“From doing to knowing”: medical students’ experiences of working as Healthcare Assistants

ABSTRACT

There is growing recognition that doctors need to deliver person-centered care. More evidence is needed on how to best equip students in an already busy curriculum. Providing medical students with the opportunity to work as Healthcare Assistants (HCAs) can help them develop the desired skills. This study examined medical students’ experiences of working as HCAs and perceived impact on their future practice. Adopting an Interpretative Phenomenological Analysis approach, we analyzed narratives from two focus groups of 13 ‘Year 0ʹ and ‘Year 1ʹ medical students, who had completed an HCA project. This project allowed participants to experience a new dimension of patient care whereby learning by “doing” evolved to a deeper level of “knowing” patients, the HCA role and the wider team. Four major themes were identified: seeing the doctor: gaining new perspectives; building confidence: learning from and about patients; understanding the overall patient experience: providing personal care; finding “the person behind the patient”: exploring beyond the diagnosis. This study suggests that working as an HCA enables participants to develop sustainable skills that equip them for their future role as doctors able to deliver person-centered care as part of an interprofessional team. Recommendations for inclusion of this type of intervention into the medical curriculum are discussed.

KEYWORDS:

• medical curricula
• patient-centred care
• healthcare assistant
• values-based practice
• interprofessional
• qualitative research

Introduction

With the growing recognition that doctors must provide more person-centered care, there is a call for a more targeted approach during their education, by allowing students time to connect to and be guided by the feelings of the patient (Knorring et al., 2019). Prominent international academics argue that curriculum leaders should ensure that the skills needed to develop caring relationships with patients are given equal emphasis to students’ clinical competence (Gillespie et al., 2018; Kelly et al., 2020). One way of introducing such skills is to create early opportunities in the curriculum that allow medical students to work as Healthcare Assistants (HCAs) (Walker et al., 2017).

Established in 1986 within the National Health Service (NHS) in the United Kingdom, HCAs are highly visible to patients, predominately spending their time at their bedside. The HCA role is found in many other countries, but with different job titles (Kroezen et al., 2018). As HCAs see and support patients at their most weak and vulnerable, they offer unique role modeling opportunities of how to deliver empathic, person-centered care.

Within their role, HCAs often provide comfort by listening and holding hands (Kelly et al., 2020) thus making time for an “unhurried” pause (Pieterse et al., 2019). By giving the patient time and space to share what matters to them, HCAs often discover valuable clinical information (Spilsbury & Meyer, 2004). This relationship permits patients to be active participants in their own care, and for the HCA and patient to relate to each other on a more human level, which brings with it a number of associated holistic benefits (Ralston & Walsh, 2017). Sadly, the important contribution to the patient’s wellbeing by HCAs often goes unnoticed by doctors – due to the lack of time and/ or the skills and empathy needed to appreciate the value of knowing the “person” as well as the “patient.”

Background

Hojat et al. (2004) stated the importance of helping students retain and cultivate empathy as part of improving clinical outcomes. Within their literature review, Cohen and Sherif (2104) argue that HCA work can expose medical students to important humanistic values, evidenced within their daily contact with patients that can influence perceptions of care. They also found that students felt such an experience provided respite from more structured learning, whilst reminding them of their vocation as a doctor. This was endorsed by medical students Ahmad (2009) and Fearnley (2014) within their experiences of working as HCAs. They identified HCAs as a rich source of information, but also recognized the frequent conflict between taking the time to provide person-centered care and fulfilling more clinical duties as a doctor.

In a meta-ethnographic analysis of how education affects empathy and compassion in medical students, Krishnasamy et al. (2019) concluded that there is a need for innovative strategies that provide opportunities for students to foster a person-centered approach to care. Current literature thus helps educators recognize the importance of providing such learning opportunities. However, there is a clear lack of empirical evidence linked to targeted interventions to support decisions on what to include in the already very busy curriculum. Little is known about medical students’ experiences working as HCAs and what is learnt. This paper presents findings from a study investigating the lived experience of medical students working as HCAs and the perceived impact of this experience on medical students’ values and future practice.

Methods

Study design

Because we sought to understand the lived experience of medical students working as HCAs, we adopted a qualitative design. Interpretative phenomenological analysis (IPA) was selected, as making sense of experience is central to phenomenological enquiry. Based on early work in hermeneutics (Willig & Stainton Rogers, 2008), IPA was developed as an explicit qualitative method of inquiry where the dual process of interpretation, by both researcher and participant, the “double hermeneutic” is central to the analysis (Smith, 1996). By studying participants who have lived the experience, we were able to develop deeper insights into issues that affect the broader context of medical education and the delivery of person-centered care. IPA considers experience or phenomena, as accessible through interpretation and that both participant and researcher are sense makers, and interpreters – one of their life world and the other, interpreting the participant’s sense making (Smith & Eatough, 2007). In this way, the double hermeneutic reflects that both are active interpretative players in the analysis.

Context

This study is focussed around the origins and evaluation of a HCA project delivered to Foundation (Year 0) and Year 1 medical students at the University of East Anglia, from 2015–2018 (Davison & Lindqvist, 2019). Based in a range of different hospitals, students initially complete a three-day induction that equips them with core skills linked to the HCA role including: infection control, basic life support, manual handling (that includes the moving, lifting and lowering of patients), personal hygiene, and nutrition. This enables students to undertake three days of shift work, each shift lasting on average eight hours working as HCAs with patients, under supervision.

Sampling procedure

All medical students who had worked as HCAs as part of this project were invited by e-mail to participate in this study by joining a focus group and were given a deadline by which to respond. In all, 131 (51 year 0 and 80 year 1) students were approached, from which sixty students responded, (21 students from year 0 and 39 from year 1). Participants were purposively selected to ensure wide representation of students who completed the project in either Year 0 or Year 1, across different genders and workplace settings in order to arrive at a cross section of students who would take part in two focus groups. Students who were not selected were thanked for coming forward.

Data collection

Focus groups were used in this study because they offer epistemological flexibility (Wilkinson, 1998) and build complex narratives that explicitly emerge from being in a group (Flowers et al., 2001). Thirteen students were selected to participate in the two focus groups. In order to allow new ideas and experiences to emerge from the data, we used a semi-structured design style adopting an open-ended approach that encouraged participants to expand and discuss their experiences (Langdridge & Hagger-Johnson, 2013). The focus group guide can be found as a supplementary document. Each focus group lasted one hour and was recorded and transcribed verbatim.

Data analysis

Eatough and Smith (2006) describe IPA’s non-prescriptive, flexible guidelines for analysis. Consequently, whilst the ideographic nature of IPA generally favors individual interviews, our study adopts Eatough and Smith (2006) approach when discussing the combining of interview data collated from focus groups. When conducting the analysis process, the preliminary and high-order themes that emerged were subsequently combined into one discreet data set.

ED was guided by JS at each stage of the analysis of the two focus group transcripts using IPA. The transcribed narratives were read line by line and initial thoughts, keywords, recurring phrases and any observations made (Lancer & Eatough, 2018). Detailed notes were kept throughout. The audio recordings were listened to several times to ensure the analytic consensus remained IPA focused and thus avoiding ED superimposing any of her own pre-suppositions, or interpretative bias onto the data (Rodham et al., 2015). The scripts were then returned to and initial thoughts and observations converted into abstract concepts and discreet and articulated themes. This process aided the third stage of analysis where connections were established between the initial concepts and themes and clustered into homogenous groups. After liaising with JS and SL, a series of sub-themes were discovered within the narratives. Finally, subordinate themes were clustered into super-ordinate, higher-order themes that captured the essence of the sub-themes.

Ethical considerations

This project was granted ethical approval from the Faculty of Medicine and Health Ethics Committee at the University of East Anglia (201,819– 033). Prior to the focus groups, the importance of maintaining confidentiality was explained to participants who agreed to take part by signing a consent form. Participants were also given an information sheet and advised that they could withdraw from the study up to the point of validation of the script. They were advised that they would receive a script of the recorded focus group via e-mail, which provided a further opportunity to validate and check their contribution. At this point participant data could no longer be withdrawn. Participants were informed that dissemination of findings from this study would preserve participant anonymity.

Results

Thirteen students whose details are summarized in Table 1 took part in two focus groups: one with seven students (Year 0), and one with six students (Year 1).

Table 1. Participant characteristics, venue for HCA project and year completed.

Participant	Gender	Year of study	Year when project was completed	HCA Project setting
1	Female	Year 0	2017	Rehabilitation and palliative care
2	Female		2017	Acute mental health/ dementia
3	Male		2017	Community rehabilitation unit
4	Female		2017	Acute mental health/ dementia
5	Female		2017	Community hospital
6	Female		2018	Acute mental health/ dementia
7	Female		2018	Acute mental health/ dementia
8	Female	Year 1	2015	Academic teaching hospital
9	Female		2016	Acute hospital
10	Female		2017	Academic teaching hospital
11	Male		2018	Academic teaching hospital
12	Female		2018	Academic teaching hospital
13	Male		2018	Academic teaching hospital

The findings showed that the project allowed participants to experience a new dimension of patient care whereby learning by “doing” evolved to a deeper level of “knowing” patients, the HCA role and the wider team. All participants described lasting impact from the experiences they had during the HCA project and expressed how valuable they had found the opportunity to work in the role of HCA.

We present the four super-ordinate higher-order themes identified from the IPA analysis, which illustrate the lived experience of medical students working as HCAs:

(1) Seeing the doctor: gaining new perspectives;

(2) Building confidence: learning from and about patients;

(3) Understanding the overall patient experience: providing personal care;

(4) Finding “the person behind the patient”: exploring beyond the diagnosis.

Seeing the doctor: gaining new perspectives

The HCA project created opportunities for participants to gain new perspectives of the doctor’s role in patient care. One participant admitted that before this project she was unaware of the HCA role and also how this experience would benefit her as a future doctor. However, working alongside HCAs provided opportunities for participants to observe how HCAs talked to patients and the bonds that formed with them. In contrast, participants noticed that doctor-patient contact was often hurried and brief, with little time to interact, or indeed encouraged:

I think just chatting to the patients, getting to know patients. Really, I feel medicine is often, quite time pressured. I’ve heard doctors say to me “you’re not here to be their friend” kind of “don’t talk to them in that way– don’t get to know them,” whereas as HCA, that was a bit more encouraged. [P9,Year 1]

Some participants described their sense of a clinical “divide,” separating doctors and other healthcare staff. One participant noticed that doctors appeared to ignore HCAs and indeed her, in her role as HCA. Notably, one said:

Hopefully projects like these will be able to help make unity between the medical students and the healthcare professionals as well. [P11, Year1]

One participant agreed that quiet moments spent with patients helped her gain valuable insights into what kind of doctor she wanted to become. When asked to hold a patient’s hand whilst a medical procedure was performed, she realized the importance of having time to be with someone in this way:

… so I just sat there and held her hand, and you know I always hope that I’ve got this kind of time for people … just to be there for people if they need your help and yes, I think it does teach you about the kind of doctor you want to be. [P12, Year 1]

Building confidence: learning from and about patients

Closeness to patients allowed participants to experience a new dimension of treatment that helped to develop confidence. Several participants initially described a sense of powerlessness and the need to learn new skills fast in order to meet expectations. One described her reaction when asked to carry out patient observations early on in her shifts:

I think it also really improves medical students’ confidence cos [because] I know when I started on the first day they gave me the task of taking the obs [observations] on my own with these patients and I was like “oh gosh I can’t do that.” [P9, Year 1]

For most participants, the prospect of working alone and providing hands-on patient care was subsequently viewed positively, with the patient no longer approached with apprehension. Some now preferred the unpredictable nature of day-to-day working on the wards. One described her new sense of enablement and pride:

I know I’m a medical student, but obviously you were given that responsibility as a HCA, and from Module 1 you do know how to do that, and it just gives you the confidence like “oh yes I have learnt this and can do it in real life,” so it’s the first experience of being given a bit of freedom to actually do something good. [P9, Year 1]

Learning from and about patients was woven throughout participant extracts. Some revealed a sense of urgency to connect with patients in order to carry out care, sometimes leaving participants initially feeling confused. One student depicted each patient as distinctly individual, each possessing valuable knowledge she could not initially access. In this sense, patients became “teachers” whereby it was necessary for her to be taught and guided by them in order to provide care.

… because I didn’t know how I was going to interact … some of the patients had dementia, but it was different spectrums … but they [all] had a process … by the end of the third day I had got used to the patients, I knew how to respond to them. [P6, Year 0]

Participants compared their regular placements and taught medical practices to providing basic hands-on care and spending time by the patient’s bedside as HCAs. They believed this experience had enhanced their learning, compared to their more “rehearsed” regular placements. Patients had become a valuable source of knowledge that participants were both keen and anxious to discover, such as when feeding a person with dementia:

… he was in a chair and [I was] feeding him … I don’t think I have ever been in a position … He just wasn’t aware … I was thinking “am I feeding him too fast, or too slow?,” “is this cold?” … I was thinking “I have never thought about this before.” So it was quite nice – it was different. [P5, Year 0]

Understanding the overall patient experience: providing personal care

Some participants viewed their upcoming HCA training and shifts with unease - regarding it as unpredictable, unpractised territory. Another felt daunted when they had to provide personal patient care for the first time:

… I’ve never cleaned a patient before and I think at first, when it was said to me, it was a bit daunting … it’s not something that you are told to do as a medical student. [P11,Year1]

Other participants valued the opportunity to experience providing personal care for patients, something they agreed they might have missed had they not taken part. One participant also recognized how the time spent providing personal care can help improve patients’ overall experience:

… I think for example, when you are helping a patient wash and dress that’s something you probably won’t do now as a medical student and you learn so much about that, like making sure the patient’s OK, finding out how you can help them [P5,Year0]

Another realized just how challenging it can be to be stripped of one’s clothes and dignity, but how the HCA can help make this easer:

I remember having a man that was crying and he was so emotional, he was trembling and just said … “I don’t want you to see me [naked] as I have never been with a woman” and he was really embarrassed … afterward he held my hand and he said “thank you, you’ve made my stay in hospital, you’ve actually made me feel comfortable.” I think that was my main memory of the HCA project, because it made it human, it made it real. [P10,Year1]

Finding “the person behind the patient”: exploring beyond the diagnosis

Providing hands-on care and spending extended lengths of time by the patient’s bedside, allowed participants time to reflect on the importance of exploring “beyond the diagnosis.” Being alongside and sitting with patients was for many participants new to them. Afternoons and evenings were described by several, as times when patients often appreciated company. One discovered how much her time spent with apatient was valued:

There was this one patient who I got close to as she asked me to read out stories for her and I used to sit there reading out loud like an hour every evening … By the end of my shift she said: “oh, are you leaving and are you coming back tomorrow?” and I said that: “it’s my last shift” and she was quite sad. [P4, Year0]

Participants realized that patients were valuable holders of knowledge that awakened a new awareness and thirst to think like and discover the “person behind the patient.” One had, since the HCA project, become aware of the importance of picking up on cues:

You notice the little things and I think that when the patient does disclose something that isn’t medically related I would explore that a little bit more. [P6, Year0]

Patient’s lives and their wider needs came into focus dissolving perceived differences between doctors and patients:

… at the end of the day the only thing standing in the way between you and a patient is circumstance … any of us could be a patient at any time in our life … The HCA project really I think cemented that for me. [P12, Year1]

This project also provided participants with powerful, memorable experiences and opportunities to understand how HCAs care for the patient as a person, even after their death, as one participant described:

There was a patient who had died on the ward … You have to dress them in these special white sheet things, which I’d never seen before as a medical student and still haven’t seen since. … What stays with me was the care that was displayed. The kind of feeling I felt there I hope to carry with me when I’m a doctor as well. [P9, Year1]

Participants reflected on how their deeper patient awareness could be applied to medicine in terms of respecting “what means a lot” to patients in order to gain a better understanding of them. One described “connecting” with patients as “humbling” believing the project to be an affirming experience. Another mentioned that taking part in the HCA project early in their learning had allowed them space to think holistically, focus on listening and responding to patients’ needs:

The fact we did this project early in our Foundation year … forces you to think holistically about the patient, rather than just a medical perspective … some patients I did think “I wonder what’s wrong with this patient,” but that’s a very transient thought and you think more about other things [that] are more important at that point. [P3, Year0]

Discussion

Principal findings

This study explored the lived experience of medical students working as healthcare assistants (HCAs) and the perceived impact of this on their future values and practice as doctors. Our findings show that participants were positively affected by their experience working as HCAs and with lasting impact of this on their values and future intended practice. This study identified four super-ordinate high-order themes describing how participants: i) gain new perspectives on the doctor’s role in patient care from a HCA vantage point; ii) build confidence by learning from and about the patients; iii) develop understanding of the overall patient experience by providing personal care; and, iv) begin to look beyond the diagnosis and appreciate the human dimensions of care, whereby the person within the patient becomes evident.

Early exposure to hands-on fundamental care helps participants appreciate that they can learn from both HCAs and patients in ways that transcend the classroom and placements. Unable to rely on their existing medical knowledge, participants initially experienced a sense of unease and vulnerability in the patient’s presence. This study reveals that working as HCAs allows participants to appreciate the difference between “procedural touch” associated with physical examination, and “expressive touch” conveying emotion, connection and humane understanding (Kelly et al., 2020). Notably, by performing unpractised, hands-on patient care, knowledge is gained from both HCA and patients that allows participants to appreciate the necessity of practising holistic care alongside clinical skills specifically related to medicine.

Connecting with patients

As part of the provision of care Kelly et al. (2020) also emphasize the need to maintain eye-contact, be aware of body language and to read a patient’s facial expression. These elements of connection are strongly identified in our study. This suggests that active learning, in the presence of the HCA and patients, can provide medical students with unique role modeling opportunities. This can potentially be very impactful, not only when it comes to helping students develop skills directly related to patient care, but also in shaping students’ values and attitudes toward HCAs and their contribution to care. Ultimately, this can influence their future quality of interprofessional collaborative practice, thus creating more “unity” amongst professionals. Creating learning opportunities for students to witness positive role modeling examples are key within early years when attitudes toward other members of the interprofessional team are formed (Hawkes et al., 2013).

Time is a most common barrier to shared decision making. When pressurized, doctors may communicate with a complexity and tempo that may easily overwhelm ill and worried patients (Pieterse et al., 2019). This study provides a valuable alternative insight into the impact made on participants having witnessed the HCA’s patience and time available to care, talk and listen to patients, that they in turn emulate. However, results presented here further highlight the known dilemma faced by doctors with limited time that prioritizes diagnosing and treating patients. Interestingly, it also reveals how participants notice that doctors do not always appear to recognize, or appreciate, the HCA’s skills, potential and contribution to holistic patient care. Working as HCAs allows participants to witness HCAs’ ability to use their time while performing basic tasks to discover other facts about the patient. This suggests that these participants will seek and listen to the views of HCAs as future doctors, knowing how much more time the HCA spends alongside patients.

Experiencing the HCA role

Being alongside and caring for patients is cited by participants as their most challenging, yet memorable experiences, amplifying the importance of thinking “beyond the diagnosis” and integrating empathy into their existing skills. Branch et al. (1998) discuss such “seminal moments” experienced at the bedside, described by participants as “humbling” and “memorable,” that ultimately inspired them to reassess their values. Krishnasamy et al. (2019) and Jeffrey (2016) both stress the need to introduce medical students to a more person-centered approach to care, that develops understanding of empathy as being of equal importance to other clinical skills within the curriculum. This study suggests that this type of experience allows participants to appreciate and relate to the patient’s vulnerability on a deeper level.

We suggest that by introducing the HCA project early, students will be able to enhance their ability to recognize the human side of care at the outset, to help them develop into more patient-centered doctors (Knorring et al., 2019). A follow-up study will be a useful next step to investigate the longer-term impact of this project on these students as they work as doctors. It is this study’s recommendation that all medical students could benefit from experiencing working as HCAs in the early years of their course, in order to provide a grounding and basic awareness of the need for doctors to provide holistic, person-centered care as part of an interprofessional collaborative team.

Allowing medical students to step outside their familiar learning environment and into the role of the HCA, helps them understand concepts that are merely abstract in the classroom (Dharamsi et al., 2010) and to practise very different skills compared to their regular placements. The HCA project offers valuable experience-based learning through actively contributing to patient care, thus easing the transition of newly qualified doctors into practice (Coakley et al., 2019). Immersion in the practice setting makes participants appreciate their own and the patient’s vulnerability. It also helps develop a genuine desire to build relationships with patients and colleagues based on empathy, care and compassion. This underscores the importance of showing early learners what person-centered collaborative care looks like as part of the medical curriculum (Knorring et al., 2019), and why caring relationships have equal value to clinical competence (Gillespie et al., 2018).

Strengths and limitations

The qualitative design of the study enabled a thorough exploration of the phenomenon from the students’ perspective. Whilst individual interviews are commonly used when conducting IPA research, the focus group design allowed group discussions to generate diverse views. Future research using individual interviews may allow a deeper exploration of some of the themes. Additionally, this study included participants who had completed the project in a hospital context. The current HCA project now also offers shifts in care homes, and future research could therefore investigate whether students perceive any differences between learning and working as HCAs in care homes compared to the hospital setting. The double hermeneutic, interpretative analytic work, is limited always by both the researchers’ own “presuppositionless apprehending” (Heidegger, 1962) of the phenomena and the limitations of any participants’ ability to articulate their sense-making through language. Nevertheless, IPA offers a strong and clear opportunity for dynamic, analytic work allowing back and forth across accounts and interpretations that offers as proximate an understanding as possible, through the idiographic commitment to systematic exploration of experience.

Conclusion

Working as HCAs allowed participants to encounter a new dimension of patient care whereby learning by “doing” evolved to a deeper level of “knowing” patients, the HCA role and the wider team. It also offered them an opportunity to learn how they want to be as future doctors. Working as HCAs early in their course can enable medical students to recognize the meaning of person-centered care and how “little things” matter. Findings of this study suggest that this type of educational intervention is worthy of investment into the medical curriculum in building confidence, awareness and perhaps resilience too. The ability of actively being able to develop caring relationships with patients and members of the wider team, such as the HCAs, is likely to positively impact on outcomes. Certainly, this study implicates that doctors may be able to gain strength by taking time to acknowledge their own and their patients’ vulnerabilities.

Conflicts of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Acknowledgments

We wish to thank the participants for taking part in our study and all our wonderful practice partners without whom we could not deliver the HCA project. Special thanks also to Charlotte Salter, Kevin Bryant, Sally Homden, Atiya Jannat and Kim Martins who assisted with the study process at various stages.

Supplemental Material

Supplemental data for this article can be accessed on the publisher’s website

Additional information

Funding

No funding was received for this study.

Notes on contributors

Elizabeth Davison

Elizabeth Davison is a Research Associate in the Centre for Interprofessional Practice, Norwich Medical School at the University of East Anglia. Her research interests are focussed around investigating how best to prepare students for life-long interprofessional learning and working.

Joanna Semlyen

Joanna Semlyen is an Associate Professor of Psychology and Medical Education at University of East Anglia, a Registered Health Psychologist (HCPC) and a Chartered Psychologist (BPS). Her interdisciplinary research focus in medical education includes curriculum development and diversity in medical education. She has particular interest in developing qualitative methodologies in health professions and is regional lead for Interpretative Phenomenological Analysis (East of England).

Susanne Lindqvist

Susanne Lindqvist is a Professor of Interprofessional Practice at University of East Anglia. She is Director of the Centre for Interprofessional Practice and Director of Educational Strategy and Learning and Teaching Quality at Norwich Medical School. Her research interests focus around key elements that underpin optimal interprofessional practice in education and the workplace.