Unit Seven

Integration of health care assistants into the general practice workforce

Unit key benefits

Reading this unit will:

  • explain how team working helps to deliver better services and underpins good clinical governance
  • describe the benefits of having a clear understanding of responsibility and accountability within team
  • explains how tasks and responsibility are cascaded down practice teams and why supervision is important
  • describe the potential for conflict and how this can be avoided.  

Team working and integration

The importance of good teamwork has been emphasised in many government documents.1–4 Teams produce better patient care than single healthcare workers operating in a fragmented way.5 Development through the exchange of knowledge and skills is enhanced, and learning is more readily retained within the team.

A group of people who happen to work or meet together are not always a team – and nor do they necessarily have to be!

To be a real team, the group must have certain characteristics.

  • Team members have shared work objectives, interact together to achieve them and have defined roles.
  • The group forming the team should have an organised identity with a defined function, be recognised as a team by others and affect change through the performance of its team members.
  • The members are interdependent for the provision of effective services.

The national report The Effectiveness of Healthcare Teams in the National Health Service7 showed that team working delivered effective and innovative healthcare for patients. Effective teams were those that:

  • emphasised quality, had clear objectives and had high levels of participation
  • introduced more innovations in patient care
  • had members that worked well together with relatively low stress levels
  • communicated and integrated well
  • had good-quality meetings
  • showed clear leadership with effective team processe
  • showed higher levels of innovation in patients’ care – innovation was associated with a diverse range of skilled people working together, particularly in primary care.

It’s important to consider to what extent the team or teams you belong to share these characteristics. Very high numbers of people working in health and social care say they work in a team, yet very few teams appear to share these characteristics. Why might that be? As we shall see, there are many significant barriers that need to be overcome in order for teams to be truly effective. If they are not overcome you may find yourself working in a ‘pseudo team’, in which team processes are not sufficiently developed or effective.

Of course, health care assistants (HCAs) are an integral part of any primary care team and an increasing number of general practice teams. With ever increasing demands on the services provided by GP practices, new challenges and opportunities are emerging for HCAs and other groups of staff through the emergence of new roles, responsibilities and ways of working. Services are being delivered in new and exciting ways as part of an ongoing radical programme of reform and modernisation intended to deliver services in a way that is determined by the needs of patients and the public. All this presents major challenges to even the most effective of teams.

In this context, planning for the adoption and integration of new roles, including that of the HCA, is being largely determined by the increasing needs of the service users. Some, particularly innovative practice teams, may consider developing roles that go well beyond existing role boundaries with a very specific set of responsibilities to meet very specific needs. What effective teams need are the right resources to do the job – or to come up with new ideas and solutions to get them! They also need the right support to develop effective ways of working as a team. The HCA role is an increasingly important resource in many primary care and practice-based teams.

Effective team processes are in place when team members:

  • are clear about their roles and responsibilities
  • understand how they need to work with other teams to provide the right service to a high standard
  • have clarity of leadership roles and responsibilities
  • are clear about the task and objectives of the team, and how every team member contributes to them.

Not only does it feel good to be a member of a really effective team but in a really high-performing team, team members take a real and active interest in each other’s development.
 

In some cases, this might mean improved access to excellent care by freeing up differently qualified staff to do complex tasks, and provide enhanced job satisfaction to those providing care and treatment in a practice. Cost effectiveness dictates that expensive and highly trained staff need to be performing tasks in accordance with their skills and abilities.

Task and responsibility cascade:

Task and responsibility cascade

For example, as the how diagram above shows, many tasks and responsibilities that were once the domain of medical practitioners have been taken over by professional nurses. Many tasks previously done by professionally trained nurses are now done by HCAs. This is good for patients and the public, and also creates the opportunity for team members, with clearly identified roles and responsibilities, to fulfil their own potential. It is important for all healthcare workers in the practice team, as well as patients and the public, to know what the role of the HCA (and others) is and how this role is different to others. This clarity is an important part of the integration of the HCA role into the team.

The concept of the team in primary healthcare is a very dynamic one. The team needs to change and adapt to meet the changing needs of patients and groups of patients in different situations, and to reflect the changing nature of healthcare delivery. We are rarely members of only one team and may find ourselves contributing as members of different teams at different times, or even simultaneously!

While the benefits of effective team working are well recognised, we know that team working is hard work! The potential for conflict is enormous and will exist wherever there is a difference. The way teams work with the diversity they represent is also a vital component of their effectiveness.

Difference and associated conflict may manifest itself in many ways. For example:

  • when HCAs have been recruited from existing reception staff, resentment from former receptionist colleagues may occur if the HCAs are seen as being ‘above’ them in the pecking order of a hierarchical regime
  • practice nurses may be resentful that simpler tasks are removed from them, giving them more complex and demanding work patterns
  • practice nurses may regret the loss of some practical skills to HCAs
  • practice nurses may feel imposed on if their support for training and supervision has been assumed rather than gained through full involvement
  • confusion among the practice team may exist over the exact role, responsibilities and associated levels of authority of the HCA.

These may all be symptoms of a lack of true integration of the HCA role into the team.

Good team working requires action to increase the opportunities for discussion between team members about the needs of the patient, and the central role of the patient to the team and the role of the HCA. Regular team meetings and inter-disciplinary/inter-team development can help with the more precise delineation of roles and requirements, as well as defusing possible misunderstandings and resentments.8 Fundamentally, if teams are to be truly effective, spending time considering how they work is as important as what they do and is certainly time well spent.

The section written for HCA members of the practice team contains some ideas and questions to consider to assist you in becoming a full member of the team. However, issues of accountability, responsibility and authority are also team issues, and being clear about these will also help the integration of your role into the team.

Accountability, responsibility and teamwork

Shared accountability for team working is different to professional accountability. Team members take personal responsibility for their own actions and consider how their behaviour affects other team members. Commitments made to the team are critical to achieving high standards of patient care and must therefore be constantly upheld.

Health professionals – like nurses, doctors, dentists, pharmacists, midwives, allied health professions, such as physiotherapists, speech therapists, osteopaths, chiropractors and some healthcare scientists – all have professional accountability and responsibility. They are accountable for the assessment, planning and evaluation of standards of care, and for delegating work to support staff like HCAs.

Professional accountability is different to legal accountability.

Legal accountability relates to the obligation of citizens to obey the laws of the country and to be able to defend their actions through the court if required to do so. Legal responsibility encompasses civil law (eg the duty of care), criminal law (duty towards the public) and employment law (duty towards the employer).

Professional accountability relates to the additional obligation of the professions not to abuse trust and to be able to justify their professional actions, even when they are not against the law. Actions can only be justified if the alternatives, and the reasons and the consequences for taking that action are understood.

So, HCAs, like other team members, are accountable for their actions. All HCAs have social, ethical, legal and contractual accountabilities and are responsible for the tasks that they undertake. HCAs must not work beyond their level of competence.

Hence, the continued supervision of HCAs remains an integral part of the nurse’s role. When a nurse has delegated a task, he or she remains accountable for upholding the principles of delegation and the HCA is responsible for his or her actions, while the nurse holds responsibility for the standard of nursing within her workplace. (NMC Guidance: Delegation of Care. www.nmc-uk.org/aFrameDisplay. aspx?DocumentID=1720)

Currently, HCAs are not regulated, but could be in the future. However, as with other employees, employers of HCAs hold vicarious liability.

Professional regulation exists to help ensure standards of practice and to protect the public, as far as possible, against the risk of poor practice by practitioners who are regulated by their regulatory bodies. Regulation works by setting agreed standards of practice and competence, by registering those who are competent to practise and (if statutory) by restricting the use of specified titles to those who are registered. It may apply sanctions, such as removing anyone whose fitness to practise is impaired and through his/her actions is considered to be a danger to the public. Nurses can be removed from the nursing and midwifery council register if deemed to put the patients in their care at risk.

Accountability for team working includes a commitment that team members make to themselves and their team members to demonstrate the attitudes, behaviours and actions that promote team effectiveness and therefore high standards of care. The part that nurses play in the act of delegation is a critical one and an essential factor in enabling the HCA to become a fully integrated member of the team.

Delegation

Principles of Delegation

The primary motivation for delegation is to serve the interests of the patient and public.

When delegating the registered nurse must ensure that:

  • the needs of patients are always assessed: their personal needs should define who within the team carries out particular activities
  • the level of experience, competence and role of the person to whom the task is delegated is appropriate
  • appropriate assessment, planning, implementation and evaluation of the delegated activity is undertaken
    the level of supervision and feedback is appropriate to the task delegated
  • rigorous protocols clearly define the HCAss role within a clinical activity
  • protocols should be regularly reviewed
  • the competences of the HCA to deliver specific delegated clinical activities must be assessed prior to delegation and reviewed at regular intervals (6 - 12 monthly).

Appropriate delegation can be enabling and empowering and improve the capacity and capability of the team. It can create appropriate opportunities for team members to demonstrate leadership, confidence and authority in enhancing job satisfaction and improved patient care.

Example: Competence, responsibility and authority

Patsy, AN HCA is working in the asthma clinic with the practice nurse. She measures the peak-flow change in a patient being assessed for reversibility, having been previously assessed as competent to carry this out following training and education about asthma (assessed competence). The role forms part of her job description (responsibility). The practice nurse has delegated this activity (authority) to her in full knowledge of her competences and job description. The practice nurse retains the professional responsibility of appropriate delegation and Patsy, although not currently regulated is accountable for her actions.

Delegating to HCAs depends on a clear definition of the role and responsibilities of the HCA, consistent valid training and education, and established competences to carry out that role. Uncertainty about the level of competence makes delegation a risky business and criticisms have been made that untrained people are carrying out tasks that have been traditionally carried out by nurses and therefore raising concerns over patient safety.

The distinction between the roles and responsibilities of professionally trained nurses and HCAs is often not clear to others, as boundaries between different health disciplines are becoming increasingly blurred. Team members, patients and the public frequently misunderstand the difference between the nurse and the HCA role. In order to maximise safety and quality of care, HCAs must only be asked to perform tasks that fall within their assessed competence. However, with a clear understanding of the role and level of competences of an HCA, an HCA can free up the time of a registered nurse to undertake more complex tasks, improve patient care and job satisfaction to both.

Example: Ensuring quality of care

James was being interviewed for a practice nurse post in a general practice. He asked about the support from HCAs and was told that the previous practice nurse, who was taking early retirement through ill health, had trained two of the receptionists to ‘give her a hand’. When James was appointed he found that this training was patchy and, in some cases, unsafe as the HCAs were unaware of their deficiencies and had assumed capacity for a greater range of tasks than those for which they had sufficient training. No external assessment or validation of the training had been sought.

The Nursing and Midwifery Council (NMC) Code of Conduct states that nurses

‘…may be expected to delegate care delivery to others who are not registered nurses or midwives. Such delegation must not compromise existing care but must be directed to meeting the needs and serving the interests of patients and clients. You remain accountable for the appropriateness of the delegation, for ensuring that the person who does the work is able to do it and that adequate supervision or support is provided.’

The lines of responsibility are usually identified clearly within any job description in relation to what the HCA is responsible for and to whom. It is important that the person delegating duties and the person carrying them out have clear understanding of what that responsibility entails.

Protocols and guidelines can help in this process.

However, protocols and guidelines are not the only things that help the integration of the HCA role into the team. HCAs themselves, line managers or team leaders, employing organisations, education providers and patients can all assist with this process. Some of these issues will be looked at in more detail from the perspective of each of these stakeholders in subsequent sections of this Unit.

Summary

  • Team working is vital to providing safe and efficient health services.
  • To be effective, teams need to share a common understanding of their role, responsibilities and where each member fits.
  • The HCA is part of a carefully managed system that allows the delegation of work within the team.
  • Protocols and guidelines provide a framework for managing the delegation of tasks to the HCA.
  • Working in teams also creates the potential for conflict, so this needs to be recognised and managed when it arises.
  • Each of the stakeholders has the potential to make the HCA an effective member of the practice team. 

References

  1. NHS Executive.The New NHS: Modern and Dependable. London: NHS Executive; 1997.
  2. NHS Executive. Working Together. Securing a Quality Workforce for the NHS. London: NHS Executive; 1998.
  3. NHS Executive. Patient and Public Involvement in the New NHS. London: NHS Executive; 1999.
  4. Dunning M, Abi-Aad G, Gilbert D et al. Experience, Evidence and Everyday Practice. London: King’s Fund; 1999.
  5. West M. Health Care Team Effectiveness Project. The Research Findings Register. 2002; Summary Number 847. http://www.ReFeR.nhs.uk/ViewRecord.asp?ID=847
  6. Arthur H, Wall D, Halligan A. Team Resource Management: a programme for troubled teams. Int J Clin Gov 2003; 8(1): 86–91. http://www.cgsupport.nhs.uk/PDFs/articles/Team_Resource_Management.pdf (date accessed: 7 December 2005).
  7. Borrill C, Carletta J, Carter AJ et al. The Effectiveness of Healthcare Teams in the National Health Service. Final Report. Department of Health: London; 2000.
  8. Nursing and Midwifery Council. Code of Professional Conduct. London: NMC; 2004. http://www.ukcc.org.uk/(p53s3dbdtitql1552u3h2a45)/aFrameDisplay.aspx?DocumentID=201
  9. Scottish Executive. Framework for Nursing in General Practice. Edinburgh: Scottish Executive; 2004. http://www.scotland.gov.uk/Publications/2004/09/19966/43301