Assessing the implementation process and outcomes of newly introduced assistant roles: a qualitative study to examine the utility of the Calderdale Framework as an appraisal tool

Figures & data

Table 1 Overview of new roles projects

Project 1: The implementation of a speech pathology assistant utilizing a traineeship approach.

Workforce change tool employed: No

Setting: Rehabilitation, aged, and community care service within an Australian metropolitan health directorate.

Roles: Delivering group therapy, direct client contact, indirect client contact, file reviews and preparation of files, resource preparation, and administration.

Methodology: Mixed methods: interviews with key stakeholder groups involved in the development and delivery of the role, including the speech pathology assistant (n = 1), service users and their carers (n = 5), speech pathologists who worked with the trainee speech pathology assistant (n = 3), and managers involved in the development and implementation of the role (n = 5). Documentary evidence provided by the training institute and a time use analysis were included.

Project 2: The implementation of a podiatry assistant utilizing a traineeship approach. The podiatry assistant was introduced to replace enrolled nurses performing basic foot care.

Workforce change tool employed: No

Setting: Community health and continuing community care service within an Australian metropolitan health directorate.

Roles: Provision of basic foot hygiene (eg, wiping down of the feet, cutting of nonpathological nails, filing of rough skin, and applying cream), assist in nail surgery, do basic modifications to orthotics, padding, and strapping.

Methodology: Qualitative interviews with key stakeholder groups involved in the development and delivery of the role, including the podiatry assistant (n = 1), service users (n = 5), a consumer group (n = 3), podiatrists who worked with the podiatry assistant (n = 3), enrolled nurses who had previously performed the role (n = 3), and nursing and allied health managers (n = 5).

Project 3: The introduction and evaluation of an assistant practitioner in occupational therapy.^Citation9

Workforce change tool employed: No

Setting: A new transition/intermediate care service within an English Primary Health Care Trust.

Roles: The assistant practitioners work autonomously and manage their own caseload. Assistant practitioners could perform most of the roles undertaken by the qualified occupational therapists, with the exception of discharge home visits.

Methodology: A qualitative evaluation of the assistant practitioner role was undertaken 2 years after its introduction. Focus groups were held with four groups of key stakeholders including assistant practitioners (five of a possible seven); supervising occupational therapists (five of a possible seven); service managers (four of a possible six), and service users from the occupational therapy patient panel (n = 3).

Figure 1 Relationship between the processes of assistant practitioner implementation and outcomes.

Note: Blue boxes denote processes; green boxes denote outcomes.

Table 2 Population of the Calderdale Framework using new role data

Calderdale Framework	Role implemented
	PA	SPA	OTAP
1. Awareness raising → staff engagement
1.1 Managers and clinical staff engaged with processes	1	2	2
1.2 Whole team/service aware of and educated in the implementation process	1	2	0
1.3 A clear leader/clear leadership (“champion”) with skills to lead and facilitate the implementation process and “project manage”	2	2	1
1.4 Leader is supported by a project lead and others undertaking similar workforce change projects	2	2	0
2. Service analysis → potential to change
2.1 Frontline clinical staff identify and clarify the purpose of their service and all the functions that are carried out in order to deliver this service	0	1	1
2.2 Functions are broken into tasks and these are matched to patient needs	1	1	0
3. Task analysis → risk management
3.1 Open discussion with clinicians regarding suitability of tasks for delegation, identifying what and where risks will occur if delegating a given task (using the Calderdale Framework decision table and risk rating scale), and also how much training would be needed for each task	1	2	1
4. Competency generation → quality
4.1 Tasks accepted as suitable to delegate are written into a “competency” format, which sets out the performance criteria of the task	2	2	2
4.2 Clinicians agree on how task is to be performed, embedding best practice	1	2	1
5. Supporting systems → governance (is the workplace able to manage the new roles?)
5.1 Ensuring clinical supervision processes are in place	1	2	2
5.2 Ensuring reflective practice is encouraged for all staff (including assistants)	1	2	2
5.3 Ensuring personal development review processes are in place	1	2	0
5.4 Ensuring communication channels are clear and robust	2	2	1
6. Training → staff development
6.1 Training developed for both qualified and support staff	1	1	0
6.2 Support staff trained in competencies, each comprising a knowledge-based element and a practical element	2	2	2
6.3 Support staff also trained so they understood what feedback to give, when and how to give it, and when a task should be halted	0	2	0
6.4 Competence assessed prior to performing on a patient	2	2	0
6.5 Training in core competencies first. Once competent, then more specific competencies are introduced	2	2	0
6.6 Qualified staff were trained so all understood how the competencies were derived and what the support staff were competent to perform	0	2	0
7. Sustaining → embedding and monitoring
7.1 Resulting “framework” embedded into local induction and personal development review for new members of staff	0	1	0
7.2 Audit plan developed to monitor outcomes and use of competencies	0	2	0

Notes: 0, criterion was not met at all; 1, criterion was only partly met (where only part of the stage/process has been completed. For example, only a selection of staff were consulted with and engaged in the implementation process for the podiatry assistant role, champions were not identified, and project planning was not formally deployed); 2, criterion was fully met.

Abbreviations: OTAP, occupational therapy assistant practitioner; PA, podiatry assistant; SPA, speech pathology assistant.

Table 3 Barriers and facilitators to successful implementation of assistant roles

	Barriers and facilitators	Stage of CF
Organizational
Timing	Implementation of roles was not well timed with training organization (PA) The OTAP role was introduced at the same time as new services were being developed (OTAP)	Stage 1: incorporates project planning and project management elements around time lines/time frames and key dates for implementation
Overall strategy	An overall strategy/approach was not identified prior to the implementation (PA, SPA and OTAP)	Stage 1: assists staff to plan the change management process
Recruitment	Targeted recruitment strategy was key to success of the role (SPA and PA) Managers suggested succession planning for OTAP staff through targeted recruiting in non-health area	Stage 7: Competency based role descriptors are written that can then be used for recruitment process.
Organizational and team culture	The implementation of the PA role involved managing the cultures of two different organizations (training organization and the health service). The culture of the organization was perceived as supportive to the introduction of the new role (SPA). An innovative and flexible working environment enhanced the implementation of the OTAP role.	Stage 1: works with staff to identify key contextual factors that may or may not facilitate the implementation process, including discussion around local, state wide and national barriers and drivers
Classification of roles/pay	Delay in Industrial classification of new roles led to a delay in recruiting, paying and providing initial training for the PA. Split industrial classification led to two tiered industrial relations system (PA and SPA).	Stage 1: includes identification of facilitators and barriers and also discussion and planning around the targeted grade the new role will be. Stage 7: facilitates identification of key areas for sustainability e.g. need for negotiation at a higher level for new roles to be created.
Resourcing	Protected time to allow staff to perform all stages of implementation (including planning and engagement). Lack of this led to high workload levels and lack of engagement of all stakeholders	Stage 1: incorporates project identification of what resources will be required of and provided by the organization to support the implementation process. Stage 6: plans training resources.
Attributes
Of the assistant	Personal traits of the assistant: specifically, maturity, flexibility, adaptability, fits well into the team; should know their own boundaries and capabilities and not exceed these boundaries; well-developed insight with regard to their skill set and role boundaries	Stages 1, 3 and 4: facilitation of what attributes are required of the assistant. These attributes are then written into role descriptions (stage 1). Every competency requires an understanding of the specific skills and attributes a worker needs to perform their role competently (stage 4).
Of the team	Managers and the team needed to be innovative and flexible while remaining committed to clinical governance. Team members needed to embrace ‘modern ways of working’ and be willing to try new things	Stage 1: incorporates engagement of staff, nominating champions and leaders and project planning (such as how to manage staff, how to assess willingness for change, developing a strategy to drive change) Stages 2–6: involvement of staff in these stages helps to identify and reinforce team attributes that will drive change
Skills	A clinical educator role was seen as essential in providing supervision and guidance to all staff including the PA. The SPA role was facilitated by a leader with formal training experience who was able to break down the role into discrete competencies, and develop competencies for the role where none existed previously. Lack of previous experience working with an assistant can make staff uncomfortable “letting go” of their work	Stage 1: includes project planning, which involves identifying trainers. Also awareness raising identifies champions for change. Stage 5: aids planning around supporting systems such as supervisors. Stage 6: Includes training trainers and developing links with training providers
Overall strategic direction, nationally, locally and professionally	At a national strategic level, Health Workforce Australia (HWA) established several broad policy directions around the introduction of new roles, including assistant roles. The relatively small numbers of people accessing the PA training precluded investment in and further development of training packages for the PA and OTAP. The podiatry and speech pathology professional associations had developed scope of practice documents, but no competency frameworks.	Stage 1: pre-awareness includes identification of supporting bodies/resources; links planning with professional/government strategic directions Stage 6: includes identification of local training bodies and facilitates engagement with them
Relationships
Training organization	Specialized skills required for podiatry training meant unique requirements that could not easily be met within the training organization resources. A strong, and consultative relationship with the training organization was identified as key to the SPA success. The OTs had minimal understanding of the training organization and the specific training undertaken by the OTAPs	Stage 1: engagement with all key stakeholders, including the training organization. Links also with identifying contextual facilitators and barriers. Stage 7 sustaining: links with higher education institutions are encouraged to develop bespoke training packages for individuals and organizations
Other stakeholders/ service providers	The enrolled nurses who undertook the role prior to the introduction of the podiatry assistant role were not consulted in the implementation process. IMPACT = > nurses expressed that they felt ‘a bit used’ and were disappointed that they would be ceasing the role

NancarrowSMackeyHThe introduction and evaluation of an occupational therapy assistant practitionerAust Occup Ther J2005524293301

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