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The Study of Occupational Roles: The Case of the Healthcare Assistant*

Ian Kessler, Paul Heron & Sue Dopson Said Business School, University of Oxford. The Study of Occupational Roles: The Case of the Healthcare Assistant*.

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The Study of Occupational Roles: The Case of the Healthcare Assistant*

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  1. Ian Kessler, Paul Heron & Sue Dopson Said Business School, University of Oxford The Study of Occupational Roles: The Case of the Healthcare Assistant* *This presentation presents independent research commissioned by the National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO) Programme. The views expressed in this presentation are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The NIHR SDO programme is funded by the Department of Health.

  2. Unregulated Direct Care Assistant The Assistant Role GTC, Future of Work Seminar, 14th October 2010

  3. The Healthcare Assistant (HCA) • NMC: • “Those who provide a direct service – that is they have a direct influence/effect on care/treatment to patients and members of the public and are supervised by and/or undertake duties delegated to them by NMC registrants” • The regulation of Health Care Support Workers: A Scoping Paper. London: NMC; 2006 GTC, Future of Work Seminar, 14th October 2010

  4. The Healthcare Workforce* *Department of Health and the NHS Workforce Review Team, cited by House of Commons Health Committee (2007) Workforce Planning: Fourth Report of Session 2006-07. GTC, Future of Work Seminar, 14th October 2010

  5. Positioning • Public policy • Multi-methods • Theory GTC, Future of Work Seminar, 14th October 2010

  6. Overview • Objectives: • Evidence base • Indicative theory • Data processing / presentation • Structure: • Context • Focus • Approach • Findings GTC, Future of Work Seminar, 14th October 2010

  7. Unregulated Direct Care Assistant Context Nurse training Workforce restructuring Nurse professionalisation Modernisation Regulation • Relief • Substitute • Apprentice • Co-producer GTC, Future of Work Seminar, 14th October 2010

  8. Outcomes for: HCAs Nurses 1. Who takes up the HCA role? 2. What do HCAs do in their role? 3. What is the impact of the HCA role? Patients Background Details Personal Characteristics Shape of the HCA role Aspirations Primary Research Questions GTC, Future of Work Seminar, 14th October 2010

  9. South • Midlands • North • London Multi Case Multi Division • Medical • Surgical • Patient • HCA • Nurse • Manager Multi Stakeholder • Interviews • Observation • Surveys • Focus • groups Multi Method Research Approach GTC, Future of Work Seminar, 14th October 2010

  10. The Research (1 of 2) GTC, Future of Work Seminar, 14th October 2010

  11. The Research (2 of 2) GTC, Future of Work Seminar, 14th October 2010

  12. Who are they? Debates • Atypical careers • Life histories • Secondary labour markets • Gendered career • Tacit skills • Intersectionality GTC, Future of Work Seminar, 14th October 2010

  13. HCA Backgrounds • Mature women with partners and children • More local/less diverse than nurses • Breadth of previous work experience • Limited gateways • Profiles sensitive to local factors GTC, Future of Work Seminar, 14th October 2010

  14. Personal Characteristics aHCAs > Nurses at all Trusts: Trust 1 p < .001; Trust 3 p < .01; Trusts 2 & 4 p = .05 bNurses > HCAs: Trusts 1, 2 & 4 p < .001; Trust 3 ns GTC, Future of Work Seminar, 14th October 2010

  15. HCA Background Trust 4_HCA3: Well at sixteen I got married. I was working in a greengrocers head office doing banking and then had two children, so gave up work for a while. Marriage broke up. I was a single parent for quite a while, and I met another gentleman and moved back up this way, because I've come back to sort of be around family. And I then married a second time which I have now got more children from. So I have a total of eight children between my husband and I which keeps me quite busy as well. And in between that I've done sort of part-time jobs. I did like evening cleaning because of having young children. I've worked in local shops like Co-Op, Tesco’s. And then did a little bit of engineering because…that was for, yes, that was an engineering factory. I did chemical cleaning. When we got made redundant from the engineering company I set my husband up in his own business, so someone had to work to pay the mortgage. GTC, Future of Work Seminar, 14th October 2010

  16. HCA Background Trust 4_HCA3: [Cont/d]And I actually got a job in a nursing home before I came here. The reason I left it is because I felt there was no future at the nursing home, I’d got a little bit depressed with people coming to us to die. I know they're going to die anyway but I just wanted, just something to say, you know, I have seen this person go home for a change. And I thoroughly enjoyed it, it’s been really good. As a youngster I’d always wanted to be a nurse. I think we all really want to be an air hostess or a nurse, and at the back of my mind I’d always wanted to be in nursing, it’s something that appealed to me but never had the opportunity to get into it, everything else came first, the children and things like that. GTC, Future of Work Seminar, 14th October 2010

  17. Healthcare Assistants at Trust 1 Healthcare Assistants at Trust 1 Healthcare Assistants at Trust 1 Healthcare Assistants at Trust 1 One HCA’s career move More than one HCA’s career move Career Paths of 30 HCAs at One Trust GTC, Future of Work Seminar, 14th October 2010

  18. What do they do?Debates • Indeterminacy • Occupational formation • Structure / agency GTC, Future of Work Seminar, 14th October 2010

  19. Trust Clinical Area Type Staffing policy Training policy Performance mgmt Patient acuity Patient age Patient care needs Patient throughput Ward Individual Size Shift Staffing/Skill mix Nurses’ approach Mgmt style Work organisation Speciality Aspirations Experience Qualifications Training Disposition Domestics Working pattern HCA Role Shaping the HCA Role GTC, Future of Work Seminar, 14th October 2010

  20. Shape of the Surgical Ward HCA Role (n = 11) GTC, Future of Work Seminar, 14th October 2010

  21. Shape of the Medical Ward HCA Role (n = 13) GTC, Future of Work Seminar, 14th October 2010

  22. Types of HCA GTC, Future of Work Seminar, 14th October 2010

  23. High Task Complexity All rounder Expert High Task Diversity Bedside tech. Low Citizen Currentextension Ancillary ‘Old’ core Low The Role: HCA Clusters GTC, Future of Work Seminar, 14th October 2010

  24. Agency Task discretion Qualifications BME Length of service Self esteem Pre-role aspirations HCA Cluster Type Structure Trust Division Shaping the HCA Role GTC, Future of Work Seminar, 14th October 2010

  25. Influence of Trust *** p < .001 GTC, Future of Work Seminar, 14th October 2010

  26. Influence of Division ** p < .01 GTC, Future of Work Seminar, 14th October 2010

  27. Influence: Agency *** p < .001; ** p < .01; * p < .05 GTC, Future of Work Seminar, 14th October 2010

  28. What are the Consequences for HCAs?Ghetto v. Opportunity • Dirty work • Emotional labour • Degradation of work • Job satisfaction GTC, Future of Work Seminar, 14th October 2010

  29. Consequences for HCAs: Opportunities? GTC, Future of Work Seminar, 14th October 2010

  30. Consequences for HCAs: Aspirations ** p < .01; * p < .05 GTC, Future of Work Seminar, 14th October 2010

  31. Consequences for HCAs: Pay Band – NVQ – Task Misalignment *** p < .001; * p < .05 GTC, Future of Work Seminar, 14th October 2010

  32. Consequences for HCAs • Band – NVQ – task misalignment • No voice • (Thwarted) career ambitions • ‘Work horses’ • Emotionally intense • Satisfied GTC, Future of Work Seminar, 14th October 2010

  33. Consequences for HCAs:Emotionally Intense Trust 2_HCA10: The first time I ever saw a lady who’d passed on cause it was a side room and I remember opening the door and looking thinking ‘god’, and I just shut the door and I wouldn't go in the room until I’d got someone else with me, I couldn't go in there on my own and just, oh. And I remember like the two auxiliaries were washing and they says, they asked me if I wanted to just watch and just make sure, so I knew what to do for when I had to do it in, like in the present. And I remember sitting there and I was absolutely crying my eyes out because obviously being on a ward, they're on for a longer time as what they are there, they're not on our ward that long or they're not meant to, but she’d obviously been on there for a while and I’d known her for a while. And they were washing her and everything, and I’ll always remember the one thing that got me was the fact that the nurse, the auxiliary opened the window and she went “go on”, and then she shut the window. Oh, it sends shivers up my, ever since, just thinking about it. That was probably, that was my very first one, and I remember sitting there thinking I can't do this. And I remember going home and I was crying my eyes out because I thought I can't do it, I honestly couldn't do it. But then, as I say, you just protect yourself from it now, that kind of thing, so. Sorry, I’m getting all emotional, sorry… GTC, Future of Work Seminar, 14th October 2010

  34. What are the Consequences for Nurses?Debates • Professionalisation • Job boundaries / jurisdictions • Degradation GTC, Future of Work Seminar, 14th October 2010

  35. Consequences for Nurses: Job Boundaries GTC, Future of Work Seminar, 14th October 2010

  36. Consequences for Nurses: Support or Threat? • Qualitative: • HCAs valued • Misconceptions • Accountability • Quantitative: • Ambiguity GTC, Future of Work Seminar, 14th October 2010

  37. HCA-Patient Relationship Distinguish? Inter-views Inter-views ? ? Survey Survey Different? HCA Nurse Matters? Focus Groups ? Survey Patient What are the Consequences for Patients?Accessible or Second Best? GTC, Future of Work Seminar, 14th October 2010

  38. Distinguishing *** p < .001; * p < .05 GTC, Future of Work Seminar, 14th October 2010

  39. Rapport “I think [HCAs] have a more friendly sort of, like a friend’s rapport” [RN] More approachable “If [patients are] in pain…they 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 it’s because they see the patients more but I’ve 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] Difference: HCA / Nurse Perspective GTC, Future of Work Seminar, 14th October 2010

  40. Observation: Task Data • Observed shape of the HCA role: HCAs vs RNs (early shift only) GTC, Future of Work Seminar, 14th October 2010

  41. Similar background “They’re one of us…they’re 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] you’ve got to watch your Ps and Qs” More engaging “[HCAs] would come and talk to you while they were taking your blood pressure…The nurses didn’t seem to have time to talk to you” Patient Perspective UNISON HCA Conference, 21st September 2010

  42. Different Relationship: Co-Production • 6 item scale: ‘Compared to registered nurses, HCAs are more likely to’ • …notice patients in discomfort • …show concern when patients complain • …talk to patients in a warm friendly manner • …be told by patients about their worries and concerns • …explain what they are doing when working with patients • …take time to listen to patients when they need to talk aHCAs > Nurses at all Trusts (p < .001) Measured on a 5-point scale: strongly disagree to strongly agree GTC, Future of Work Seminar, 14th October 2010

  43. Does it Matter? • Overall rating of care by knowledge of staff role difference aWithin Trust differences: Trust 1 p < .03, Trusts 2, 3 & 4 p < .001, Measured on a 5-point scale: poor to excellent GTC, Future of Work Seminar, 14th October 2010

  44. Does it Matter? Trust 1_Patient12: The thing that’s really hit me just in the last 20 minutes or so is that part of my experience and the bad part of the experience I had now I can see because I was asking the wrong questions to the wrong people, because I didn’t understand the difference. So I was probably asking a healthcare assistant something that he or she wasn’t qualified really to deal with, and done their best to accommodate me but didn’t deliver my expectation and made me more frustrated. So I think this comes around that the communication of really understanding who’s doing what roles and where their roles stops in turns of qualification and the next role starts, because that awareness I think helps the patient as much as it does help the system. GTC, Future of Work Seminar, 14th October 2010

  45. Summary & Conclusions • Public policy • Theory • Methods GTC, Future of Work Seminar, 14th October 2010

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