Summary of the impact

Research at Oxford has played a central role within the recent restructuring of the nursing workforce to improve healthcare quality in a context of growing service demands and tightening resource constraints. Much of this restructuring has been heavily dependent on the use of the Healthcare Assistant (HCA) role, provoking much controversy. Presented as a flexible, low cost resource, these HCA roles are also unregulated and therefore seen as a potential source of patient risk. Oxford researchers have fed into this debate across a number of projects, strengthening the evidence base on the nature and consequences of the HCA role. Examining the role from the perspective of different stakeholders, these projects have impacted on national, regional and local policy and practice centred on the management and use of HCAs. In so doing, the research has contributed to the development of a more productive and safer nursing workforce.

Underpinning research

The HCA research stream emerged from an ESRC funded project (2003-05) exploring the contribution made by support roles to the government's public service reform programme. Public policy interest in the NHS workforce encouraged the researchers to concentrate on the HCA role. The succeeding research comprised two National Institute of Health Research funded projects (2007-09; 2010-13). Both projects were characterised by the following [Section 3: see R1, R2]:

— Early two-way engagement with policy makers and practitioners at different levels of the NHS with a view to: deepening understanding of the management of HCAs; feeding back research findings; and encouraging informed decision-making by them.

— The adoption of a stakeholder approach which allowed a wide variety of issues to be addressed. In examining the HCA role from the perspective of the HCAs themselves, it was possible to examine their work histories, motivations, aspirations, job satisfaction and contribution to various performance outcomes. In adopting the supervisors' perspective, the research could explore practices used to manage HCAs: recruitment, induction, training and reward. A service perspective provided an opportunity to consider how HCAs engaged with patients. In assessing a co-worker perspective, it was possible to look at how the HCA role might be designed to contribute toward team performance.

— Multi-methods case studies which provided insight into the contingencies and process issues affecting the use and impact of the HCA role and allowed for the triangulation of different data sources.

More specifically, the first NIHR project (2007-9) sought to test assumptions underpinning public policy which viewed the HCA as: a `relief', removing `burden' from nurses; as a `substitute' reducing staff costs; as an `apprentice' providing a future supply of nurses; and a `co-producer', bringing distinctive capabilities to patient care. In so doing, the research sought to provide both a stronger evidence base for such policy and a deeper understanding of work organisation in the NHS and its consequences for various stakeholders and outcomes. Addressing these issues, the fieldwork centred on four acute trusts (Oxford, Hillingdon, Wolverhampton and Leeds), and involved around 200 interviews, some 250 hours of observation, patient focus groups, and surveys covering over 3,000 HCAs, nurses and patients. The findings (for overview see [R1]):

— Confirmed the increasing use of the HCA as a `relief' and `substitute', taking over an increasing range of direct care tasks from nurses [R4, R6], However, the extension of the HCAs' role, traditionally restricted to ancillary tasks, was typically under rewarded and at a cost to the quality of their working life [R3]. These findings linked to theoretical debates on the regulation of task allocation at the workplace.

— Cast doubt on the use of the HCA as an `apprentice' by revealing the under-developed career pathways, training opportunities and performance management systems [R2, R6]. These results connected to a neglected issue in the human resources literature on the management of low paid, gendered work roles.

— Highlighted the significant contribution made by HCAs to healthcare as co-producers, dealing more effectively than nurses with the patients' emotional well-being [R5]. This was an under-valued contribution and challenged a growing public policy consensus that the increased use of HCAs undermined the quality of care provision. These findings fed into the research literature on emotion management in interactive service industries.

Building upon the first project, the second NIHR study (2011-13) considered how the use and management of the HCA roles by national, regional and local policymakers and practitioners might be improved. It comprised a number streams:

— An innovation stream, including six hospital case studies (UCLH, Oxford (2), York, Torbay, Hillingdon) revealed and unpacked the organizational architecture needed to support and sustain different forms innovation in the management and use of HCAs.

— An evaluation stream assessed the impact of interventions designed to develop the HCA role in three trusts (North Bristol, Oxford, West Suffolk) revealing the efficacy of various initiatives.

— An engagement stream which brought together actors with a stake in the HCA role in four regional workshops, providing an opportunity to share experiences and supporting the development a new HCA toolkit for practitioners [for an overview of these streams and the results see R2].

Researchers involved in this research include:

• Ian Kessler, Reader in Employment Relations, Saïd Business School, Oxford 1990-2012 (Involved in all aspects of the fieldwork on both research projects, Responsible for writing both final reports, all feedback reports to case trusts and all academic papers).
• Paul Heron, Research Associate, Saïd Business School, 2008-2012. Full time researcher on both projects. Involved in all aspects of the fieldwork and responsible for project administration and capturing/processing qualitative and quantitative research data.)
• Sue Dopson Professor of Organisational Behaviour, Saïd Business School, (1993- to date) (Contributed to first project 2007-10: involved in some aspects of the fieldwork and the write-up of the final report)
• Helen Magee, Research Fellow, Picker Institute Oxford (Contributed to the first NIHR project by conducting the patient focus group on first NIHR project, 2007-10
• Karen Spilsbury, Professor in Nursing Studies, University of York (Contributed to the second NIHR project, 2010-13, by undertaking one of six the evaluation cases)

References to the research

*denotes output submission to REF2014.

Research Grants:

2003 - 2005 Economic and Social Research Council grant: Assistant Roles and Changing Job Boundaries in the Public Services (£180,000), PI: Ian Kessler (with P. Heron)

2007 - 2010 NHS National Institute for Health Research SDO Programme: Support Roles in Secondary Care (£440,000), PI: Ian Kessler (with P. Heron and S. Dopson)

2010-2013 NHS National Institute for Health Research SDO Programme: Developing a high performance assistant workforce (£300,000) PI: Ian Kessler (with P. Heron and K. Spilsbury).

Details of the impact

This research has had a direct impact on national policy debates relating to the use of HCAs, the appropriate staffing and management of the HCA workforce, as well as its training [Section 5: C9, C11]. Locally, the research has influenced regional and trust policy and practice.

National Impact:

The HCA is an unregistered role, with no statutory minimum training requirements or any means of `striking-off' of `poor' performers. Governments have adopted a light touch approach to HCA registration, reflected in the current position - a proposed form of voluntary registration. However, pressure has grown for a stronger form of registration, not least in the wake of the Francis Report on the failures at the Mid-Staffordshire Trust. National policy makers have drawn upon the Oxford research in seeking stronger forms of registration [R2, C1, C4]. As the RCN note in referring to this research, `recent studies have shown that registered nurses have a deep anxiety regarding the absence of national regulation of healthcare assistants' [C6].

More specifically, the research [R4] has impacted onthe development of appropriate staffing levels. It has highlighted the problems associated with current skill mix practice, based on a crude distinction between qualified (nurses) and non-qualified staff (HCAs) [R1, R2]. In revealing the different forms assumed by the HCA role, the research has also supported calls for skill mix to display greater sensitivity to the varied nature of the HCA role and post holder capabilities [R4, R6]. As the Cavendish Report [C5: p.18] notes,' Kessler et al's research supports the assertion that advanced skills... that were once the remit of registered nurses are now more common for a certain kind of HCA'.

The research has also impacted on national policy deliberations on the management of the HCA workforce [C11]. In general terms, NHS Employers, the organisation providing advice to Trusts on the management of their workforces, includes a summary of the Oxford research on HCAs and a link to the full research reports [C11]. More specifically, the Oxford research has drawn attention to the uneven and underdeveloped nature of HCA training [C11]. This evidence has been extensively used by those policy makers and practitioners calling for more robust training standards amongst HCAs [C1]. These calls have directly led to the government introducing minimum training standards for these workers. Indeed, `Skills of Health' [C3] makes considerable use of the research (including 10 separate references to the team's work) in making the case for more development opportunities for healthcare assistants.

Moreover, the Cavendish Review, an inquiry, commissioned by the government into the training and development of HCAs, draws heavily on the research [C5, C9]. There are 13 references to the work in the final report, which also makes extensive use of the substantive findings [C5, C9]. For example, the report uses a case study from the second research project [C9], on a values based approach to recruitment, in calling for the development of national systems to support the adoption of such an approach across the NHS in taking on HCAs [C5, Recommendation 6]. Cavendish also presents findings from the Oxford research on the backgrounds and previous work experiences of newly recruited HCAs as the basis for recommending the introduction of a training certificate for all HCAs [C5, Recommendation 3]. The government has committed to implementing all the Cavendish recommendations, including those based on the research described above, with preparatory work, particularly undertaken by Health Education England, already at an advanced stage [C9, C11].

Local Impact:

At lower levels in the NHS, the research has impacted on the development of regional policies and practices. For example the Oxford research is referred to in a leaflet published in NHS Wales entitled `Streamlining the role of the healthcare support worker' aimed at healthcare providers dealing with Neonatal Abstinence Syndrome.

More significantly, the research has impacted at Trust level. This impact has been delivered through various routes or mechanisms, reflected in the use of the findings made by a wide range of Trusts. These routes-to-impact include:

i) Dissemination: In writing-up and disseminating the material, the research has helped the spread of `good' practice, with evidence to suggest that Trusts have drawn upon this `good practice' to develop new approaches to the management of HCAs. For example, York hospital's introduction of values-based recruitment (VBR) for HCAs, which was written-up as an innovation case (second project), impacted on Oxford University Hospitals (OUH). OUH became aware of the York VBR model by reading the research case, and piloting it. Off the back of this pilot, OUH has received a grant from the Health Foundation to roll-out VBR across much of its workforce [C7].

ii) Exposure: The research exposed the difficulties faced by Trusts in the use and management of HCAs, which in turn prompted change in local policy and practice. For example the Hillingdon case study in the first project established that patients valued, but were unable to distinguish between, HCAs and nurses. In response, the Trust developed a patient handbook clarifying the HCA role. At the same Trust, the absence of a meaningful HCA `voice' was revealed: in response the Trust established a new HCA forum [C8].

iii) Deep Engagement: Deep engagement has been involved in both of the projects. A number of Trusts, including OUH and Hillingdon, developed a strong relationship with the researchers, providing an opportunity to use data collected over many years in assessing an initiative and contributing to its roll-out across the Trust [C7, C8]. For example, OUH introduced an HCA academy based on an extended HCA induction, a portfolio of HCA competences and the creation of a new HCA educator role. In assessing this initiative as part of the second project, the researchers drew upon data from the first project to benchmark these recent developments: exploring whether and how the academy had impacted HCA attitudes and behaviours [C7].

iv) Evaluation: The research has impacted on Trusts through a robust `before' and `after' evaluation of various initiatives. The outcome of these evaluations has provided the evidence basis for the roll-out of the initiative across each Trust. Examples included:

• The administration of medicine: Traditionally reserved for registered nurses, this task was extended to Assistant Practitioners (APs) in one Trust case, North Bristol. Interviewing and surveying APs and nurses before and after the introduction of a pilot was formally part of the Trust's evaluation of this initiative, influencing its adoption.
• The development of an Emergency Department Technician role: Extending the HCA role to perform tasks such as plastering was designed to improve care quality for patients visiting A&E. In tracking HCA experiences before and after its introduction at Hillingdon, the research contributed to the `bedding down' of this role [C8].

v) Facilitation: The research team organised workshop activities designed to develop HCA capabilities. In one Trust case, the Royal Wolverhampton Trust, the research contributed to the development of HCA capacity to constructively challenge more senior healthcare professionals. The researchers designed, organised and delivered a workshop to develop constructive challenge amongst HCAs, and then assessed the impact of this workshop on HCA behaviours [C10].

In summary, the Oxford research has been noteworthy for impacting on NHS policy and practice at different levels of the NHS, in so doing has contributed to the development of a more productive and safer nursing workforce.

Sources to corroborate the impact

Reports and Publications:

[C1] Royal College of Nursing (2012) Position Statement on the education and Training of HCAs, London: RCN

[C2] House of Commons Health Committee, Annual accountability hearing with the National Midwifery Council Seventh Report of Session 2010-12, para. 4.2

[C3] Skills for Health (2011) The Role of Assistant Practitioners in the NHS, London: SfH

[C4] Unison (2010:2) Regulation of Health Care Assistants, London: Unison

[C5] The Cavendish Review (2013), London: HMSO

[C6] Royal College of Nursing (RCN) (2012:3) The Weakness of Voluntary Registration for Health Care Support Workers, London: RCN.

Practitioner and Policy Makers:
(There are number of people, in addition to those listed below, who would be willing to confirm the impact of this research)

[C7] Chief Nurse, Oxford University Hospitals

[C8] Deputy Director of Patient Experience and Nursing, Hillingdon NHS Trust

[C9] Chair of the Cavendish Review (an inquiry commissioned by the government into the training and development of HCAs)

[C10] Director of Nursing and Midwifery, Royal Wolverhampton Hospital, New Cross Hospital

[C11] Unison Head of Nursing