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The patient experience of ward-based nursing care: reconciling multiple perspectives

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The patient experience of ward-based nursing care: reconciling multiple perspectives

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    1. The patient experience of ward-based nursing care: reconciling multiple perspectives* Ian Kessler, Paul Heron & Sue Dopson Said Business School, University of Oxford

    2. UNISON HCA Conference, 21st September 2010 Structure Research questions Research approach HCA backgrounds The shape of the role Impact on: HCA Patients

    3. UNISON HCA Conference, 21st September 2010 Research approach and questions The overall research project was designed to answer three primary questions: Firstly, who are HCAs, in terms of what is their background, their career histories and working lives leading up to the HCA role, and also their motivations and future aspirations Secondly, what are the tasks they are performing and are they able to exercise agency in determining the shape of their role? Thirdly, what is the impact of the role for HCAs themselves, the professionals they work with and the patients they care for? It was a three year project funded by the National Institute of Health Research and based around four regional hospital Trust case studies: Within each Trust we focused on general medical and general surgical wards Interviewing, observing and surveying a range of actors on the wards and across the divisionsThe overall research project was designed to answer three primary questions: Firstly, who are HCAs, in terms of what is their background, their career histories and working lives leading up to the HCA role, and also their motivations and future aspirations Secondly, what are the tasks they are performing and are they able to exercise agency in determining the shape of their role? Thirdly, what is the impact of the role for HCAs themselves, the professionals they work with and the patients they care for? It was a three year project funded by the National Institute of Health Research and based around four regional hospital Trust case studies: Within each Trust we focused on general medical and general surgical wards Interviewing, observing and surveying a range of actors on the wards and across the divisions

    4. UNISON HCA Conference, 21st September 2010 Perspectives: HCA-patient relationship Within the research project we explored a number of different perspectives. The solid arrows represent those that Ill be focusing on today. In order to understand the HCA-patient relationship we captured the views of all three primary stakeholders to the HCA role: Recently discharged patients from the case study wards were invited to discuss the role in focus groups HCAs and nurses were asked in semi-structured interviews to provide their perspectives And all three were surveyed with questions that tapped into the HCA-patient relationship Finally, there was 275 hours of ward-based observation that allowed the research team to see the HCA role in actionWithin the research project we explored a number of different perspectives. The solid arrows represent those that Ill be focusing on today. In order to understand the HCA-patient relationship we captured the views of all three primary stakeholders to the HCA role: Recently discharged patients from the case study wards were invited to discuss the role in focus groups HCAs and nurses were asked in semi-structured interviews to provide their perspectives And all three were surveyed with questions that tapped into the HCA-patient relationship Finally, there was 275 hours of ward-based observation that allowed the research team to see the HCA role in action

    5. UNISON HCA Conference, 21st September 2010 HCA backgrounds Mature women with partners and children More locally embedded than nurses More representative of local ethnic mix Breadth of previous work experience Limited gateways Profiles sensitive to local factors

    6. UNISON HCA Conference, 21st September 2010 Career paths of 30 HCAs at one trust

    7. UNISON HCA Conference, 21st September 2010 Types of HCA

    8. UNISON HCA Conference, 21st September 2010 The role: HCA clusters

    9. UNISON HCA Conference, 21st September 2010 HCA cluster: Ancillary Trust 4_HCA14: So we have a handover, then we do breakfast so we, most of the patients here are fed, some, a couple feed themselves, most of them now we feed or are peg-fed, so we don't have a busy breakfast round and thats it. So we wash, get everyone washed, some people get up, most of them don't. Wash, shave, do everything for themand then that's it, apart from, you know, maybe, obviously if they've, you know, dirtied the bed or something weve got a washing machine and we tend to put the linen out.

    10. UNISON HCA Conference, 21st September 2010 HCA cluster: Bedside Technician Trust 1_HCA28: Well we do our initial role, you know, care of the patients, commoding them, washing them, dressing them, feeding them, but we also do, obviously when the staff nurses are busy and maybe the bells aren't ringing, we help the nurses do the obs. We do dinners, we do blood sugars.

    11. UNISON HCA Conference, 21st September 2010 HCA cluster: All Rounder Trust 4_HCA11: After handover we're checking probably machines or equipment. After that were helping patients with breakfast because especially on our ward some of the patients they need a help, they need assistance with feeding. Afterwards we're getting on with daily hygiene. Some patients, they can manage to do that themselves, some of them, they can't do anything. We just do bed, bed baths as well and we assessing skin then, skin integrity, pressure sores. Its not just bath for a bath, its bath to just assess the patient skin. After that we make patient comfortable for the day, if we can we move patients out from beds. We observe, we do observations which is the blood pressure, pulse, saturation, temperature. We, of course we do all this paperwork as well, were doing monitoring. We do observations very closely with patients which they are unstable, after an operation we set every fifteen minutes, every half an hour, hourly. We do, we check blood sugar. We help patients mobilise a lot when they, when they likes to go to the toilet sometimes we used to go with them, that takes the time as well. What else do we do? Interviewee: Sounds a lot. Trust 4_HCA11: No, its much more! Like now I can do ECGs officially because I done this unit as my NVQ. We do catheter care. I can catheterise female now as well. I can take bloods.

    12. UNISON HCA Conference, 21st September 2010 Influence of Trust

    13. UNISON HCA Conference, 21st September 2010 Influence of division

    14. UNISON HCA Conference, 21st September 2010 Consequences for HCAs: opportunities?

    15. UNISON HCA Conference, 21st September 2010 Consequences for HCAs: aspirations

    16. UNISON HCA Conference, 21st September 2010 Consequences for HCAs: pay band-NVQ-task misalignment

    17. UNISON HCA Conference, 21st September 2010 Consequences for HCAs: lack of voice?

    18. UNISON HCA Conference, 21st September 2010 Consequences for HCAs: emotionally intense Trust 4_HCA2: You have to keep it in, I mean the family, if you're very close with the family its nice for, I suppose when I say nice maybe that's the wrong word, but you dont want them to think you're cold, so you have to show them that you do care, which obviously you do, but at the same time you have to be in control and consult them and reassure them. It can be very hard, I mean there was one time again on [name of ward] when we had a particular nasty one, you know, like quite a horrible death actually and we had to do all that and then come out, and another man was celebrating his 60th birthday and wanted us to put balloons up and that. I found that was very hard to come from that situation straight into a sort of little, hed had his stroke and some of his family were coming and we had to, you know, put balloons up for him and make it special, and it was sort of coming out from a really horrible situation into a bubbly situation. That was very hard, and I think at times like that you sort of take five minutes on your own and just to sort of, you know, get your bearings back. Because youve got to be professional still, other patients are relying on you.

    19. UNISON HCA Conference, 21st September 2010 Consequences for HCAs: dumped on?

    20. UNISON HCA Conference, 21st September 2010 Consequences for patients

    21. UNISON HCA Conference, 21st September 2010 Rapport I think [HCAs] have a more friendly sort of, like a friends rapport [RN] More approachable If [patients are] in painthey might not say to some of the nurses because they might not feel they could approach them [HCA] Type of tasks [HCAs] are the ones who do most of the hands-on care. So maybe its because they see the patients more but Ive always found that patients do confide more in [HCAs] [RN] Work pressure [Nurses] flit in and flit out, the HCAs at least are constant [RN] HCA/nurse perspective Turning to the staff interviews we found a general consensus between HCAs and nurses. Both roles commented on the friendly nature of the relationship that existed between HCAs and patients. HCAs were also seen as more approachable than nurses and as a consequence were able to provide nurses with valuable patient related information. Some nurses went on to speculate as to why the HCA-patient relationship was different to their own. This centred on two main areas: It was thought that HCAs were carrying out more direct care tasks and so were more available to patients Nurses were also concerned about how busy they were and the amount of paperwork they were involved with that kept them away from patients. Overall, HCAs and nurses were positive about the HCA contribution to patient care.Turning to the staff interviews we found a general consensus between HCAs and nurses. Both roles commented on the friendly nature of the relationship that existed between HCAs and patients. HCAs were also seen as more approachable than nurses and as a consequence were able to provide nurses with valuable patient related information. Some nurses went on to speculate as to why the HCA-patient relationship was different to their own. This centred on two main areas: It was thought that HCAs were carrying out more direct care tasks and so were more available to patients Nurses were also concerned about how busy they were and the amount of paperwork they were involved with that kept them away from patients. Overall, HCAs and nurses were positive about the HCA contribution to patient care.

    22. UNISON HCA Conference, 21st September 2010 Observation: task data Turning to the task data first, we were interested to assess whether HCAs and nurses do different things with patients on the ward? The chart represents the percentage of shift time that HCAs and nurses spent on a range of different activities. The results showed that HCAs were spending almost 60% of their shift on direct and indirect care tasks with patients compared to about 35% of nurse time. Direct care tasks involve bathing, feeding and toileting. Indirect care tasks cover amongst others, making beds and serving drinks. Almost a third of a nurses shift was spent on drugs round and technical procedures. Although HCAs were seen to perform a number of routine technical procedures such as observations, blood monitoring and dressings, this accounted for less than 10% of their shift. Of interest is that both HCAs and nurses spent the same amount of time on pastoral care, about 5% of their shift. This is where staff were involved with a patient when no task was involved, for example when a patient needed reassuring or was confused. [ward/team centred: handover, updating, answering phone, clerical, stocking up]Turning to the task data first, we were interested to assess whether HCAs and nurses do different things with patients on the ward? The chart represents the percentage of shift time that HCAs and nurses spent on a range of different activities. The results showed that HCAs were spending almost 60% of their shift on direct and indirect care tasks with patients compared to about 35% of nurse time. Direct care tasks involve bathing, feeding and toileting. Indirect care tasks cover amongst others, making beds and serving drinks. Almost a third of a nurses shift was spent on drugs round and technical procedures. Although HCAs were seen to perform a number of routine technical procedures such as observations, blood monitoring and dressings, this accounted for less than 10% of their shift. Of interest is that both HCAs and nurses spent the same amount of time on pastoral care, about 5% of their shift. This is where staff were involved with a patient when no task was involved, for example when a patient needed reassuring or was confused. [ward/team centred: handover, updating, answering phone, clerical, stocking up]

    23. UNISON HCA Conference, 21st September 2010 Different relationship: caring behaviours 5 item scale: Challenging types of patient behaviour Caring for verbally abusive patients Calming patients very stressed about condition Caring for patients from different backgrounds Cheering up deeply upset patients Caring for confused patients5 item scale: Challenging types of patient behaviour Caring for verbally abusive patients Calming patients very stressed about condition Caring for patients from different backgrounds Cheering up deeply upset patients Caring for confused patients

    24. UNISON HCA Conference, 21st September 2010 Similar background Theyre one of ustheyre just a person like us, you can talk to them Less threatening You could have a laugh and a joke with [HCAs], but those [nurses] youve got to watch your Ps and Qs More engaging [HCAs] would come and talk to you while they were taking your blood pressureThe nurses didnt seem to have time to talk to you Patient perspective Beginning with the patient focus groups we found that accurate identification of the ward nursing roles was a problem for a large minority of patients. However for those that were able to correctly identify HCAs from nurses we found three broad themes: HCAs were viewed as coming from a similar background to patients and this was supported by the survey results which found that HCAs compared to nurses were significantly more embedded in the local community, less ethnically diverse, were older and more likely to have children than nurses. Patients also reported that they felt less intimidated by HCAs and that HCAs could be more personable HCAs were also thought to carry out tasks with a more friendly demeanour and had more time for patients. Overall, patients gave a positive assessment of their relationship with HCAs and valued the role as one which made a positive contribution to their patient experience.Beginning with the patient focus groups we found that accurate identification of the ward nursing roles was a problem for a large minority of patients. However for those that were able to correctly identify HCAs from nurses we found three broad themes: HCAs were viewed as coming from a similar background to patients and this was supported by the survey results which found that HCAs compared to nurses were significantly more embedded in the local community, less ethnically diverse, were older and more likely to have children than nurses. Patients also reported that they felt less intimidated by HCAs and that HCAs could be more personable HCAs were also thought to carry out tasks with a more friendly demeanour and had more time for patients. Overall, patients gave a positive assessment of their relationship with HCAs and valued the role as one which made a positive contribution to their patient experience.

    25. UNISON HCA Conference, 21st September 2010 Patient perspective Trust 1_Patient: I think a healthcare assistant would have been more helpful. I wasnt sure because it was after my operation I wasnt sure whether Id actually wet the bed or whether I was actually because I was dopey or whether I was actually sweating a lot. I think actually I was sweating a lot, but it could have been either. And she [the nurse] sort of, she really wasnt particularly nice about it. And I think probably a healthcare assistant would have just taken it as a matter of course and dealt with it. She did, the nurse did, but I just felt that she said, oh you stupid woman, you know, thats it, but I don't think a healthcare assistant would have treated me like that. Interviewer: Because of this, perhaps what you were talking about before, this sort of greater sort of empathy? Trust 1_Patient: Yes, I think so, yes.

    26. UNISON HCA Conference, 21st September 2010 Summary & conclusions Who are HCAs? Distinctive What do they do? Different types How does the role impact on HCAs? A mixed blessing How does the role impact on patients? A distinctive contribution

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