How training could improve the way HCAs relate to older people
This is the first in a series of six articles that aim to encourage nurse leaders to explore how to use research findings to improve practice and services where they work. The series focuses on research that has been funded by the National Institute for Health Research (NIHR) and included in NIHR Dissemination Centre publications. The authors seek to relate the content directly to the Nursing and Midwifery Councils code of professional standards of practice and behaviour, specifically the themes of practising safely and promoting professionalism and trustIntroduction by Elaine Maxwell, clinical adviser at the National Institute for Health Research Dissemination Centre:
The NIHR Dissemination Centre provides good research evidence for decision-making in health and social care. Our review of research into hospital care of older people living...
This is the first in a series of six articles that aim to encourage nurse leaders to explore how to use research findings to improve practice and services where they work. The series focuses on research that has been funded by the National Institute for Health Research (NIHR) and included in NIHR Dissemination Centre publications. The authors seek to relate the content directly to the Nursing and Midwifery Council’s code of professional standards of practice and behaviour, specifically the themes of practising safely and promoting professionalism and trust
Introduction by Elaine Maxwell, clinical adviser at the National Institute for Health Research Dissemination Centre:
The NIHR Dissemination Centre provides good research evidence for decision-making in health and social care. Our review of research into hospital care of older people living with frailty, published recently, identified the importance of good relationships for clinical outcomes as well as for patient satisfaction.
The review also describes the challenges of doing this in busy hospital settings. You can read more about the research findings on this and other aspects of managing frailty by downloading the report, Comprehensive Care.
‘Caring’ can be seen as less skilled than task-based work, and is often perceived to be based on personal attributes, hence the focus on values-based recruitment. Caring involves developing meaningful relationships that lead to dignity, empathy and emotional support, although Benner and Wrubel (1989) assert that caring for strangers is significantly different from caring for friends and family members.
Caring for family happens in the context of long-term relationships, but caring for strangers requires staff to develop therapeutic relationships quickly and in atypical circumstances. Despite this, few resources are devoted to teaching these skills, particularly to healthcare assistants (HCAs), who provide much of the direct care of older people in hospital.
One of the studies featured in Comprehensive Care looked at the feasibility of developing a relational care training programme for HCAs. In this article, lead researcher Tony Arthur describes the study and a chief nurse, Cheryl Lenney, discusses the implications for nurse managers.
Tony Arthur, professor of nursing science at the University of East Anglia:
Our aim was threefold: to understand the relational care training needs of HCAs caring for older people, to design a training intervention to meet these needs, and to assess the feasibility of a cluster randomised controlled trial to test the new intervention.
The first task was to conduct a telephone survey of all acute NHS hospital trusts in England. We wanted to understand what training HCAs receive in relational care, a term used to encompass care that is compassionate, empathetic and respectful and that maintains dignity.
Our choice of a telephone survey was based on the need to identify the right person in each trust to speak to, arranging a time convenient for each respondent, and evidence that telephone surveys result in a better response than doing it online.
Older People’s Shoes
We obtained responses from 113 of the 161 trusts approached. One third of trusts reported providing content within HCA training that we considered to be relational care, but most training was targeted at new starters rather than established HCAs.
We developed our training intervention, called Older People’s Shoes, based on a review of the evidence, interviews with HCAs, focus groups with older people and discussion with experts, including four companies in the retail sector, to better understand the role of customer service in healthcare.
Older People’s Shoes is a two-day training course for HCAs caring for older people. Each day has three units: Getting into Older People’s Shoes, Getting to Know Older People and Learning from Customer Care.
The study was methodologically ambitious in terms of study design and choice of outcome measures. A randomised controlled trial is the best way to test new interventions but it is expensive and needs to meet stringent quality criteria for them to provide gold-standard evidence.
We chose to conduct a feasibility cluster randomised controlled trial to find out if a randomised trial was viable and also to obtain important information about key aspects of a definitive trial, such as how best to recruit wards, HCAs and patients.
In total 12 wards, 72 HCAs and 88 patients were recruited across three participating acute NHS trusts. Older People’s Shoes was received positively by trainers and HCA learners and appears to meet a need, particularly for established HCAs, that is not met through other training provided by trusts.
‘The age profile of those who access care services continues to rise, and how front-line staff relate to older people is fundamental in ensuring good quality care’
From the start we knew it was a complex intervention and that the risk of contamination between trial arms was high. Due to this, clustering was used at the ward level, so that HCAs on six wards were randomised to receive Older People’s Shoes training and those on the other six wards were randomised to ‘training as usual’.
Cost of training
We were committed to looking at outcomes that went beyond how HCAs evaluated the training, though this too was important. At the ward level, observers rated the quality of the interactions between HCAs and patients.
We measured HCA empathy and their attitudes towards older people using validated self-report questionnaires. Patient-reported quality of life and their experience of care were measured using a written questionnaire two weeks after hospital discharge.
Although we were asking for wards to commit to allowing front-line staff to undertake two full days of training, we estimated that the cost per patient cared for was about £14.
For a definitive trial to be possible, a number of methodological and contextual challenges would need to be overcome. Ward manager commitment is key and needs to be ongoing, and they need to be confident that there are long-term gains in quality from the investment of staff time.
HCAs are willing to participate in research, but measurement of outcomes needs to be simple and not burdensome. The approach to gaining patient feedback, currently collected routinely but not systematically, needs to be examined to see if greater methodological rigour can be incorporated into the way trusts collect this information.
The age profile of those who access care services continues to rise, and how front-line staff relate to older people is fundamental in ensuring good quality care. Older People’s Shoes meets a need perceived by patients, HCAs, managers and policymakers. We conclude that the study can inform the debate on how interventions like this can be tested, using the most robust research design available.
Cheryl Lenney, chief nurse at Manchester University NHS Foundation Trust:
This research questions our approach to continuing education and training for HCAs and whether we have considered the need for training in the relational aspects of care.
Further education and training for the healthcare workforce seems intuitively the right thing to do.
As healthcare organisations, we invest significantly in the ongoing professional education and training needs for most healthcare professionals, but the study suggests that continuing education and training for HCAs, specifically those in older people’s care, are variable and in some cases non-existent. This struck a chord with me.
We appoint HCAs through an apprenticeship model that ensures they have a robust induction into the service using an accredited programme. It is a generic programme that all HCAs undertake, but the continued education and training needs of this group can be forgotten and left to individual wards as an addition to the mandatory requirements for annual education and training set out by the trust.
As a result, it is perhaps unsurprising that areas such as renal, emergency, maternity and other care specialties with a reputation for a strong ethos of continuing professional development (CPD) often extend those programmes to the HCA. Care of older people appears to be a latecomer to specialty-based education and training, so the concepts outlined in Older People’s Shoes are welcome.
While a multicentre trial with several specific, simple qualitative indicators could be supported, the article focuses on one intervention. It may be that organisations already undertake different education and training programmes that provide this training.
‘We need to take a leadership role in developing practitioners including HCAs to implement evidence-based interventions, and equip care providers with the skills and knowledge to undertake their roles’
One of the ward managers in our trust explored the programme further and felt the intervention supported the organisational philosophy of caring ‘about’ not just ‘for’ people. We would like to explore the programme further and would be keen to take part in another assessment of the impact of such an intervention.
It was difficult to understand how the cost of the training of £14 per person could be quantified, and we felt this distracted from the importance of the programme. It would seem more important to assess the outcomes of the training rather than focus on the cost.
The cost of mandatory training in areas such as the taking of physiological measurements, infection control and falls prevention, for example, is accepted as part of the need to improve patient experience, safety and outcomes, and this training can be supported if clear benefits can be demonstrated.
The programme could possibly be included as part of the assessment for the Quality Mark for Elder-Friendly Hospital Wards, a scheme run by the Royal College of Psychiatrists that was developed with organisations including the Royal College of Physicians, the Royal College of Nursing and the British Geriatrics Society to assess the provision of specialised care for older people based on staff perception of their preparedness to give appropriate care to older people.
Not just a series of tasks
The Quality Mark does not focus on the training staff receive or include any intervention, but it does include, for example, observations of care and collects feedback through questionnaires from a prescribed proportion of patients discharged from the ward over a three-month period.
Delivering high-quality evidenced-based care to older people is so much more than a series of tasks. Despite having significant vacancies for registered nurses, we need to build multidisciplinary teams around the needs of patients.
This article presents independent research commissioned by the National Institute for Health Research (NIHR) under Health Service (HS) and Delivery Research (DR) (Grant Reference Number 12/129/10).
The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.
The sponsor of the study had no role in study design, data analysis, data interpretation or writing of the report.
Increasingly, the care needs of this group are not provided directly by registered nurses but by nursing assistants. The role of the HCA across all care sectors including social care has increased, but without any standards for education and training.
Skills and knowledge
These care workers are often unsupervised, whether in hospital, the community or home settings, so assessing the impact of training would be useful, not just in the acute sector.
Writing this article has led us to reflect on the continuing education and training we provide for HCAs working with older people, and more importantly whether we have a standardised approach across the organisation to meeting older people’s needs. We would be interested in participating in further studies.
All too often there is reliance on campaigns or social movements such as #EndPJParalysis, John’s Campaign or #hellomynameis, all of which have been developed to address gaps in practice. This cannot be the mark of an evidence-based profession, and we need to take a leadership role in developing practitioners including HCAs to implement evidence-based interventions and to equip care providers with the skills and knowledge to undertake their roles.
- Arthur A, Aldus C, Sarre S et al (2017) Can Healthcare Assistant Training improve the relational care of older people? (CHAT) A developmental and feasibility study of a complex intervention. Health Services and Delivery Research. 5, 10, 1-202.
- Benner P, Wrubel J (1989) The Primacy of Caring: Stress and coping in health and illness. Addison-Wesley/Addison-Wesley Longman, Reading MA.
Using research findings to improve practice and services
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