SAP, with the education lead at OUH able to translate the consultant dermatologist’s aspirations for the role into a viable training programme through the design of the FD. The education lead at Torbay was similarly important, developing a strong relationship with the local college to devise a FD well suited to the trust’s needs.

More generally, it can be argued that RNs working alongside the nurse support worker also play a crucial, but often overlooked, part in institutional change. We have seen that change often rests on training up support workers to perform new tasks in order to extend their roles. This training is, in turn, heavily dependent on workplace learning and the willingness and ability of RNs to provide and supervise such learning and to sign off competencies once acquired by the support worker. Findings from our three themes suggested that supervision and sign-off were often problematic. Nurses did not have the time, the opportunity and, in some instances, the inclination to supervise support workers. Certainly, these difficulties were apparent in the MCA case as well as in attempts to develop the beginner competencies in one of our ECs. Indeed, recognition of these difficulties was encouraging some trusts to seek more efficient and effective ways of supervising support workers, whether through the creation of protected time on shift or through the development of roles dedicated to such supervision.

This is not the place to explore the wide range of techniques associated with institutional work, and used to disrupt, create and maintain institutional practices associated with the use and management of nurse support workers. 42–44 It is sufficient to say that central to the application of these techniques is the search for legitimacy, seen by institutional theorists as the basis for such practice being accepted or taken for granted at the workplace. 76,77 There are grounds for arguing that many of the practices presented in our IC studies had become legitimised and embedded in local routines; certainly this was apparent in relation to the C-SW and the SAP roles. Both cases were small scale – involving single post-holders – and their incremental or organic development allowed them to mould themselves around established ward/departmental practices and to become trusted by colleagues. It was also stressed that the establishment of these roles rested on a confluence of organisational need and the availability of a person well suited to meet this need. This tight ‘organisation need–available person’ nexus raises some interesting questions about the sustainability of such roles: if their legitimacy rests so much on who performs them, it remains open to debate as to whether or not they will survive when the current post-holder leaves.

More generally, the one process which consistently emerged as crucial to the legitimacy of changes in the use and management of support workers was involvement, and the degree to which institutional change was inclusive of different stakeholders. Given the range of actors with a stake in support roles, legitimate change would seem to require a process which builds consensus on the nature of the change and the ways to progress it. Despite the difficulties of implementation highlighted in our EC study, the CF was founded on this premise, seeking to heighten awareness among and engage workplace actors in the different stages seen as underpinning the redistribution of nursing tasks and responsibilities.

Indeed, in a number of ECs, the trusts acknowledged shortcomings in communicating with and involving key stakeholders. In the roll-out case, there was a general view that the nature of the AP role and the reasons for its introduction were not fully understood at ward level. In the new 2-week HCA induction case, matrons had been consulted about the design of the programme but ward managers had not, while the downgrading of many band 7 midwifery roles in the MCA case dissipated any support for broader organisational change in the midwifery services and any willingness to engage in the implementation of this change.

Recommendations for future research

Against the backdrop of these limitations, a number of recommendations on future research in the field of health-care support workers in acute care can be presented:

• Further research is required into different functional views on, and approaches to, the management and use of health-care support workers. Our research has found that the efficacy of trust attempts to innovate and develop support roles is crucially dependent on partnership working between functions: for example, nursing, HR and pharmacy. However, such partnership working has also been revealed as often problematic, not least reflected in differences of perspective on whether or not and how health-care support workers might be developed. More research is needed to explore such differences of perspective – their nature and intensity – and how they might be reconciled.

• There is a need for more research on the resistance faced at ward level as new support roles and ways of working are introduced. Our research has suggested that, regardless of how well support workers are trained and however well planned their introduction, new roles and practices can still be contested by members of the ward team. Unless new health-care roles and practices are accepted by colleagues, the investment made in them might well be wasted. Our work indicated that this resistance in part stemmed from uncertainty about whether or not and in what sense RNs were accountable for support workers, a particular concern given the growing pressure on nurses to delegate tasks. A focused piece of research on perceived nurse accountability for support workers might contribute to attempts to address these uncertainties. More generally, there would be considerable value in undertaking ethnographic studies on how new support roles are viewed, developed and used at ward level, as a means of exploring and then addressing resistance to them.

• Public policy developments are likely to create a new but still uncertain training agenda for support workers, related not least to the Skills for Health minimum training standards64 and the Cavendish Review’s65 call for a care certificate. Given the uneven development of training for support workers, trusts are likely to vary in their need and capacity to meet the challenges associated with this new agenda. A research project working closely with trusts, and adopting a training needs analysis approach, would help these organisations to address the new training agenda, and generate a deeper understanding of how they approached the development of their support workers to deliver higher-quality health care.