Helping health care assistants develop skills in caring for sick children

Introduction

At the UK Association of Chief Children’s Nurses (ACCN) annual educational symposium which was held in the Italian city of Florence in September 2013, the future direction of the education of children’s and young people’s nurses was debated. The University of Florence and the Meyer Children Hospital through the good offices of Professor Filippo Festini, a board member of ICPN, acted as hosts for the symposium. The city of Florence was a poignant venue for the meeting, being the birthplace of Florence Nightingale, the founder of modern nursing, who was born there in 1820.

The ACCN annual symposium brings together child health academics and senior children’s nursing managers from across the UK, but on this occasion colleagues from across Italy were also invited. A principal objective of these annual symposiums is to ensure that children’s and young people’s nurses of the future have the right skill set for future practice.

The symposium was initiated by a thought-provoking presentation by Professor Judith Ellis MBE, Executive Dean of the Faculty of Health and Social Care at London South Bank University. Her paper entitled “Educating tomorrows children’s and young people’s nurses” also highlighted the continuing demand for highly qualified children’s nurses especially in intensive care environments. She also confirmed that the number of undergraduate commissions for children’s nurses in British Universities have actually been cut in recent years. Across the world the nursing workforce is facing significant challenges that may impact on its ability to ensure that future health care remains of the highest quality. It is a shortage of nurses, especially in speciality areas of children’s health care, which is worrying.

It is important to stress in this context that the UK and some European Counties such as Italy have uniquely retained a direct entry children’s nursing course leading to state registration whereas the rest of the world has adopted generic nurse preparation with children’s nursing being offered as a post graduate qualification.

Professor Ellis was emphatic that skill mix in some UK children’s hospitals and child health clinical areas of general hospitals remains problematic with an over reliance on untrained health care support workers (HCAs).

Unlike the USA where the Certified Nursing Assistant undertakes a formal training course in community colleges and is annotated on A Family Care Safety Registry, in the UK healthcare assistants have no compulsory or consistent training and they use a profusion of job titles which confuses patients and clients.

The crisis surrounding the role of HCAs in the UK has worsened following the failures in care which were exposed by the Francs Inquiry into the events at Mid-Staffordshire NHS Foundation Trust (http://www.midstaffspublicinquiry.com/).

The Mid-Staffordshire public inquiry led by the Queens Council lawyer Robert Francis was commissioned by the English Secretary of State for Health in 2010 to investigate the catalogue of events which took place within these hospitals during the period January 2005 and March 2009. In particular it has considered why the serious problems within them were not identified and acted on sooner. The report has identified important lessons to be learnt for the future of patient care. As the role of HCA was highlighted in this enquiry and as this group of health care workers are a large component of the caring workforce in the UK, the Secretary of State for Health asked Camilla Cavendish the deputy editor of the Times Newspaper to undertake an independent review of what steps can be taken to ensure that unregistered carers such as HCAs within the English National Health Service treat all patients and clients with respectful care and compassion (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/212732/Cavendish_Review_ACCESSIBLE_-_FINAL_VERSION_16-7-13.pdf).

Her review was published in July 2013 and contains a number of recommendations for the future preparation of HCA’s much of which is applicable to children’s health care.

Background

Glasper (2011) reminds us that the number of people employed as HCAs in the UK continued to grow after the introduction of the 1919 Nurses Bill which heralded the formation of the General Nursing Council, the predecessor of the UK’s Nursing and Midwifery council. After World War II existing nursing assistants were subsequently enabled to enroll with the General Nursing Council on the basis of their previous experience whilst new nursing assistants had to first undergo a new 2 year enrolled nurse training programme which continued through to the late 1980s.This enrollment of the former HCAs into the nursing profession did not stem the need for HCAs and the demand for increased numbers of HCAs began to grow. Today there are approximately 1.3 million support staff employed in the caring sectors of UK society. Cavendish estimates that the current HCA contingent in NHS hospitals makes up approximately 33% of the total carer workforce and she believes that If the NHS wants to improve patient care, it should see HCAs as a critical, and strategic resource. She indicates in her review that many HCAs feel undervalued and overlooked despite many of them undertaking roles that were formerly the preserve of nurses and doctors.

Importantly for children’s nursing and, unlike the situation in the USA, HCAs have no compulsory or consistent training. The Cavendish review has made a number of recommendations focused around rrecruitment, training and education.

The principal recommendation of the review is that the commissioners of health care education in England should design a curriculum for a “Certificate of Fundamental Care” and subsequently a “Higher Certificate of Fundamental Care” in conjunction with the UK Nursing and Midwifery Council (NMC) Cavendish wants the NMC to incorporate aspects of the current practical elements of the nursing degree curriculum (essential skills) into this new Certificate and also suggests HCAs should be jointly taught with undergraduate nursing students and that both should complete this certificate. As the undergraduate nursing curriculum in the UK is separated into four fields of practice including children’s and young people’s nursing (the others being. adult, mental health and intellectual disability nursing) HCAs who plan to work with sick children should be enabled to acquire those skills commensurate with this special client population. Health care assistants who have completed this new “Certificate of Fundamental Care” should be allowed to adopt the title “Nursing Assistant”. Currently these recommendations for the HCA workforce are generic and not applied to any particular field of nursing. If such HCAs are to make a career in the field of children’s and young people’s nursing the certificate in fundamental care should reflect the reality that children are not simply small adults who occupy less bed space and eat less! Despite this, in giving HCAs the right to use the title “Nursing Assistant” it is hoped that they will adopt the same spirit of unification or esprit de corps which symbolizes the nursing profession and that this will result in the driving up of care standards.

Discussion

With so many unregistered HCAs and support staff in the frontline of UK health care, this lack of formal training can no longer be tolerated. There is no doubt that the model adopted in the USA is worthy of replication but registered children’s nurses in the UK remain uncertain as to what aspects of child care, especially in acute care situations they can or cannot delegate to HCAs.

The tasks undertaken by HCAs range from the routine such as bed making and assisting children to meet eating, drinking and hygiene needs through to the more complex such as cannulation, venepuncture and ECGs. Some will develop and update care plans but in many hospitals HCAs despite delivering care are not allowed to record that care in the child’s records. The educational background of HCAs in the UK is often bewildering with some having foundation degree preparation and others with National Vocational Qualification training and some virtually none. There is no doubt that HCAs want to be educated and trained and be given the ability to progress. Furthermore they want to be recognised for their contribution to the child health care team but regretfully Cavendish reveals in her report that 60% of HCAs feel unappreciated by employers and in some cases feel under pressure to undertake tasks for which they feel incapable, especially during periods of staff shortage. This is not acceptable in acute child care.

Conclusion

The proposed development of certificate of fundamental care for HCAs presents a real opportunity of raising standards of care and in bridging the void between them and nurses. Significantly if this proposal is brought to fruition, specific child care skills will need to be taught to those who seek to work with sick children and young people.

Next year the ACCN are hosting their first international conference entitled “Building the evidence base for practice” on the wonderful Island of Jersey (channel islands) on 4 and 5 September 2014. ICPN board member Professor Tony Long has co-opted other board members from around the world to develop an abstract committee, and successful papers will be considered for publication in sequential issues of the journal.

Declaration of interest

The author declares no conflicts of interest. The author alone is responsible for the content and writing of the paper.