Health and Social Care in the Community (2014)
doi: 10.1111/hsc.12158
Mechanisms to enhance the effectiveness of allied health and social care assistants in community-based rehabilitation services: a qualitative study Anna Moran BAppSci (Physiotherapy) (USyd) PhD (USheffield)1, Susan A. Nancarrow 1 2 PhD(ANU) and Pamela Enderby MBE DSc (Hons) PhD MSc FRCSLT
BAppSc(Pod)(QUT) MAppSc(QUT)
1
School of Health and Human Sciences, Southern Cross University, Lismore, New South Wales, Australia and 2School of Health and Related Research, University of Sheffield, Sheffield, UK
Accepted for publication 14 August 2014
Correspondence Anna Moran School of Health and Human Sciences Southern Cross University PO Box 157, Lismore, New South Wales 2480, Australia E-mail: [email protected]
What is known about this topic
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Assistants provide a high proportion of direct client care in community settings. Better client outcomes are associated with a higher proportion of treatment by assistants in community settings. Assistants can improve service capacity and efficiency in community settings.
What this paper adds
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Successful employment of assistants is where an assistant is seen to enhance client, service and/or staff outcomes. Facilitators for successful use of assistants include multidisciplinary team working, timely assessment by qualified staff, strong communication channels and role flexibility. Barriers to the successful employment of assistants include not using assistants to their full or appropriate scope of practice; insufficient qualified to assistant staff ratios; and insufficient resources to train and supervise assistants.
© 2014 John Wiley & Sons Ltd
Abstract This research aims to describe the factors associated with successful employment of allied health and social care assistants in communitybased rehabilitation services (CBRS) in England. The research involved the thematic analysis of interviews and focus groups with 153 professionally qualified and assistant staff from 11 older people’s interdisciplinary community rehabilitation teams. Data were collected between November 2006 and December 2008. Assistants were perceived as a focal point for care delivery and conduits for enabling a service to achieve goals within interdisciplinary team structures. Nine mechanisms were identified that promoted the successful employment of assistants: (i) Multidisciplinary team input into assistant training and support; (ii) Ensuring the timely assessment of clients by qualified staff; (iii) Establishing clear communication structures between qualified and assistant staff; (iv) Co-location of teams to promote communication and skill sharing; (v) Removing barriers that prevent staff working to their full scope of practice; (vi) Facilitating role flexibility of assistants, while upholding the principles of reablement; (vii) Allowing sufficient time for client–staff interaction; (viii) Ensuring an appropriate ratio of assistant to qualified staff to enable sufficient training and supervision of assistants; and (ix) Appropriately, resourcing the role for training and reimbursement to reflect responsibility. We conclude that upholding these mechanisms may help to optimise the efficiency and productivity of assistant and professionally qualified staff in CBRS. Keywords: aged care, allied health, assistant, community rehabilitation, enablement, interprofessional, reablement, social care
Background Healthcare assistants are the largest group of health sector workers in the United Kingdom (UK) and are growing rapidly in other developed countries (Saks & Allsop 2007, Australian Workforce and Productivity Agency, 2013). Internationally, growth in assistants is a focus of health workforce reform to alleviate problems associated with workforce shortages and inefficiencies (Health Workforce Australia 2011, Department of Health 2012). Australia and the UK have been steadily embracing devolved models of care evidenced by increasing ratios of assistant workers to allied health practitioners (AHPs), introducing compulsory credentialing of assistants (Cavendish 2013) and changing models of care where the allied health professional is the ‘assessor’ and the assistant the care giver (Nancarrow et al. 2013). 1
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Over 300 job titles have been used to describe support workers/assistants (Saks & Allsop 2007). For this research, the term ‘assistant’ includes all workers who work with professionally qualified staff, who may have vocational qualifications, but do not require tertiary or equivalent qualifications to perform their role. These include profession-specific assistants who work within clinical or therapeutic teams such as physiotherapy assistants; and workers providing front-line support for patients, users or carers in the community and in their own homes, who work across multiple professional groups, such as community rehabilitation assistants, generic support workers and home helpers/enablers/reablement carers. The growing trend to employ assistants is particularly evident in community-based rehabilitation services (CBRS) in the UK. CBRS, also called intermediate care and transition care, aim to promote the independence or reablement of people who have suffered an acute event by reducing avoidable hospital admission or assisting the transition home after hospital discharge (Glendinning et al. 2010). Around 80% of CBRS employ assistants who provide, on average, 36% of the direct care provision to clients in these settings (Moran et al. 2012a). The impact of assistant roles in CBRS includes improved service capacity and efficiency (Hart et al. 2005, Stanmore et al. 2005, Moran et al. 2012b, Nancarrow et al. 2013), increased staff satisfaction with assistant roles (Anderson 1997, Saunders 1998, Daykin & Clarke 2000, Lindsay 2004, Cattrell et al. 2005, Mackey & Nancarrow 2005, McCartney et al. 2005, Moran et al. 2012b), client satisfaction (Brown et al. 2000, Hek et al. 2004, Mackey & Nancarrow 2004, Hart et al. 2005, Stanmore et al. 2005) and job satisfaction of assistants (Mackey & Nancarrow 2004, Moran et al. 2012c). One study found that better client outcomes were associated with a higher proportion of treatment by assistants in CBRS, although associated with increased service costs (Nancarrow et al. 2010b). Job satisfaction of assistants in CBRS is associated with levels of autonomy, career development opportunities (Nancarrow 2007) and the content and level of supervision and training they receive (Hek et al. 2004, Hancock et al. 2005, Spilsbury & Meyer 2005). Assistants are more likely to report an intention to leave their employer and profession in the next 12 months compared with professionally qualified staff in CBRS (Nancarrow et al. 2010b). These findings are replicated in other settings where higher rates of turnover and poor retention among support workers have been linked to lack of stable work relationships; 2
insufficient and discontinuous training; and lack of a clear division of roles among healthcare professionals (Si et al. 2006). While the ‘success’ of the assistant role in CBRS has been explored in terms of their impact on client, staff and service outcomes, research into the mechanisms to support the successful implementation of new assistant roles is lacking. For this study, success was defined as evidence that the input from an assistant influenced or enhanced client, service and/or staff outcomes. Therefore, this research explores the perceptions of assistants and staff working with assistants in CBRS to understand the mechanisms for successful use of allied health and social care assistants in CBRS.
Methods This study was part of a broader programme of research, involving six component studies, to examine the relationship between workforce flexibility and the costs and outcomes of older peoples’ services (Nancarrow et al. 2010a). The findings reported here are drawn from one component study which explored, qualitatively, the relationships between skill mix, organisational contexts, and staffing and patient outcomes. The results presented here involve a re-analysis of the data specifically relating to the barriers and facilitators associated with implementing assistants in CBRS. The research was undertaken within older peoples’ CBRS in England. Study participants were staff employed by older people’s teams that self-identified as CBRS with a primary client base of people over the age of 65. Teams were recruited via the Community Therapist Network and by letter of invitation to chief executives of National Health Service (NHS) Trusts in England. We intended to conduct focus groups with all 20 participating teams; however, data saturation was evident after interviews with 11 teams that were representative of the variety of CBRS, so data collection ceased at that stage. Multiple focus groups were undertaken with larger teams (n > 20 team members) to optimise participant participation, while keeping the focus groups a manageable size. In some teams, the managers chose to be interviewed separately so they would not influence the team responses. Separate face-to-face and telephone interviews were conducted with five purposively sampled health and social care support workers and their managers (n = 4) to capture more in-depth perspectives. Table 1 summarises the topic schedules for both the focus group and individual interviews. © 2014 John Wiley & Sons Ltd
Enhancing assistant staff effectiveness
Table 1 Topic schedules for focus group and individual interviews Focus group topics
Individual interview topics
The aims and objectives of the service The way the team is organised Roles and responsibilities of different staff members Impact of different roles in the team/team structure Benefits and difficulties of the current staffing models Challenges to delivering the service Working relationships between different types of staff members Management processes (frequency of team meetings, service location, information systems and transfer) Workforce priorities
The role of the staff member Training levels and requirements Interdisciplinary/interprofessional role relationships
All focus groups and interviews were recorded and transcribed verbatim. Focus group and interview data were combined in the NVivo Package (Version 7) as an administrative tool. Three researchers analysed the transcripts using the Framework approach (Ritchie & Spencer 1995). Data were analysed under the headings barriers and facilitators to the successful use of assistants, which are subsequently reframed to form the mechanisms for the successful use of assistants. The consolidated criteria for reporting qualitative research guided the reporting approach used for this study (Tong et al. 2007). NHS ethical approval was obtained (06⁄Q1606⁄132) and informed, written consent was obtained from all participants. The data were collected between June 2007 and December 2008.
Results We performed 18 focus groups, involving 153 staff (52 assistants) all of whom were NHS and/or Social Services employees. Additional individual interviews were undertaken with managers (n = 4) and assistants (n = 5). Respondents included 27 different types of professionally qualified staff or managers and 22
Staff members’ perception of their role How the role is perceived by others Impact of the role Job satisfaction Reward and recognition for the role
different types of assistants (Table 2). Team characteristics are summarised in Table 3. Focus groups aimed to proportionally represent the numbers of AHPs, social care practitioners and assistants within each team. Assistants were not present in three team focus groups (C, J and L) as they were not released from clinical care to participate. Team-level information (Table 3) was used to stratify transcript data from participating teams into those with low, medium and high proportions of assistant staff as a basis for comparing themes between teams. The contribution of assistants in CBRS Staff perceived that assistants, particularly those with an interdisciplinary skill set, increased the team’s capacity to provide high-intensity therapy to clients. Indeed, an overarching theme was that assistants are a focal point of care within an interdisciplinary team. They co-ordinate the delivery of several different therapies, follow the client’s progress against a care plan and provide feedback to the team: Well normally therapists will write the care plan and we adhere to the care plan but we can actually report, you know, increase or reduce services as people’s ability
Table 2 Types of respondents Professionally qualified staff titles
‘Assistant’ staff titles
Occupational therapist, Physiotherapist, Nurse, Social worker, Speech and language therapist, Geriatrician/consultant medical practitioner, ‘Link Worker’, Health assessor, Counsellor, Manager, Team leader, Psychotherapist, Liaison Officer, Care management assistant, Coordinator/Manger, Care co-ordinator, Case manager, Team manager, Stroke co-ordinator, Dietician, General Practitioner/Medical, Psychologist, Mental Health practitioner (including those who identified as a Community mental health nurse, Mental health nurse), Pharmacist, Podiatrist
Assistant Practitioner, Technical instructor, Rehabilitation assistant, Social work assistant, Physiotherapy assistant, Rehabilitation technician, Psychology assistant, Occupational Therapy technician, Carer, Community Care Worker, Care worker, Intermediate care technician, Care management assistant, Intermediate care support worker, Technician, Falls assistant, Therapy assistant, Technical assistant, Technician, Home enabler, Home Carer, Enablement Assistant
© 2014 John Wiley & Sons Ltd
3
4
21.6 (Low)
23.4 (Low) 26.1 (Low) 35.2 (Med)
40.7 41.7 52.5 55.1 82.4
L* J
B
D C A
E M G N F
7.2 7.2 40.0 22.3 22.8
12.4 15.3 44.1
14.8
9.0 3.5
Number of clinical staff in team† (WTE)
8 6 9 9 11
8 8 13
9
4 4
Total number of different staff types in team
Home Home Home Home Resource Centre
Home Home Home
Home Accident and Emergency Home
Setting of care provision
320 576 1650 728 183
285 398 1800
310
240 777
Patient throughput (average per annum)
18
1 1 3 2 1
1 1 4
2
1 1
Number of focus groups undertaken
153 (52 assistants)
15 (2) 7 (1) 15 (3, 6, 6) 8 (4) 15 (8)
15 (2) 10 (0) 40 (3, 4, 4, 4)
20 (2, 3)
5 (0) 3 (0)
Total number of focus group participants (assistants per focus group)
Med (medium); WTE, whole time equivalent; n/a, not applicable. * Team L reported that they had no support staff employed within their team, but utilised and worked with support staff from other healthcare teams. †,‡ As a proportion of all clinical staff (not including administrative staff) excluding administrative and management. $ Manager responsible for an entire location’s service which incorporated five teams (G, J, L, M and N).
Total
0 (Low) 14.3 (Low)
Team ID
(Med) (Med) (High) (High) (High)
Proportion of assistants in team (%)‡
Table 3 Team- and participant-level information
Manager (1) and assistant (1) 0 0 Manager (1) and assistant (1) 0 0 Manager (1)$ 0 Manager (1) and assistants (3) 9 (five assistants)
0 0
Individual interviews (n)
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Enhancing assistant staff effectiveness
improves but we do feed back. Normally verbally because we don’t do like case meetings and things like that. [Team M, focus group]
Assistants were satisfied with their role and qualified practitioners were satisfied both with the assistant role and working with assistants. Other benefits include the potential for avoidance of hospital admissions: I worked last Saturday and we had a rapid response and we got our services in, we had health care support workers going in to support a lady, who quite probably could have been admitted to hospital were it not for that. [Team G focus group]
Facilitators of successful use of assistants Multidisciplinary team input to assistant training Having input from a range of different disciplines within a team was perceived as important to increase the repertoire of assistant roles and confidence in a range of therapies: And also working with different professions . . . we just learn to feed off each other and it’s much better for the client again. [Team B focus group]
This in turn was seen to increase service capacity and enable assistants to identify a greater range of client needs. Although several assistants and qualified practitioners perceived that better access to formal training would enhance the success of the assistant role, the most valued sources of skill and knowledge acquisition were through working relationships with professionally qualified practitioners: Yes, I think if you give the support workers training in all the different roles, that helps with the therapists who are able to do assessments on a weekly basis rather than to go in and do it daily. [Team A, focus group]
Assistant skills and knowledge were enhanced by working closely with qualified practitioners through joint visits, delivering care plans made by qualified staff and being part of a multidisciplinary team. Furthermore, the success of the role depended on ‘in house’ training, structured supervision and support or ‘mentoring’ by qualified practitioners. Timely assessment of clients by qualified staff Having a timely and thorough client assessment by qualified practitioners before assistant input enabled the assistants to deliver safe and risk-free interventions to clients: F: . . .what happens is the occupational therapist goes in first anyway and assesses them, you know, © 2014 John Wiley & Sons Ltd
having a dry run in the shower, so really when we go, there shouldn’t be any problems. I: So you always feel safe performing your therapy role F: Yes, because you know somebody’s already been, one of the occupational therapists has been. [Team F, individual assistant interview] Strong communication between qualified and assistant staff Both qualified and assistant staff emphasised the importance of access to qualified professionals to voice concerns or provide feedback about a particular client’s progress. Participants described the importance of good communication channels which was reinforced when an assistant felt uncertain or out of their depth with a client: If I felt as if I was out of my depth then I would ask somebody, you know, I would always ask about whatever I was worried about. [Team B, individual assistant interview]
Co-location of teams Team co-location enhanced communication by enabling informal, daily client feedback and discussion. Participants valued the ability to access advice easily, in person. This facilitated good team working and communication, with the benefits cascading to client level: I’m based in the office here, all Enablers come in and out of this office at the beginning and end of the shift, the social workers and CCO [community care officer] are based in that same office, so there’s a lot of informal feedback goes on every day, so we all have our own picture, really, of all the clients and all the service. [Team F, individual assistant interview]
Role flexibility of generic assistant roles The flexibility embedded in generic or interprofessional support roles encapsulated the positive aspects of interdisciplinary working as expressed below: I think one of the most positive aspects of the service since it began has been the flexibility of the staff to change and to try all new ways of working. If it hadn’t have been for that, we wouldn’t be doing what we are doing now. [Team M, focus group]
A lack of professional role protection was perceived to enhance service delivery because assistants could perform tasks from a wide range of disciplines. Staff perceived that client outcomes were enhanced by the mixture of social interaction, personal care, 5
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therapy intervention and a philosophy of enablement that assistants provided in the home-care setting. A varied caseload was considered a source of job satisfaction for assistants. Furthermore, assistants’ satisfaction was increased by their ability to follow and support clients throughout the whole episode of care: . . .sometimes it can be incredibly boring if somebody wants to take three quarters of an hour to make a cup of tea but that’s our job, you know what I mean, and it’s so satisfying at the end of it to see them making themselves a cup of tea that, you know, might only take them 10 minutes in the end. [Team F, focus group]
Allowing time for client interaction All participants mentioned the importance of having time to give to clients. Time was necessary to allow relationships develop between the assistant and client, which in turn, positively enhanced the client’s rehabilitation process: F: . . .so you’re sitting having a cup of coffee with them . . . and you’ll listen to them and you get some conversation with them and it’s having those times that you can spare that time that I think really works well with the relationship building I: And do you think that it’s, that it’s a balance of what you deliver as, say, a therapist or an enabler and also the friendship component that helps them get to their final goal? F: Definitely, definitely, yes. [Team B, individual assistant interview] Barriers to successful use of assistants Not using assistants to their full, or appropriate scope of practice Several assistants reported being seconded into roles outside their regular team to address staff shortages in other sectors, such as acute hospital wards or assisted discharge. In one example, home-care services were unable to provide home carers to support hospital discharge of clients, so assistants assumed a personal care role until the service was available. While this model provided workforce flexibility, participants expressed that their own reablement philosophy was often at odds with the ‘caring’ role required in the services to which they were seconded and that they risked ‘deskilling’. Taking assistants away from their enablement role was also perceived to reduce the therapy time available to clients: . . .so some days we might be staffed quite well on the ward and have asked them [the rehabilitation assistants] to do a
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certain amount of tasks with clients but because the acute ward on the main hospital site has got a shortfall, they will come and take our rehab assistant who should have been doing rehab tasks. [Team M, focus group]
The negative impact of the fluidity of the assistant role was illustrated by assistants from one team who were trained phlebotomists; however, when nurses were working on the team, they took over the role of taking blood, leaving assistants feeling demoralised and deskilled: Well I take blood, the support workers are a very mixed group, we all have our areas, but I very rarely get to do it and they will put nurses in the same day as I go in to take a blood, and we’ve all got skills that perhaps we could use a little bit more. [Team A, assistant individual interview]
Insufficient qualified to assistant staff ratios The employment of assistants to increase service capacity needs to be balanced against sufficient qualified staff with the time and skills to deliver training: It is the old problem where you have to hit the ground running, so you employ people into the posts but they might have the basic level – you need a comprehensive programme of training to get them to the point where they are appropriate to do the job. It takes a lot of time, it doesn’t happen overnight. . .. [Team M, focus group]
Assistants identified that therapy plans were sometimes compromised by insufficient input from the therapist to reinforce therapy programmes. In one example, assistants perceived that they did not have the authority to make clients carry out their exercise programmes, but felt this could be addressed by having a greater presence of therapists on the unit: . . .when we go round, if the physio is there they actually do their exercises and they do them really well, but the following day when we go, ‘oh no, I can’t do them today’ and obviously we can’t force them. So sometimes the work that [the therapist] has put in is a waste of time because they won’t do it for us. [Team F, focus group]
Insufficient resources allocated to train and supervise assistant staff Several teams expressed concern over the time required to train, supervise and manage support staff and the implications of insufficient protected time to deliver these activities. Similarly, many assistants lacked access to formal training or assessors. Budget and service capacity constraints meant that many assistants achieved their qualification in their own time: I did my NVQ3, more or less off my own back. [Team D, focus group] © 2014 John Wiley & Sons Ltd
Enhancing assistant staff effectiveness
Lack of access to formal training was perceived to impinge on career progression opportunities and overall job satisfaction and turnover: . . .we’ve been offered NVQ, but there’s nobody to do it, so we can’t progress to get an NVQ because there’s nobody around to give us the training and the qualification, so we’re stuck because we can’t get the NVQ through no fault of our own, we can’t move on to apply for other jobs which say we must have an NVQ. So we’re being held back because the training isn’t there for us. [Team B, individual assistant interview]
Budget constraints meant that training was often unavailable to equip assistants with specific competencies to perform tasks that would ‘free up’ professional time, such as equipment prescription or using electrotherapy equipment. Formal training of assistants reassured the qualified professionals that the assistant was qualified to undertake particular tasks and practice autonomously in some settings: . . .they [assistants] have all been trained and they can actually work at NVQ level 3 and actually augment the care plans that are in there, just with the minimal reference back to us. [Team N, focus group]
The ratio of qualified to assistant staff impacted on the team capacity to train and supervise assistants. Teams with a lower ratio of assistants (Teams C, B and J) did not report any difficulties supervising and training assistants. Conversely, teams with medium to high ratios of qualified to assistant staff (Teams M, E, F and G) reported that training of assistants was a burden on their time. This was exacerbated in teams that also reported staff shortages and/or problems accessing social services (M and G). Similarly, assistants from teams with high ratios of assistant staff (F and G) felt it was sometimes difficult to access therapists for support or training: I think I personally feel that I’ve come into this role now and people expect me to know what I’m supposed to be doing and I don’t. So I think they sort of just let me get on with it. [Team G, focus group]
Insufficient recognition and rewards for the assistant roles While assistants perceived that their role was highly valued by clients and their team, they felt that wages did not reflect the level of responsibility required of the role. This was regardless of their level of qualification and autonomy. This impacted on morale and satisfaction as expressed by the assistant: Well everybody would like more money. I think that our course is very academic, very academic, for the amount of
© 2014 John Wiley & Sons Ltd
money that I will be earning, it is not going to be that much more than a rehab assistant’s money and I think if people really looked at the last 2 years and the amount of academic work that we have to do, to quite a high standard, I think we should be paid a bit more, but I accepted it at the beginning, so I have to accept it at the end. [Team A, assistant interview]
Discussion The barriers and facilitators above form the basis of several mechanisms that facilitate the successful use of assistant roles in CBRS, namely: 1 Having multidisciplinary team input into assistant training and support 2 Ensuring the timely assessment of clients by qualified staff 3 Facilitating communication between qualified and assistant staff 4 Co-location of teams to promote communication and skill sharing 5 Enabling staff to work to their full scope of practice 6 Facilitating role flexibility of assistants, while upholding the principles of reablement 7 Allowing sufficient time for client interaction 8 Ensuring an appropriate ratio of assistant to qualified staff to enable sufficient training and supervision of assistants 9 Appropriate resourcing of the role for training and reimbursement to reflect responsibility
A key finding from this study is that staff perceived that interprofessional assistants, that is, assistants who cross professional boundaries, enhance successful client and service outcomes in CBRS. Role sharing was essential to delivering services and ‘getting the job done’. Several key elements were required to ensure the success of assistants in this setting. They need to be appropriately supported to develop contextually relevant skills, knowledge and competence, and in some cases be a ‘jack of all trades’ (Rolfe et al. 1999, Hek et al. 2004). This is facilitated by promoting skill sharing and translation of these skills into confidence and competence in delivering an interprofessional role. These include multidisciplinary working, good team working relationships, delivery of ‘in house’ training to assistants by qualified staff, clear communication channels and sharing a common location or base. The importance of involving qualified staff in assistant training has been demonstrated in other settings (Hancock et al. 2005, Nancarrow et al. 2012). However, there is a risk that providing the majority of training ‘in house’ and relying on multidisciplinary working to impart knowledge and skills may
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restrict the extent of skills and knowledge transfer. Qualified practitioners tend to determine the content of training delivered to assistants (Baldwin et al. 2003); therefore, a broad skill mix of practitioners is necessary to provide access to a range of learning opportunities (Nancarrow et al. 2009). Lack of access to formal training for assistants exacerbates this problem. This is a particular concern in teams with low ratios of qualified staff who report lack of time to provide training and supervision. Insufficient training is a known risk factor for adverse client outcomes (Axelsson & Elmstahl 2004). This is important in CBRS, where most clients are unwell, vulnerable and often suffer from multiple acute and chronic medical conditions (Barton et al. 2005, Godfrey et al. 2005). Given that having a greater proportion of assistants in the skill mix is associated with better client outcomes in CBRS (Dixon et al. 2010, Nancarrow et al. 2010a) and there is demonstrated link between assistant competence and client functional gains (Nelson et al. 2007), there may be room for even greater health benefits if assistants can access more formal training opportunities. The data also confirm previous findings that assistant staff risked ‘deskilling’ in CBRS (McClimens et al. 2010). This occurred when qualified staff ‘reclaimed’ roles that the assistants had been trained to perform, such as phlebotomy. When an assistant is qualified and deemed competent to perform a task, it makes sense to allow them to perform that task, to free up the time of the more highly qualified (and more expensive) staff member to perform more highly skilled tasks. An exception to this would be where the more qualified staff member is already attending the client and the less qualified staff member would need to travel to perform their role. Otherwise, inefficiencies arise from qualified staff reclaiming roles that an assistant is qualified to perform. Deskilling was also perceived to occur when assistants were temporarily transferred into settings which did not use their reablement skills. To optimise workforce efficiency, staff who are competent to undertake a task should be enabled to work to their full scope of practice as much as possible. The results also demonstrate that although the fluidity of assistant roles can, on the one hand, be key to filling ‘service gaps’ and therefore successful service and client outcomes, role ambiguity may also lead to low job satisfaction. Role ambiguity has been found to be a precursor to burnout in the assistant workforce (Blumenthal et al. 1998). The composition of assistant roles depends on several factors including qualified staff numbers, 8
roles, attitudes and delegation practice as well as the setting of care, length of care and clientele (Moran et al. 2011). An additional finding from this study was the need to ensure the ratio of qualified to assistant staff facilitates sufficient supervision and training support. This ratio is likely to depend on levels of client need and the geographical dispersion of service users, so cannot be clearly prescribed; however, it is an important consideration in establishing a safe service. Study limitations We worked with teams to ensure that as many staff as possible were able to participate in the team focus group; however, complete staff coverage was not possible due to shift work and the need to maintain clinical services. The heterogeneity of assistant types makes generalisations about specific types of assistants impossible; thus, this study has sought to identify broad principles that are relevant in a range of contexts. Engaging with ‘natural’ groups, such as teams that work together, brings the internal dynamics that operate within the group on a daily basis (Leask et al. 2001). Therefore, it is possible that some participants may have participated less or been more outspoken than others.
Conclusion To optimise the efficient employment of assistants, it is useful to consider the mechanisms for successful use of assistants highlighted in this research. In particular, services should remove barriers that prevent staff working to their full scope of practice, consider that assistants are satisfied, competent and confident in their role through addressing role ambiguity, shortcomings in training, remuneration and career pathways. By upholding the mechanisms proposed in this paper, there may be potential to increase the efficient use, and hence productivity, of assistant and professionally qualified staff in CBRS.
Acknowledgements This study was funded by the National Institute for Health Research Service Delivery and Organisation (NIHR SDO). We acknowledge and thank the study participants.
Conflicts of interest No conflicts of interest have been declared. © 2014 John Wiley & Sons Ltd
Enhancing assistant staff effectiveness
Author contribution SN, AM and PE conceived the study. All authors participated in its design and co-ordination, in particular AM and SN constructed the interview schedules and all authors undertook interviews and focus groups. AM carried out the thematic analysis and drafted the initial manuscript. SN assisted with thematic analysis and advised the theoretical approach. SN and PE helped to draft and review the manuscript. All authors read and approved the final manuscript.
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Dixon S., Kaambwa B., Nancarrow S., Martin G.P. & Bryan S. (2010) The relationship between staff skill mix, costs and outcomes in intermediate care services. BMC Health Services Research 10, 221. Glendinning C., Jones K., Baxter K. et al. (2010) Home Care Re-Ablement Services: Investigating the Longer-Term Impacts (Prospective Longitudinal Study). University of York, 253 pages. ISBN: 978-1-907265-08-2. Godfrey M., Keen J., Townsend J. et al. (2005) An Evaluation of Intermediate Care for Older People. Final Report. Institute of Health Sciences and Public Health Research, University of Leeds, Leeds. Hancock H., Campbell S., Ramprogus V. & Kilgour J. (2005) Role development in health care assistants: the impact of education on practice. Journal of Evaluation in Clinical Practice 11, 489–498. Hart E., Lymbery M. & Gladman J. (2005) Away from home: an ethnographic study of transitional rehabilitation scheme for older people in the UK. Social Science and Medicine 60, 1241–1250. Health Workforce Australia (2011) National Health Workforce Innovation and Reform Strategic Framework for Action 2011– 2015. Health Workforce Australia, Adelaide. Hek G., Singer L. & Taylor P. (2004) Cross-boundary working: a generic worker for older people in the community. British Journal of Community Nursing 9, 237–244. Leask J., Hawe P. & Chapman S. (2001) Focus group composition: a comparison between natural and constructed groups. Australian and New Zealand Journal of Public Health 25, 152–154. Lindsay P. (2004) Introduction of maternity care assistants. British Journal of Midwifery 12, 650–653. Mackey H. & Nancarrow S. (2004) Report on the Introduction and Evaluation of a Occupational Therapy Assistant Practitioner. North Staffordshire Combined Healthcare Trust, Stoke-on-Trent. Mackey H. & Nancarrow S. (2005) Assistant practitioners: issues of accountability, delegation and competence. International Journal of Therapy and Rehabilitation 12, 331–338. McCartney E., Boyle J., Bannatyne S. et al. (2005) ‘Thinking for two’: a case study of speech and language therapists working through assistants. International Journal of Language and Therapy Disorders 40, 221–235. McClimens A., Nancarrow S., Moran A., Enderby P. & Mitchell C. (2010) ‘Riding the bumpy seas’: or the impact of the Knowledge Skills Framework component of the Agenda for Change initiative on staff in intermediate care settings. Journal of Interprofessional Care 24, 70–79. Moran A., Enderby P. & Nancarrow S. (2011) Defining and identifying common elements of and contextual influences on the roles of support workers in health and social care: a thematic analysis of the literature. Journal of Evaluation in Clinical Practice 17, 1191–1199. Moran A., Nancarrow S., Enderby P. & Bradburn M. (2012a) Are we using support workers effectively? The relationship between patient and team characteristics and support worker utilisation in older people’s communitybased rehabilitation services in England. Health and Social Care in the Community 20 (5), 537–549. Moran A., Nancarrow S., Wiseman L., Maher K., Boyce R. & Borthwick A.M. (2012b) Assisting role redesign: a qualitative evaluation of the implementation of a podiatry assistant role to a community health setting utilising a traineeship approach. Journal of Foot and Ankle Research 5, 30.
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Moran A., Wiseman L. & Nancarrow S. (2012c) Assisting Role Redesign Utilising a Traineeship Approach. An Evaluation of the Implementation of a Podiatry Assistant Role to a Community Health Setting Utilising a Certificate IV in Allied Health Assistance Traineeship. Charles Sturt University, Albury. Nancarrow S. (2007) The impact of intermediate care services on job satisfaction, skills and career development opportunities. Journal of Clinical Nursing 16, 1222–1229. Nancarrow S.A., Moran A., Freeman J., Enderby P. & Bradburn M. (2009) Looking inside the black box of community rehabilitation and intermediate care teams in the United Kingdom: an audit of staff and service configuration. Quality in Primary Care 17, 323–333. Nancarrow S., Moran A., Enderby P. et al. (2010a) The Relationship Between Workforce Flexibility and the Costs and Outcomes of Older Peoples Services. National Institute of Health Research, London. Nancarrow S.A., Enderby P., Moran A.M., Dixon S., Parker S., Bradburn M. & Mitchell C. (2010b) The Relationship Between Workforce Flexibility and the Costs and Outcomes of Older Peoples’ Services. NIHR SDO, Southampton, 296. Nancarrow S.A., Moran A., Wiseman L., Pighills A. & Murphy K. (2012) Assessing the implementation process and outcomes of newly introduced assistant roles: a qualitative study to examine the utility of the Calderdale Framework as an appraisal tool. Journal of Multidisciplinary Healthcare 5, 303–317. Nancarrow S.A., Roots A., Grace S., Moran A.M. & Vanniekerk-Lyons K. (2013) Implementing large-scale workforce change: learning from 55 pilot sites of allied health workforce redesign in Queensland, Australia. Human Resources for Health 11, 66.
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Nelson A., Powell-Cope G., Palacios P. et al. (2007) Nurse staffing and patient outcomes in inpatient rehabilitation settings. Rehabilitation Nursing 32, 179–202. Ritchie J. & Spencer L. (1995) Qualitative data analysis for applied policy research. In: A. Bryman & R.G. Burgess (Eds) Analyzing Qualitative Data, pp. 174–194. Routledge, London. Rolfe G., Jackson N., Gardner L., Jasper M. & Gale A. (1999) Developing the role of the generic healthcare support worker: phase 1 of an action research study. International Journal of Nursing Studies 36, 323–334. Saks M. & Allsop J. (2007) Social policy, professional regulation and health support work in the United Kingdom. Social Policy and Society 6, 165–177. Saunders L. (1998) Managing delegation, a field study of a systematic approach to delegation in out-patient physiotherapy. Physiotherapy 84, 547–555. Si D., Bailie R.S., Togni S.J., D’Abbs P.H.N. & Robinson G.W. (2006) Aboriginal health workers and diabetes care in remote community health centres: a mixed method analysis. Medical Journal of Australia 185, 40–45. Spilsbury K. & Meyer J. (2005) Making claims on nursing work: exploring the work of healthcare assistants and the implications for registered nurses’ roles. Journal of Research in Nursing 10, 65–83. Stanmore E., Ormrod S. & Waterman H. (2005) New roles in rehabilitation – the implications for nurses and other professionals. Journal of Evaluation in Clinical Practice 12, 656–664. Tong A., Sainsbury P. & Craig J. (2007) Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care 19, 349–357.
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doi: 10.1111/hsc.12158
Mechanisms to enhance the effectiveness of allied health and social care assistants in community-based rehabilitation services: a qualitative study Anna Moran BAppSci (Physiotherapy) (USyd) PhD (USheffield)1, Susan A. Nancarrow 1 2 PhD(ANU) and Pamela Enderby MBE DSc (Hons) PhD MSc FRCSLT
BAppSc(Pod)(QUT) MAppSc(QUT)
1
School of Health and Human Sciences, Southern Cross University, Lismore, New South Wales, Australia and 2School of Health and Related Research, University of Sheffield, Sheffield, UK
Accepted for publication 14 August 2014
Correspondence Anna Moran School of Health and Human Sciences Southern Cross University PO Box 157, Lismore, New South Wales 2480, Australia E-mail: [email protected]
What is known about this topic
• • •
Assistants provide a high proportion of direct client care in community settings. Better client outcomes are associated with a higher proportion of treatment by assistants in community settings. Assistants can improve service capacity and efficiency in community settings.
What this paper adds
• •
•
Successful employment of assistants is where an assistant is seen to enhance client, service and/or staff outcomes. Facilitators for successful use of assistants include multidisciplinary team working, timely assessment by qualified staff, strong communication channels and role flexibility. Barriers to the successful employment of assistants include not using assistants to their full or appropriate scope of practice; insufficient qualified to assistant staff ratios; and insufficient resources to train and supervise assistants.
© 2014 John Wiley & Sons Ltd
Abstract This research aims to describe the factors associated with successful employment of allied health and social care assistants in communitybased rehabilitation services (CBRS) in England. The research involved the thematic analysis of interviews and focus groups with 153 professionally qualified and assistant staff from 11 older people’s interdisciplinary community rehabilitation teams. Data were collected between November 2006 and December 2008. Assistants were perceived as a focal point for care delivery and conduits for enabling a service to achieve goals within interdisciplinary team structures. Nine mechanisms were identified that promoted the successful employment of assistants: (i) Multidisciplinary team input into assistant training and support; (ii) Ensuring the timely assessment of clients by qualified staff; (iii) Establishing clear communication structures between qualified and assistant staff; (iv) Co-location of teams to promote communication and skill sharing; (v) Removing barriers that prevent staff working to their full scope of practice; (vi) Facilitating role flexibility of assistants, while upholding the principles of reablement; (vii) Allowing sufficient time for client–staff interaction; (viii) Ensuring an appropriate ratio of assistant to qualified staff to enable sufficient training and supervision of assistants; and (ix) Appropriately, resourcing the role for training and reimbursement to reflect responsibility. We conclude that upholding these mechanisms may help to optimise the efficiency and productivity of assistant and professionally qualified staff in CBRS. Keywords: aged care, allied health, assistant, community rehabilitation, enablement, interprofessional, reablement, social care
Background Healthcare assistants are the largest group of health sector workers in the United Kingdom (UK) and are growing rapidly in other developed countries (Saks & Allsop 2007, Australian Workforce and Productivity Agency, 2013). Internationally, growth in assistants is a focus of health workforce reform to alleviate problems associated with workforce shortages and inefficiencies (Health Workforce Australia 2011, Department of Health 2012). Australia and the UK have been steadily embracing devolved models of care evidenced by increasing ratios of assistant workers to allied health practitioners (AHPs), introducing compulsory credentialing of assistants (Cavendish 2013) and changing models of care where the allied health professional is the ‘assessor’ and the assistant the care giver (Nancarrow et al. 2013). 1
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Over 300 job titles have been used to describe support workers/assistants (Saks & Allsop 2007). For this research, the term ‘assistant’ includes all workers who work with professionally qualified staff, who may have vocational qualifications, but do not require tertiary or equivalent qualifications to perform their role. These include profession-specific assistants who work within clinical or therapeutic teams such as physiotherapy assistants; and workers providing front-line support for patients, users or carers in the community and in their own homes, who work across multiple professional groups, such as community rehabilitation assistants, generic support workers and home helpers/enablers/reablement carers. The growing trend to employ assistants is particularly evident in community-based rehabilitation services (CBRS) in the UK. CBRS, also called intermediate care and transition care, aim to promote the independence or reablement of people who have suffered an acute event by reducing avoidable hospital admission or assisting the transition home after hospital discharge (Glendinning et al. 2010). Around 80% of CBRS employ assistants who provide, on average, 36% of the direct care provision to clients in these settings (Moran et al. 2012a). The impact of assistant roles in CBRS includes improved service capacity and efficiency (Hart et al. 2005, Stanmore et al. 2005, Moran et al. 2012b, Nancarrow et al. 2013), increased staff satisfaction with assistant roles (Anderson 1997, Saunders 1998, Daykin & Clarke 2000, Lindsay 2004, Cattrell et al. 2005, Mackey & Nancarrow 2005, McCartney et al. 2005, Moran et al. 2012b), client satisfaction (Brown et al. 2000, Hek et al. 2004, Mackey & Nancarrow 2004, Hart et al. 2005, Stanmore et al. 2005) and job satisfaction of assistants (Mackey & Nancarrow 2004, Moran et al. 2012c). One study found that better client outcomes were associated with a higher proportion of treatment by assistants in CBRS, although associated with increased service costs (Nancarrow et al. 2010b). Job satisfaction of assistants in CBRS is associated with levels of autonomy, career development opportunities (Nancarrow 2007) and the content and level of supervision and training they receive (Hek et al. 2004, Hancock et al. 2005, Spilsbury & Meyer 2005). Assistants are more likely to report an intention to leave their employer and profession in the next 12 months compared with professionally qualified staff in CBRS (Nancarrow et al. 2010b). These findings are replicated in other settings where higher rates of turnover and poor retention among support workers have been linked to lack of stable work relationships; 2
insufficient and discontinuous training; and lack of a clear division of roles among healthcare professionals (Si et al. 2006). While the ‘success’ of the assistant role in CBRS has been explored in terms of their impact on client, staff and service outcomes, research into the mechanisms to support the successful implementation of new assistant roles is lacking. For this study, success was defined as evidence that the input from an assistant influenced or enhanced client, service and/or staff outcomes. Therefore, this research explores the perceptions of assistants and staff working with assistants in CBRS to understand the mechanisms for successful use of allied health and social care assistants in CBRS.
Methods This study was part of a broader programme of research, involving six component studies, to examine the relationship between workforce flexibility and the costs and outcomes of older peoples’ services (Nancarrow et al. 2010a). The findings reported here are drawn from one component study which explored, qualitatively, the relationships between skill mix, organisational contexts, and staffing and patient outcomes. The results presented here involve a re-analysis of the data specifically relating to the barriers and facilitators associated with implementing assistants in CBRS. The research was undertaken within older peoples’ CBRS in England. Study participants were staff employed by older people’s teams that self-identified as CBRS with a primary client base of people over the age of 65. Teams were recruited via the Community Therapist Network and by letter of invitation to chief executives of National Health Service (NHS) Trusts in England. We intended to conduct focus groups with all 20 participating teams; however, data saturation was evident after interviews with 11 teams that were representative of the variety of CBRS, so data collection ceased at that stage. Multiple focus groups were undertaken with larger teams (n > 20 team members) to optimise participant participation, while keeping the focus groups a manageable size. In some teams, the managers chose to be interviewed separately so they would not influence the team responses. Separate face-to-face and telephone interviews were conducted with five purposively sampled health and social care support workers and their managers (n = 4) to capture more in-depth perspectives. Table 1 summarises the topic schedules for both the focus group and individual interviews. © 2014 John Wiley & Sons Ltd
Enhancing assistant staff effectiveness
Table 1 Topic schedules for focus group and individual interviews Focus group topics
Individual interview topics
The aims and objectives of the service The way the team is organised Roles and responsibilities of different staff members Impact of different roles in the team/team structure Benefits and difficulties of the current staffing models Challenges to delivering the service Working relationships between different types of staff members Management processes (frequency of team meetings, service location, information systems and transfer) Workforce priorities
The role of the staff member Training levels and requirements Interdisciplinary/interprofessional role relationships
All focus groups and interviews were recorded and transcribed verbatim. Focus group and interview data were combined in the NVivo Package (Version 7) as an administrative tool. Three researchers analysed the transcripts using the Framework approach (Ritchie & Spencer 1995). Data were analysed under the headings barriers and facilitators to the successful use of assistants, which are subsequently reframed to form the mechanisms for the successful use of assistants. The consolidated criteria for reporting qualitative research guided the reporting approach used for this study (Tong et al. 2007). NHS ethical approval was obtained (06⁄Q1606⁄132) and informed, written consent was obtained from all participants. The data were collected between June 2007 and December 2008.
Results We performed 18 focus groups, involving 153 staff (52 assistants) all of whom were NHS and/or Social Services employees. Additional individual interviews were undertaken with managers (n = 4) and assistants (n = 5). Respondents included 27 different types of professionally qualified staff or managers and 22
Staff members’ perception of their role How the role is perceived by others Impact of the role Job satisfaction Reward and recognition for the role
different types of assistants (Table 2). Team characteristics are summarised in Table 3. Focus groups aimed to proportionally represent the numbers of AHPs, social care practitioners and assistants within each team. Assistants were not present in three team focus groups (C, J and L) as they were not released from clinical care to participate. Team-level information (Table 3) was used to stratify transcript data from participating teams into those with low, medium and high proportions of assistant staff as a basis for comparing themes between teams. The contribution of assistants in CBRS Staff perceived that assistants, particularly those with an interdisciplinary skill set, increased the team’s capacity to provide high-intensity therapy to clients. Indeed, an overarching theme was that assistants are a focal point of care within an interdisciplinary team. They co-ordinate the delivery of several different therapies, follow the client’s progress against a care plan and provide feedback to the team: Well normally therapists will write the care plan and we adhere to the care plan but we can actually report, you know, increase or reduce services as people’s ability
Table 2 Types of respondents Professionally qualified staff titles
‘Assistant’ staff titles
Occupational therapist, Physiotherapist, Nurse, Social worker, Speech and language therapist, Geriatrician/consultant medical practitioner, ‘Link Worker’, Health assessor, Counsellor, Manager, Team leader, Psychotherapist, Liaison Officer, Care management assistant, Coordinator/Manger, Care co-ordinator, Case manager, Team manager, Stroke co-ordinator, Dietician, General Practitioner/Medical, Psychologist, Mental Health practitioner (including those who identified as a Community mental health nurse, Mental health nurse), Pharmacist, Podiatrist
Assistant Practitioner, Technical instructor, Rehabilitation assistant, Social work assistant, Physiotherapy assistant, Rehabilitation technician, Psychology assistant, Occupational Therapy technician, Carer, Community Care Worker, Care worker, Intermediate care technician, Care management assistant, Intermediate care support worker, Technician, Falls assistant, Therapy assistant, Technical assistant, Technician, Home enabler, Home Carer, Enablement Assistant
© 2014 John Wiley & Sons Ltd
3
4
21.6 (Low)
23.4 (Low) 26.1 (Low) 35.2 (Med)
40.7 41.7 52.5 55.1 82.4
L* J
B
D C A
E M G N F
7.2 7.2 40.0 22.3 22.8
12.4 15.3 44.1
14.8
9.0 3.5
Number of clinical staff in team† (WTE)
8 6 9 9 11
8 8 13
9
4 4
Total number of different staff types in team
Home Home Home Home Resource Centre
Home Home Home
Home Accident and Emergency Home
Setting of care provision
320 576 1650 728 183
285 398 1800
310
240 777
Patient throughput (average per annum)
18
1 1 3 2 1
1 1 4
2
1 1
Number of focus groups undertaken
153 (52 assistants)
15 (2) 7 (1) 15 (3, 6, 6) 8 (4) 15 (8)
15 (2) 10 (0) 40 (3, 4, 4, 4)
20 (2, 3)
5 (0) 3 (0)
Total number of focus group participants (assistants per focus group)
Med (medium); WTE, whole time equivalent; n/a, not applicable. * Team L reported that they had no support staff employed within their team, but utilised and worked with support staff from other healthcare teams. †,‡ As a proportion of all clinical staff (not including administrative staff) excluding administrative and management. $ Manager responsible for an entire location’s service which incorporated five teams (G, J, L, M and N).
Total
0 (Low) 14.3 (Low)
Team ID
(Med) (Med) (High) (High) (High)
Proportion of assistants in team (%)‡
Table 3 Team- and participant-level information
Manager (1) and assistant (1) 0 0 Manager (1) and assistant (1) 0 0 Manager (1)$ 0 Manager (1) and assistants (3) 9 (five assistants)
0 0
Individual interviews (n)
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Enhancing assistant staff effectiveness
improves but we do feed back. Normally verbally because we don’t do like case meetings and things like that. [Team M, focus group]
Assistants were satisfied with their role and qualified practitioners were satisfied both with the assistant role and working with assistants. Other benefits include the potential for avoidance of hospital admissions: I worked last Saturday and we had a rapid response and we got our services in, we had health care support workers going in to support a lady, who quite probably could have been admitted to hospital were it not for that. [Team G focus group]
Facilitators of successful use of assistants Multidisciplinary team input to assistant training Having input from a range of different disciplines within a team was perceived as important to increase the repertoire of assistant roles and confidence in a range of therapies: And also working with different professions . . . we just learn to feed off each other and it’s much better for the client again. [Team B focus group]
This in turn was seen to increase service capacity and enable assistants to identify a greater range of client needs. Although several assistants and qualified practitioners perceived that better access to formal training would enhance the success of the assistant role, the most valued sources of skill and knowledge acquisition were through working relationships with professionally qualified practitioners: Yes, I think if you give the support workers training in all the different roles, that helps with the therapists who are able to do assessments on a weekly basis rather than to go in and do it daily. [Team A, focus group]
Assistant skills and knowledge were enhanced by working closely with qualified practitioners through joint visits, delivering care plans made by qualified staff and being part of a multidisciplinary team. Furthermore, the success of the role depended on ‘in house’ training, structured supervision and support or ‘mentoring’ by qualified practitioners. Timely assessment of clients by qualified staff Having a timely and thorough client assessment by qualified practitioners before assistant input enabled the assistants to deliver safe and risk-free interventions to clients: F: . . .what happens is the occupational therapist goes in first anyway and assesses them, you know, © 2014 John Wiley & Sons Ltd
having a dry run in the shower, so really when we go, there shouldn’t be any problems. I: So you always feel safe performing your therapy role F: Yes, because you know somebody’s already been, one of the occupational therapists has been. [Team F, individual assistant interview] Strong communication between qualified and assistant staff Both qualified and assistant staff emphasised the importance of access to qualified professionals to voice concerns or provide feedback about a particular client’s progress. Participants described the importance of good communication channels which was reinforced when an assistant felt uncertain or out of their depth with a client: If I felt as if I was out of my depth then I would ask somebody, you know, I would always ask about whatever I was worried about. [Team B, individual assistant interview]
Co-location of teams Team co-location enhanced communication by enabling informal, daily client feedback and discussion. Participants valued the ability to access advice easily, in person. This facilitated good team working and communication, with the benefits cascading to client level: I’m based in the office here, all Enablers come in and out of this office at the beginning and end of the shift, the social workers and CCO [community care officer] are based in that same office, so there’s a lot of informal feedback goes on every day, so we all have our own picture, really, of all the clients and all the service. [Team F, individual assistant interview]
Role flexibility of generic assistant roles The flexibility embedded in generic or interprofessional support roles encapsulated the positive aspects of interdisciplinary working as expressed below: I think one of the most positive aspects of the service since it began has been the flexibility of the staff to change and to try all new ways of working. If it hadn’t have been for that, we wouldn’t be doing what we are doing now. [Team M, focus group]
A lack of professional role protection was perceived to enhance service delivery because assistants could perform tasks from a wide range of disciplines. Staff perceived that client outcomes were enhanced by the mixture of social interaction, personal care, 5
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therapy intervention and a philosophy of enablement that assistants provided in the home-care setting. A varied caseload was considered a source of job satisfaction for assistants. Furthermore, assistants’ satisfaction was increased by their ability to follow and support clients throughout the whole episode of care: . . .sometimes it can be incredibly boring if somebody wants to take three quarters of an hour to make a cup of tea but that’s our job, you know what I mean, and it’s so satisfying at the end of it to see them making themselves a cup of tea that, you know, might only take them 10 minutes in the end. [Team F, focus group]
Allowing time for client interaction All participants mentioned the importance of having time to give to clients. Time was necessary to allow relationships develop between the assistant and client, which in turn, positively enhanced the client’s rehabilitation process: F: . . .so you’re sitting having a cup of coffee with them . . . and you’ll listen to them and you get some conversation with them and it’s having those times that you can spare that time that I think really works well with the relationship building I: And do you think that it’s, that it’s a balance of what you deliver as, say, a therapist or an enabler and also the friendship component that helps them get to their final goal? F: Definitely, definitely, yes. [Team B, individual assistant interview] Barriers to successful use of assistants Not using assistants to their full, or appropriate scope of practice Several assistants reported being seconded into roles outside their regular team to address staff shortages in other sectors, such as acute hospital wards or assisted discharge. In one example, home-care services were unable to provide home carers to support hospital discharge of clients, so assistants assumed a personal care role until the service was available. While this model provided workforce flexibility, participants expressed that their own reablement philosophy was often at odds with the ‘caring’ role required in the services to which they were seconded and that they risked ‘deskilling’. Taking assistants away from their enablement role was also perceived to reduce the therapy time available to clients: . . .so some days we might be staffed quite well on the ward and have asked them [the rehabilitation assistants] to do a
6
certain amount of tasks with clients but because the acute ward on the main hospital site has got a shortfall, they will come and take our rehab assistant who should have been doing rehab tasks. [Team M, focus group]
The negative impact of the fluidity of the assistant role was illustrated by assistants from one team who were trained phlebotomists; however, when nurses were working on the team, they took over the role of taking blood, leaving assistants feeling demoralised and deskilled: Well I take blood, the support workers are a very mixed group, we all have our areas, but I very rarely get to do it and they will put nurses in the same day as I go in to take a blood, and we’ve all got skills that perhaps we could use a little bit more. [Team A, assistant individual interview]
Insufficient qualified to assistant staff ratios The employment of assistants to increase service capacity needs to be balanced against sufficient qualified staff with the time and skills to deliver training: It is the old problem where you have to hit the ground running, so you employ people into the posts but they might have the basic level – you need a comprehensive programme of training to get them to the point where they are appropriate to do the job. It takes a lot of time, it doesn’t happen overnight. . .. [Team M, focus group]
Assistants identified that therapy plans were sometimes compromised by insufficient input from the therapist to reinforce therapy programmes. In one example, assistants perceived that they did not have the authority to make clients carry out their exercise programmes, but felt this could be addressed by having a greater presence of therapists on the unit: . . .when we go round, if the physio is there they actually do their exercises and they do them really well, but the following day when we go, ‘oh no, I can’t do them today’ and obviously we can’t force them. So sometimes the work that [the therapist] has put in is a waste of time because they won’t do it for us. [Team F, focus group]
Insufficient resources allocated to train and supervise assistant staff Several teams expressed concern over the time required to train, supervise and manage support staff and the implications of insufficient protected time to deliver these activities. Similarly, many assistants lacked access to formal training or assessors. Budget and service capacity constraints meant that many assistants achieved their qualification in their own time: I did my NVQ3, more or less off my own back. [Team D, focus group] © 2014 John Wiley & Sons Ltd
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Lack of access to formal training was perceived to impinge on career progression opportunities and overall job satisfaction and turnover: . . .we’ve been offered NVQ, but there’s nobody to do it, so we can’t progress to get an NVQ because there’s nobody around to give us the training and the qualification, so we’re stuck because we can’t get the NVQ through no fault of our own, we can’t move on to apply for other jobs which say we must have an NVQ. So we’re being held back because the training isn’t there for us. [Team B, individual assistant interview]
Budget constraints meant that training was often unavailable to equip assistants with specific competencies to perform tasks that would ‘free up’ professional time, such as equipment prescription or using electrotherapy equipment. Formal training of assistants reassured the qualified professionals that the assistant was qualified to undertake particular tasks and practice autonomously in some settings: . . .they [assistants] have all been trained and they can actually work at NVQ level 3 and actually augment the care plans that are in there, just with the minimal reference back to us. [Team N, focus group]
The ratio of qualified to assistant staff impacted on the team capacity to train and supervise assistants. Teams with a lower ratio of assistants (Teams C, B and J) did not report any difficulties supervising and training assistants. Conversely, teams with medium to high ratios of qualified to assistant staff (Teams M, E, F and G) reported that training of assistants was a burden on their time. This was exacerbated in teams that also reported staff shortages and/or problems accessing social services (M and G). Similarly, assistants from teams with high ratios of assistant staff (F and G) felt it was sometimes difficult to access therapists for support or training: I think I personally feel that I’ve come into this role now and people expect me to know what I’m supposed to be doing and I don’t. So I think they sort of just let me get on with it. [Team G, focus group]
Insufficient recognition and rewards for the assistant roles While assistants perceived that their role was highly valued by clients and their team, they felt that wages did not reflect the level of responsibility required of the role. This was regardless of their level of qualification and autonomy. This impacted on morale and satisfaction as expressed by the assistant: Well everybody would like more money. I think that our course is very academic, very academic, for the amount of
© 2014 John Wiley & Sons Ltd
money that I will be earning, it is not going to be that much more than a rehab assistant’s money and I think if people really looked at the last 2 years and the amount of academic work that we have to do, to quite a high standard, I think we should be paid a bit more, but I accepted it at the beginning, so I have to accept it at the end. [Team A, assistant interview]
Discussion The barriers and facilitators above form the basis of several mechanisms that facilitate the successful use of assistant roles in CBRS, namely: 1 Having multidisciplinary team input into assistant training and support 2 Ensuring the timely assessment of clients by qualified staff 3 Facilitating communication between qualified and assistant staff 4 Co-location of teams to promote communication and skill sharing 5 Enabling staff to work to their full scope of practice 6 Facilitating role flexibility of assistants, while upholding the principles of reablement 7 Allowing sufficient time for client interaction 8 Ensuring an appropriate ratio of assistant to qualified staff to enable sufficient training and supervision of assistants 9 Appropriate resourcing of the role for training and reimbursement to reflect responsibility
A key finding from this study is that staff perceived that interprofessional assistants, that is, assistants who cross professional boundaries, enhance successful client and service outcomes in CBRS. Role sharing was essential to delivering services and ‘getting the job done’. Several key elements were required to ensure the success of assistants in this setting. They need to be appropriately supported to develop contextually relevant skills, knowledge and competence, and in some cases be a ‘jack of all trades’ (Rolfe et al. 1999, Hek et al. 2004). This is facilitated by promoting skill sharing and translation of these skills into confidence and competence in delivering an interprofessional role. These include multidisciplinary working, good team working relationships, delivery of ‘in house’ training to assistants by qualified staff, clear communication channels and sharing a common location or base. The importance of involving qualified staff in assistant training has been demonstrated in other settings (Hancock et al. 2005, Nancarrow et al. 2012). However, there is a risk that providing the majority of training ‘in house’ and relying on multidisciplinary working to impart knowledge and skills may
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restrict the extent of skills and knowledge transfer. Qualified practitioners tend to determine the content of training delivered to assistants (Baldwin et al. 2003); therefore, a broad skill mix of practitioners is necessary to provide access to a range of learning opportunities (Nancarrow et al. 2009). Lack of access to formal training for assistants exacerbates this problem. This is a particular concern in teams with low ratios of qualified staff who report lack of time to provide training and supervision. Insufficient training is a known risk factor for adverse client outcomes (Axelsson & Elmstahl 2004). This is important in CBRS, where most clients are unwell, vulnerable and often suffer from multiple acute and chronic medical conditions (Barton et al. 2005, Godfrey et al. 2005). Given that having a greater proportion of assistants in the skill mix is associated with better client outcomes in CBRS (Dixon et al. 2010, Nancarrow et al. 2010a) and there is demonstrated link between assistant competence and client functional gains (Nelson et al. 2007), there may be room for even greater health benefits if assistants can access more formal training opportunities. The data also confirm previous findings that assistant staff risked ‘deskilling’ in CBRS (McClimens et al. 2010). This occurred when qualified staff ‘reclaimed’ roles that the assistants had been trained to perform, such as phlebotomy. When an assistant is qualified and deemed competent to perform a task, it makes sense to allow them to perform that task, to free up the time of the more highly qualified (and more expensive) staff member to perform more highly skilled tasks. An exception to this would be where the more qualified staff member is already attending the client and the less qualified staff member would need to travel to perform their role. Otherwise, inefficiencies arise from qualified staff reclaiming roles that an assistant is qualified to perform. Deskilling was also perceived to occur when assistants were temporarily transferred into settings which did not use their reablement skills. To optimise workforce efficiency, staff who are competent to undertake a task should be enabled to work to their full scope of practice as much as possible. The results also demonstrate that although the fluidity of assistant roles can, on the one hand, be key to filling ‘service gaps’ and therefore successful service and client outcomes, role ambiguity may also lead to low job satisfaction. Role ambiguity has been found to be a precursor to burnout in the assistant workforce (Blumenthal et al. 1998). The composition of assistant roles depends on several factors including qualified staff numbers, 8
roles, attitudes and delegation practice as well as the setting of care, length of care and clientele (Moran et al. 2011). An additional finding from this study was the need to ensure the ratio of qualified to assistant staff facilitates sufficient supervision and training support. This ratio is likely to depend on levels of client need and the geographical dispersion of service users, so cannot be clearly prescribed; however, it is an important consideration in establishing a safe service. Study limitations We worked with teams to ensure that as many staff as possible were able to participate in the team focus group; however, complete staff coverage was not possible due to shift work and the need to maintain clinical services. The heterogeneity of assistant types makes generalisations about specific types of assistants impossible; thus, this study has sought to identify broad principles that are relevant in a range of contexts. Engaging with ‘natural’ groups, such as teams that work together, brings the internal dynamics that operate within the group on a daily basis (Leask et al. 2001). Therefore, it is possible that some participants may have participated less or been more outspoken than others.
Conclusion To optimise the efficient employment of assistants, it is useful to consider the mechanisms for successful use of assistants highlighted in this research. In particular, services should remove barriers that prevent staff working to their full scope of practice, consider that assistants are satisfied, competent and confident in their role through addressing role ambiguity, shortcomings in training, remuneration and career pathways. By upholding the mechanisms proposed in this paper, there may be potential to increase the efficient use, and hence productivity, of assistant and professionally qualified staff in CBRS.
Acknowledgements This study was funded by the National Institute for Health Research Service Delivery and Organisation (NIHR SDO). We acknowledge and thank the study participants.
Conflicts of interest No conflicts of interest have been declared. © 2014 John Wiley & Sons Ltd
Enhancing assistant staff effectiveness
Author contribution SN, AM and PE conceived the study. All authors participated in its design and co-ordination, in particular AM and SN constructed the interview schedules and all authors undertook interviews and focus groups. AM carried out the thematic analysis and drafted the initial manuscript. SN assisted with thematic analysis and advised the theoretical approach. SN and PE helped to draft and review the manuscript. All authors read and approved the final manuscript.
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