An unregulated, low-cost workforce potentially putting patient safety at risk? Or an essential and inevitable addition to the health workforce that frees up valuable nurse time?

Whichever way you view them, health care assistants (HCAs) – in their many forms and titles – are a growing sector of the health workforce and are likely to keep doing so as nursing shortages loom ominously in the future.

While there was much debate amongst the nursing profession over rebuilding an enrolled nurse workforce, there has been much less debate about setting standards and training for the growing role that health care assistants play in acute patient care.

In the last four or so years, more than 500 enrolled nurse graduates have emerged from the 18-month, Level 5 diploma but many have struggled to find nursing work – particularly in the public hospital sector.

Meanwhile, the 20 district health boards in the past six years have taken on an additional 920 HCAs and hospital aides across a wide variety of DHB settings, with training levels of most of those HCAs a great unknown.

New Zealand Nurses Organisation researcher Dr Jill Clendon says she worries about the lack of accountability for an unregulated HCA workforce. The greatly varying training and qualification standards for HCAs makes it “really, really difficult for a nurse to trust an HCA unless they know them really, really well.”

“I’m not saying we shouldn’t go down that route in terms of HCAs and practice assistants, but I think we need to be very cautious,” says Clendon, who has been working on a major project looking at future models of nursing care.

“I say that because if you look at the UK experience, they disestablished their ENS and totally went to an HCA model, and now they are talking about regulating HCAs because the risks to patients were so great.”

Professor Jenny Carryer, executive director of the College of Nurses, acknowledges nurses don’t always know what to expect of an HCA on their ward.

“In the rush and craziness of the average ward, you don’t tend to have time to sit down and say have you done six-week training, three-month training, or no training at all,” says Carryer. “Or have you been there 10 years or 10 minutes.”

“My argument has always been that we should have nationally agreed employment standards for HCAs and nationally standardised training and not to employ HCAs until they’ve been trained. Then you deal with the confusion and any uncertainty (over what tasks you can or cannot delegate to them).”

Carryer is not only in favour of HCAs being able to ease the workload of nurses on the ward but also of practice nurses.

“Any RN in general practice who feels threatened by the employment of a practice assistant is probably not being fully utilised as a registered nurse,” believes Carryer.

Clendon questions setting up a new practice assistant training programme (some of it at Level Five) when graduating enrolled nurses can’t get jobs.

“Why is it that we’re not using a resource we already have? The great thing about ENs is that we know what skills and knowledge they hold and therefore we know what tasks and responsibilities they can take.”

Carryer has never been in favour of an enrolled nurse workforce and believes any advantage of being able to delegate tasks to a regulated enrolled nurse rather than an unregulated HCA is countered by the potential for employers to blur boundaries between the registered and enrolled nurse scopes.

Meanwhile, Robyn Hewlett, chair of NZNO’s enrolled nurse section, is frustrated to see new graduate ENs unemployed while unregulated HCAs are employed to do tasks that some DHBs won’t even allow qualified enrolled nurses to do.

“My firm belief is that nursing is being devalued if HCAs are increasingly employed to replace the regulated nursing workforce,” says Hewlett.

She also believes a better answer to projected nursing shortages is for every EN and RN nursing graduate to have a nursing job rather HCAs taking on duties that used to be the domain of the regulated nursing workforce.

“New Zealand could end up like the UK, where HCAs are doing the patient care and also taking on other tasks such as cannulation, bloods, etc. and the RNs are doing the paperwork,” says Hewlett.

“Eventually, the powers that be are going to say ‘well, we don’t need regulated nurses as HCAs are doing the work of the nurse’.”

She believes a team nursing model of RNs and ENs is not being explored enough or enough research being undertaken into what ENs can contribute to patient care and outcomes.

The Nursing Council is “very mindful” of the whole area of unregulated health workers, says chief executive Carolyn Reed.

“Council has on numerous occasions touched on it but quickly realised it’s not within their brief under the current legislation.”

She personally believes, like Carryer, that there needs to some form of standardisation of training and skills for HCA. She also believes that regulation is not required but would like to see considered a code of conduct for HCAs and a system for managing those who breach that code.

Maybe it is time for the benefit of all parties – the HCA, nurse, and their patients – that clear, national parameters about training, qualifications and accountability of HCAs (and delegating RNs) are given serious consideration to show patient safety is always foremost in everybody’s mind?

So what is a health care assistant?

That varies hospital to hospital. But the New Zealand Nurses Organisation and DHB collective agreement (MECA) defines an HCA or hospital aide as meaning:

“An employee who is an auxiliary to the nursing team and is able to perform tasks in their position description relating to patient care and who works under the direction of a registered nurse or midwife.”

That same agreement also recognises at least 18 different titles for the HCA/hospital aide role, including caregiver and the intriguingly named milk room aides.

What can they earn?

Under the MECA, a new HCA can earn $35,520 (compared to $42,776 for a new graduate enrolled nurse and $47,528 for a new graduate registered nurse).

Beginners’ guide to HCAs

The pay scale ends at step four ($40,994), but an HCA who achieves merit criteria can earn an extra $1000–2000 per year.

What training do they receive or require?

This also varies from hospital to hospital. Some DHBs, like Auckland, require HCAs to have a Level 4 certificate offered through an external training provider (to compare, the 18-month enrolled nurse diploma is a Level 5 qualification and the RN degree is Level 7). Others, like Waikato DHB, offer a work-based, Level 3 national certificate with the Careerforce industry training organisation. Yet other DHBs have no required level of training for HCAs, though assistants may have attended a range of in-house training courses ranging from hand hygiene to falls prevention.

How many HCAs do New Zealand hospitals have?

A breakdown of the DHBs’ quarterly workforce “snapshots” shows that:

  • There were 3156 HCAs and 25,078 RNs employed (heads) across the 20 DHBs at the end of 2013.
  • The HCA/hospital aide full time equivalent (FTE) workforce grew 30%
  • in the six years to December 2013.
  • Over the same time period the nursing workforce grew 17.6 per cent.
  • The total DHB workforce grew by nearly 12 per cent.
  • The HCAs to nurse FTE ratio has risen from 1 HCA per 9.7 nurses in 2007 to 1 HCA per 8 nurses in 2013.
  • The average age of an HCA in 2013 was 49.8 years compared with
  • 45 years for your average DHB nurse.
  • HCAs mean length of service was 8.3 years compared to 9.1 for nurses.
  • HCAs are more ethnically diverse, including 11.6% Māori (4.5% RNs), 18% Asian (15.5% RNs), and 11.7% Pacific (2.3% RNs).
  • The HCA workforce is 80 per cent female.

*Data supplied by Health Workforce Information arm of DHB Shared Services using the NZNO/DHB MECA definition of what job titles are considered HCA or hospital aide equivalent roles

New national qualification for hospital HCAs on the way?

A New Zealand Certificate in Health and Wellbeing (acute health care support) targeted for public hospital HCAs is under development with the aim of the Level 3 national certificate being available in early 2015.

The industry training organisation Careerforce led a targeted review into the heath, disability, social services, and whānau ora sectors’ training and qualification on behalf of the New Zealand Qualifications Authority and reported back late last year, leading to the various strands of the new qualification now being developed.

“The roll-out of this suite of qualifications will effectively result in national standards for the sector, and graduate profiles for each qualification,” says NZQA deputy chief executive quality assurance, Jane von Dadelszen.

She says, in particular, this review identified a need for expected competencies among HCAs and support workers who work in public hospitals, aged residential care facilities, and home and community settings.

What is happening in the general practice sector?

The new role of primary care practice assistants (PCPA) was piloted in Auckland and Northland in 2012-2013. The Health Workforce New Zealand (HWNZ) funded pilot saw 19 students from 13 general practices undergo training involving one Level 4 and three Level 5 papers (at Unitec and AUT) plus practice-based learning.

An evaluation project of the new role – in some cases PCPAs take patients blood pressure and sterilise equipment – found RNs initially reluctant to delegate tasks but became more positive and reported that it freed up time for patient education and more nurse-led clinics.

Graeme Benny, HWNZ director, said an immediate national rollout of the PCPA role and qualification was delayed because of the NZQA qualification review (see above), so HWNZ was working in the interim on a change management strategy for ensuring uptake and acceptance of the role.


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