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Improving care - Integration is key

Safety and quality can be improved through the integration of healthcare assistants in key areas of hospital care, writes Geraldine Talty

Ireland i s not unique in searching for new and innovative ways of providing effective, efficient and financially viable ways of providing healthcare. Governments throughout the world have undertaken health system reform in response to economic, political, ideological or epidemiological processes.

Recently, significant reform policy has been announced with the strategic intent outlined in a number of publications, including the ‘Future Health: A Strategic Framework for Reform of the Health Service 2012-2015’, the Programme for Government and ‘The Establishment of Hospital Groups as a Transition to Independent Hospital Trusts’.1,2,3

These policies aim to deliver:

  • Higher quality services
  • More consistent standards of care
  • More consistent access to care
  • Stronger leadership
  • Greater integration.3

Nursing and midwifery delivers the highest proportion of direct patient care, and therefore, the professions exert considerable influence over whether the change advocated by health policy makers can actually be achieved in clinical practice. The ultimate challenge in Irish healthcare is how to maintain services and improve patient care and outcomes at a time of reduced funding. This requires accelerated change and reform at a national and organisational level.

Healthcare assistants and handovers

In responding to a survey, healthcare assistants said:

  • “There is no handover and we have to ask the nurse about the patients”
  • “I would like to get a handover”
  • “We are just expected to get on with it, but if we had a handover we would know the patients and what was wrong with them”

Healthcare assistants’ experiences of handovers:

  • Find handovers to be informative
  • Handovers give them a strong sense of being part of the team
  • As a result, they feel like they belong and that their role is recognised
  • Some find the handover at times quite long, but also feel it is a good place for learning
  • The nursing staff have made them feel welcome and they feel their relationship with registered nurses has improved

Healthcare assistants
The introduction of the healthcare assistant role was driven to assist in the provision of patient care, allowing the registered nurse and midwife the flexibility to engage in role development to become more competent, expert reflective practitioners and to develop skills to meet the needs of patients.4 As the scope of nursing and midwifery changes with the development of specialist roles, the healthcare assistant role has become increasingly critical to healthcare provision.

The recognised qualification for healthcare assistants is the Further Education and Training Awards Council (FETAC) Level 5 healthcare support certificate. The knowledge gained on successful completion of the programme has had a positive impact on the role of the healthcare assistant. It has led to healthcare assistants having more confidence, greater awareness of the reasons for their work, and increased motivation.5

However, factors identified as inhibiting the integration of healthcare assistants are numerous. They include: organisational culture; resistance to change; lack of understanding by nurses and midwives of the role; the absence of healthcare assistants in staff reports and patient handovers; resources; staff ratios; lack of clinical support; lack of role clarity within the team; lack of respect for the role; and lack of confidence by the healthcare assistant to participate in the team.5 Therefore, a number of factors need to be addressed if the healthcare assistants are to reach their full potential and be integrated as a valuable member of the team and health care delivery system.

A key recommendation of the ‘National Review of the Role of the Healthcare Assistants in Ireland’ included the creation of an environment, and the development of systems, that support the integration of the healthcare assistants into the clinical care team, including participation and inclusion at patient handover.5

Continuity of care in the acute hospital setting depends on the existence of effective and efficient mechanisms of communication between all healthcare teams.6 The handover of information regarding patient care from the nurse or midwife to the healthcare assistant is a vital part of integration into the team.5 However, healthcare assistants are not included in the patient handover at the beginning and end of each day.

Change project
As part of an MSc in Leadership and Management Development with the Royal College of Surgeons Ireland, a change management project entitled, “Improving the Integration of the Healthcare Assistant in a General Hospital Surgical Ward”, was planned, developed, implemented and evaluated. The project is an example of organisational reform driven by nurses. It aimed to implement a key recommendation from the National Review of the Role of the Healthcare Assistant in Ireland, by involving healthcare assistants in patient handover within a surgical ward team.

The significance of handover cannot be overlooked and is considered a crucial part of how nurses communicate. A good handover has a profound effect on improved patient outcomes, increasing safety, reducing repetition, avoiding errors and improvements in patient satisfaction. 7 The project identified that prior to embarking on the change initiative, healthcare assistants were providing care for patients with little knowledge of the patient’s condition.

Recognising that the implementation of change is key to the success of any initiative, a number of change models were explored to select the most appropriate for the planning and implementation phase. These included the Lewin’s ‘Three Step Model’ and Kotter’s ‘Eight Steps to Transforming Your Organisation’.8,9

However, the HSE model for change, as identified in ‘Improving Our Services: a Users’ Guide to Managing Change in the Health Service Executive’,10 was identified as the most appropriate to support the change process. The four stages of implementation: initiation, planning, implementation and ‘mainstreaming’ were used to underpin the process. Trusted leadership and understanding of change, culture, power, resistance and staff engagement were fundamentally important to the success of the change process.10

In addition, considerable examination through SWOT and force field analysis of the gaps with integrating healthcare assistants, role definition, skill mix, quality and safety of the patient and service were undertaken. Nurses and healthcare assistants were interviewed using a semi-structured standardised questionnaire, which was designed and tested in advance.

Following thematic and statistical analysis of the quantitative data it was found that 83% (n=5) of healthcare assistants and 44% (n=7) of registered nurses indicated that healthcare assistants needed to be included in patient handover for a variety of reasons, in particular to enhance the quality and safety of patient care.

Other areas identified for future consideration to improve integration of healthcare assistants included: training in palliative care; wound management; blood sugar monitoring; stoma care; pressure area care; and the removal of intra venous cannula.

Other interesting findings showed that:

  • Staff are aware of healthcare assistants’ roles as detailed in the job description
  • Of the 16 registered nurses that participated in the semi-structured interviews, all stated that they had not availed of the awareness programmes, provided on the delegation of tasks to healthcare assistants.

The healthcare assistants reported that since the change was implemented, they feel their role in the team is stronger. Their inclusion in handovers has led to them feeling more equipped about caring for patients, from admission to discharge. They have said that it will take them time to fully adjust to this new environment, but they are committed to the change.

The registered nurses reported that they believe the participation of the healthcare assistant at patient handover is a forward step in their integration, which will lead to improved patient care.

Opportunities in economic challenging times
“Periods of economic downturn can be times of innovation for service delivery and dynamic changes in roles and skill mix. Nursing may not realise it but it is in pole position to give voice to the quality principle and lead the development of new models of care.”13

In recent times, the most significant issue impacting on labour markets is the global economic downturn.11 Management teams, desperate to stay within budget and deliver good quality care to increasing numbers of patients, are facing difficult decisions. The challenge is to ensure that the focus is not just on money, but also on the effects of changes to the quality of patient care.12

Healthcare assistants are received positively in areas where they have been introduced in a systematic approach with numerous benefits now recognised by the health service. Healthcare assistants can make a significant contribution through working in close collaboration under the direction of the nursing and midwifery profession, to improve services to patients and enhance capacity to utilise the skills of nurses and midwives more effectively, leading to better patient outcomes.

The timely and effective implementation of the initiative, underpinned by the national change management approach, in partnership with relevant personnel at all levels within the hospital, has resulted in a positive outcome. This can be replicated and adapted, not only within the hospital, but throughout the hospital groupings.

Geraldine Talty is a clinical nurse manager 2 at the Midland Regional Hospital, Tullamore and first vice president of the INMO

References available on request from nursing@ medmedia.ie (Quote: Talty G. WIN 2013; 21(10) 36-37

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