Journal of Nursing Management, 2010, 18, 548555

Vital signs for vital people: an exploratory study into the role of the Healthcare Assistant in recognising, recording and responding to the acutely ill patient in the general ward setting
JAYNE JAMES R N . , O r t h o . N u r s i n g C e r t . , C e r t . E d . , M S c 1, CAROLE BUTLER-WILLIAMS R G N . , P G C e r t . M e d . E d . , F H E A . , 2 3 4 D i p H E ( c r i t i c a l c a r e ) , M A , JULIAN HUNT R N . , B A ( H o n s ) . , M S c and HELEN COX M A ( E d ) , B S c ( c r i t i c a l c a r e ) , R N
1 Senior Lecturer, Department of Nursing and Midwifery, University of the West of England 2Consultant Nurse, Gloucestershire Hospital NHS Foundation Trust, 3Consultant Nurse, Royal United Hospital, Bath/Lecturer, Department of Nursing and Midwifery, University of the West of England and 4Senior Lecturer, Department of Nursing and Midwifery, University of the West of England, Bristol, UK

Correspondence Jayne James Department of Nursing and Midwifery University of the West of England Glenside Campus Blackberry Hill BristolBS16 1DD UK E-mail: jayne.james@uwe.ac.uk

JAMES J., BUTLER-WILLIAMS C., HUNT J. & COX H.

(2010) Journal of Nursing Management 18, 548555 Vital signs for vital people: an exploratory study into the role of the Healthcare Assistant in recognising, recording and responding to the acutely ill patient in the general ward setting

Aim To examine the contribution of the Healthcare Assistant (HCA) as the recogniser, responder and recorder of acutely ill patients within the general ward setting. Background Concerns have been highlighted regarding the recognition and management of the acutely ill patient within the general ward setting. The contribution of the HCA role to this process has been given limited attention. Methods A postal survey of HCAs was piloted and conducted within two district general hospitals. Open and closed questions were used. Results Results suggest that on a regular basis HCAs are caring for acutely ill patients. Contextual issues and inaccuracies in some aspects of patient assessment were highlighted. It would appear normal communication channels and hierarchies were bypassed when patients safety was of concern. Educational needs were identied including scenario-based learning and the importance of ensuring mandatory training is current. Conclusions and implications for nursing management HCAs play a signicant role in the detection and monitoring of acutely ill patients. Acknowledgement is needed of the contextual factors in the general ward setting which may inuence the quality of this process. The educational needs identied by this study can assist managers to improve clinical supervision and educational input in order to improve the quality of care for acutely ill patients. Keywords: acutely ill patient, health care assistants, patient assessment, recognizer,
responder
Accepted for publication: 7 February 2010

Aim
The overall aim of the present study was to explore the experiences of the Registered Nurse (RN) and
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Healthcare Assistant (HCA) in caring for the acutely ill adult patient within the general ward setting. A HCA (sometimes called nursing auxiliary or assistant) can be dened as a clinical support worker who is
DOI: 10.1111/j.1365-2834.2010.01086.x 2010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd

The role of the HCA

accountable to and supervised by a RN. Critical care units, emergency departments and areas such as theatre recovery were excluded from the study. This paper is the rst of two publications regarding the HCA experience. Key areas to be addressed within this rst paper include: The role of the HCA in recognizing acute deterioration and illness. The role of the HCA as recorder and responder (Department of Health (DH) 2009). Clinical practice and educational needs of HCAs in the care of acutely ill patients. Paper two will explore further issues regarding the feelings, support mechanisms and methods of feedback available to HCAs regarding the care of the acutely ill patient. The RN perspective will be available in subsequent publications.

Introduction
Improving acute care management within the general ward setting continues to be a key priority [National Institute of Clinical Excellence (NICE) (2007)]. A signicant study by McQuillan et al. (1998) identied suboptimal care of general ward patients was directly related to adverse intensive care outcomes and increased mortality rates. Similarly, McGloin et al. (1999) identied poor assessment of acutely ill patients, with delays in response and treatment in these areas. Despite previous concerns these issues regarding patient safety continue to be unresolved [NCEPOD 2005, NICE 2007, National Safety Patient Agency (NPSA) 2007]. Many inuencing contextual factors have contributed to the present management of the acute care patient within the general ward setting. Capacity issues within the National Health Service (NHS) arguably have contributed to this problem (DH 2001a, MacFarlane 2005). In addition, improved patient survival rates have resulted in an increasingly complex and elderly client group. The resultant increased patient acuity is not necessarily matched by greater resourcing leading to an increased risk of acute deterioration (NICE 2007). Further factors contribute to the likelihood of acute deterioration including mode of hospital admission, patient co-morbidities and physiological reserve (Kause et al. 2004, NICE 2007, NPSA 2007). The benets of early recognition and treatment of the deteriorating patient are well recognised (NPSA 2007) and transgress many specialties including management

of sepsis (Rivers et al. 2001), myocardial infarction (Jaffrey et al. 2009) and stroke thrombolysis (Calleja et al. 2009). Mortality rates can be signicantly reduced for patients if they are identied before they deteriorate to cardio-respiratory arrest (NICE 2007). Despite the need for early recognition there is evidence to suggest that while patients deterioration may be documented there are failings in acting upon this information (Smith et al. 2006). These failures in early recognition of patient deterioration in turn could lead to delays in calling for assistance with subsequent untimely referral for advice and treatment (Ciof 2000, Cox et al. 2006). A key recommendation to aid recognition and gain assistance has been track and trigger systems (Subbe 2007a). Both Trusts within this study use the Early Warning Scoring (EWS) system which is used by both HCAs and RNs. It is suggested that if patient outcome is to be improved then further contributing factors need to be identied and strategies developed in order to address these issues. Acutely ill patients are cared for in a variety of clinical settings and therefore there is the need for expert support for teams managing these patients (DH 2000, 2001b). A descriptor of patient need and dependency; Levels of Care [Intensive Care Society(ICS) (2009)] has been outlined to enable patient acuity and dependency to be recognised. In order to provide further clarication the DH (2009) has identied key roles in this process, and indicates the importance of a team approach to the management of such ward patients. Within this document it is implied that the HCA takes on the role of recogniser and recorder, however, the role of the responder is indicated to be a RN responsibility. Role boundaries between RNs and HCAs are becoming less distinct (Thornley 2000), with arguably an over-reliance on HCAs (Beaumont & Luettel 2008). The HCA is becoming the main caregiver at the bedside and responsible for routine clinical observations (Thornley 2000 & Hogan 2006). While NICE (2007) support this practice they emphasise the RN remains accountable. The close proximity of the HCA to patients has led them to be described as insightful observers (Boockvar et al. 2000) and well placed to detect early signs of deterioration (Robson 2002). Conversely, Wheatley (2006) raises concerns regarding the ability of HCAs to identify acutely unwell patients and delegation of this task may be given without assurance of their competence (Hogan 2006). Therefore this study sought to explore the HCA perspective regarding acute care management within the general ward setting. 549

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Methods Setting
Two district general hospitals were studied within the south west region. Staff for inclusion in the study were selected from the general wards. The rst hospital is part of a Foundation Trust, where 144 HCAs were eligible for inclusion in the study. Within the second hospital 223 HCAs were eligible.

An information sheet and survey was distributed by hand through ward managers. Return of the survey via a pre-labelled envelope indicated implied consent to participate (Parahoo 2006). As social desirability may affect nurses responses to surveys of clinical practice, anonymity was assured in order to encourage respondents to answer more honestly (Twycross 2008, p. 5).

Data analysis
Data from questionnaires were entered into a database using Microsoft Access (Microsoft Corporation, Redmond, VA, USA). This database was developed specically for the study. Data were entered by two researchers ensuring that rigorous cross-checking of the accuracy of data entry could be assured. Additionally a number of paper forms were randomly selected for an accuracy check. Where numeric data were processed, database or spreadsheet (Microsoft Excel; Microsoft Corporation) software was used. For sections which allowed recording of free text from open-ended questions and collation was by word processor but linked to Access data. Each team member independently analysed this component through a process of content analysis and agreement was reached (Parahoo 2006). The majority of results are presented utilizing a descriptive approach to statistical analysis. Fishers exact test was used in order to establish an association between two categorical variables, namely years of experience in relation to whether a doctor was called directly (LoBiondo-Wood & Haber 2005). All appropriate ethical committee approval was sought and obtained. Permission was granted from senior nurses including Directors of Nursing for recruitment at respective sites. Access to the data was restricted to the research team and complied with the Data Protection Act. No individually identiable data were collected as returns were anonymous. Exact ward locations and personal information which could identify respondents individually were excluded from data processing. Data were password protected and stored securely. Anonymity of responses was preserved throughout this study as good practice dictates (LoBiondo-Wood & Haber 2005).

Sample
Convenience samples of HCAs from two district general hospitals within the South West of England were used. HCAs from only general ward settings were recruited. The wards included medical, surgical, orthopaedic, oncology and health care of the elderly. Critical care and high-dependency areas were excluded. A total of 131 respondents were drawn from a total population of 367. Four respondents were excluded because of incomplete data. The full ranges of clinical shift patterns were represented.

Data collection
A survey design was chosen as the method of data collection. This enabled perceptions and experiences to be explored from a large study population using a cost-effective method (Bowling 2005). To ensure content validity the survey design used themes generated from a previous qualitative study (Cox et al. 2006). Additionally a review of the literature, expert opinion and a statistician informed this process (Parahoo 2006). A variety of questioning techniques including Likert scales were used in order to reduce the incidence of response set bias (Bowling 2005). The direction of these was interchanged in order to prevent the tendency to endorse the statements posed on one particular side (LoBiondo-Wood & Haber 2005). Open-ended questions were also used to enable further clarication and exploration (Bowling 2005). A pilot study of eight RNs and HCAs was undertaken prior to the proposed study commencement. The setting for this was in a hospital not part of the main study. The pilot site did reect a similar case mix to the surveyed hospitals as recommended by Parahoo (2006), but was regarded as suitable as it was isolated from the main investigated hospitals. The pilot revealed no need to revise data collection methods and indicated the time taken to complete the survey was realistic (Bowling 2005). 550

Results
One hundred and thirty-one questionnaires were returned of which four were not processed as they were incorrectly lled in. Despite reminders the response rate

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of 35%, while disappointing, is noted to be a common problem (LoBiondo-Wood & Haber 2005) (Table 1). The grade and band mix of staff was difcult to quantify with accuracy; the study was undertaken at a time when Agenda for Change (AfC) was being implemented. Health service staffs were re-graded from a lettered clinical grading system to a single pay spine which has numbered bands. In both instances, the higher the letter or the higher the number the more senior the staff. The HCAs were asked to identify either clinical grade or AfC banding. Many responded with both, some with neither. Essentially the majority were graded or banded at lower scales (band 2 or grade A). Overall the results indicated HCAs are frequently involved in caring for acutely ill patients. The majority of respondents (71%) indicated they had cared for such patients within the last month, with 45% indicating this occurred on a weekly basis. Indeed one respondent highlighted they undertook the majority of patient observations. 99% of the time we are the ones carrying out the obs and talking to the patients. Within the ward environment, 42% felt they were distracted by other patients needs and 45% indicated stafng levels were not adequate to support this process: not always the right number of staff to man the ward-puts pressure on an already busy ward to get the job done.
Table 1 Descriptors of study sample Gender Male Female Years worked Up to 1 year More than 1 and <3 years More than 3 and <10 years More than 10 years How long in current job <1 year More than 1 and <3 years More than 3 years No response Specialty Medical (including elderly care) Surgical Trauma/Orthopaedic Oncology Other Shift patterns Day duty Night duty Internal rotation No response 12 (9%) 116 (91%) 8 37 44 39 25 42 60 1 72 23 20 8 5 38 17 72 1 (6%) (29%) (34%) (31%) (20%) (32%) (47%) (1%) (56%) (18%) (16%) (6%) (4%) (30%) (13%) (56%) (1%)

The role of the HCA as a recogniser, recorder and responder

Recogniser In considering the signicance of the assessment process, some HCAs demonstrated a holistic patientcentred approach. Patient appearance was not seen by the majority (61%) as a reliable sign of clinical condition. However, there was recognition of the importance of changes in patients condition from their norm (91%) during the assessment process. A change in their breathing patterntheir colour, ngers, lips toes, and change in temperature and BP. The majority (80%) reported how the patient says they are feeling was important in the assessment process. One respondent commented: a patient had described: feeling unwell within themselves likewise They (the patient) tell us. There was evidence of both rational and intuitive approaches to the decision-making process. While from a rational approach the HCAs afforded importance to vital signs and early warning scoring systems in the assessment process. In contrast, intuition was additionally evident with 74% of respondents describing they just knew when a patient was deteriorating. Short time frames may have inuenced the usage of the later method (Thompson et al. 2004). Criticisms of intuitive approaches regarding evidence base are well reported (Thompson et al. 2004), however, it would seem that these HCAs used a combination of both approaches. Fifty-four percent acknowledged that the use of touch was important in the assessment process. For example, four HCAs recognised patients feeling clammy to the touch was signicant. This poor result may be attributed to the over reliance on equipment; however, it is of concern that this important factor was insufciently addressed. Contextual factors which may inuence this process were highlighted in relation to the general clinical setting. Distractions in the care of the acutely ill patient by other patients needs were highlighted by 42% of respondents. Other factors such as the level of support and methods of feedback they received were additionally highlighted; these issues are explored in part two of this work. Role of the recorder of vital signs A range of clinical observations were routinely performed by the HCAs within this study; however, they were not always clear what observations were needed to 551

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Table 2 Observations/vital signs routinely recorded Temperature Pulse Respiration rate Manual blood pressure Electronic blood pressure Oxygen saturations Fluid input and output GCS AVPU Oxygen delivery Early warning score Electrocardiographys Other (blood sugar, bladder scan, urinalysis) 126 124 124 86 123 125 121 48 45 103 106 79 9 (98%) (97%) (97%) (67%) (96%) (98%) (95%) (38%) (35%) (80%) (83%) (62%) (7%)

GCS, Glasgow Cona Scale; AVPU, Alert, respond to Voice, respond to Pain and Unresponsive.

Of those 23% of respondents who contacted a doctor, 86% had more than 3 years experience as an HCA. The data were analysed to see if years in post (i.e. experience) was related to the likelihood of calling a doctor directly. Fishers exact test was performed (on a two-by-four contingency table). The calculated value for P of 0.29 (n = 126) was not signicant. The majority of respondents felt they always got the help they sought when their concerns were raised regarding an acutely unwell patient (79%). They felt the equipment was immediately available and were condent in using it (88%). Time wasted as a result of locating equipment was highlighted by others. For example, one respondent highlighted: Time spent hours locating a heart monitor.

be undertaken and how often (Table 2). A track and trigger system such as the Early Warning Score (EWS) was used by 83% of respondents. Despite this apparent high use of the scoring system there appeared to be misinterpretation of this tool. Only 35% of respondents indicated they used AVPU (Alert, respond to Voice, respond to Pain and Unresponsive) as part of their patient assessment, this being an integral parameter of the EWS score in both Trusts. This may suggest these respondents did not fully understand this neurological assessment and it is implications for the acutely unwell patient thus resulting in the risk of an inaccurate EWS score. The majority of respondents (97%) routinely performed respiratory rate as part of their vital signs assessment. Blood pressure (BP) recordings were undertaken using an electronic device by 94% whereas only 67% used a manual device. While trust policy within these sites indicated HCAs were not routinely required to undertake manual BP measurements, these results demonstrate they were performing a procedure with arguably no formal training. Interestingly, 62% of respondents were routinely performing electrocardiographys (ECGs). The training undertaken for this clinical skill needs to be investigated further. Responding to acute illness When the HCA had concerns regarding their patients condition 93% alerted the RN responsible and 23% additionally indicated they contacted a doctor directly. Reasons for this included when the HCA was unable to locate the RN; one respondent commented. I always inform the nurse running the bay, although I have had to inform the Dr or Nurse in charge when unable to nd the staff nurse. 552

Education
Educational input was examined in relation to acute care management support. From the study participants 57% had undertaken either level 2 or 3 National Vocational Qualication (NVQ) training. While there was evidence of in-house vital signs and EWS, there was limited participation in acute illness primary survey courses (18%). The Resuscitation Council (UK) guidelines (2008) indicate annual basic life support (BLS) training should be mandatory for all health care workers. It was, therefore, of concern that only 57% held a current BLS certicate. Further training needs were highlighted including more regular BLS updates. Scenario-based learning was considered the most useful in aiding development of key skills (55%); however, 48% additionally felt bedside teaching would be advantageous. Acute clinical experience outside of the respondents own clinical area was additionally suggested: I feel it would be helpful if nursing assistants were given time with the critical care team. Some respondents reported needing help in identifying what their training requirements were (22%). The individual performance review process should help in identifying specic training (DH 2004).

Discussion
It is essential a good quality patient assessment is undertaken in order to ensure acutely unwell patients are detected promptly (Wheatley 2006). This study has revealed that while the HCAs were able to undertake a

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range of observations they were limited in some aspects of the overall assessment process. Distractions of the ward environment were highlighted of concern and therefore coping strategies need to be considered in order to address this. Contextual factors such as touch and how the patient looks were not afforded adequate signicance to the assessment process. This could be partly attributed to their high reliance on equipment, an issue which Wheatley (2006) and Hogan (2006) have previously reported. In order to promote the use of touch within the assessment process, perhaps prompts could be incorporated into EWS and this issue emphasised during training. Studies by both Hogan (2006) and Cox et al.s (2006) highlighted the workload and distraction of the ward environment which were seen as key barriers to acute care management. Similarly this study demonstrates this continues to be a problem. There appears to be little critical analysis of the process of obtaining and recording vital signs (Smith et al. 2006). While Subbe (2007a) discusses the need to keep scoring systems simple, this study demonstrated confusion in relation to the AVPU component of EWS. This could have signicant implications for accurate patient assessment. It indicates the need for regular feedback regarding accuracy of patient assessment. The role of the HCA is to carry out vital signs assessment, and while they are trained to do this, they are not taught to interpret the results (Beaumont & Luettel 2008). This study demonstrated appropriate help was sought in the majority of instances; however, signicantly these HCAs on some occasions bypassed the normal channels for referral and contacted the doctor directly. Determining factors need to be explored further as this study was inconclusive regarding this issue. For nursing managers this may indicate there are issues regarding adequate supervision and raises concerns regarding RN accountability which need to be explored further. On a positive note this showed that the HCA felt condent to contact the doctor in the patients best interests. It is essential that mandatory training for BLS is maintained for all of those who may undertake this role. It was not clear why a substantial number of HCAs reported to be out of date in this study. Infrastructures need to be reviewed regarding course monitoring systems in order to ensure this is facilitated. NICE (2007) recommend the need for adequate education to ensure a sufcient level of competency in the staff caring for acutely ill patients. It is suggested

that in order to develop targeted and appropriate training packages, nurse managers need to identify the knowledge and skills gap of HCAs to address shortcomings and maximise their contribution. In the recent DH document Competencies for Recognising and Responding to Acutely ill patients in Hospital (DH 2009) the responder is indicated to be a RN. This study has shown the HCA contributes to this process and the boundaries are blurring with the HCA working beyond pre-conceived levels. Acknowledgement is therefore needed of their expanding role. Efforts need to be channelled to educating those using these systems (Subbe et al. 2007b). It is suggested further input is required which is tailored to HCA needs. Scenario-based learning was indicated by these respondents to be the preferred learning option. Multiprofessional acute care courses based on primary survey assessment could be one strategy to fulll this training need. While there was a very limited access to this course within this study, it is recommended that managers provide greater availability of places for these vital bedside staff. In addition to formal courses, it is suggested that there is a need for ongoing and regular formalised bedside clinical supervision. NICE (2007) recommends the importance of adequately trained staff undertaking vital signs assessment and the need for competency-based skills. These respondents highlighted their need for updating within this area. While the theoretical aspect is important arguably this should not distract from the bedside teaching opportunity. RN responsibility for providing supervised practice at the bedside should be assured.

Limitations of the study

The response rate to this questionnaire was disappointing. As anonymity was ensured the researchers were unable to identify and remind specic individuals to encourage completion. There was limited representation of male HCAs perspective. As the majority of respondents were female HCAs, there is further exploration needed of the male HCA perspective.

Conclusion and implications for nursing management

Management infrastructures need to acknowledge the vital contribution of the HCA in the recognition and care of the acutely ill ward patient and the frequency in which they are involved in this care. Stafng levels, distraction with other patients and over use of equipment contributed to the quality of the patient 553

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assessment therefore these factors need to be addressed in order to optimize care. Some aspects of the assessment process were completed well; for example changes to a patients condition were noted as important. There were concerns regarding the AVPU component within the EWS and the use of touch in the assessment process was given limited attention. Regardless of the healthcare hierarchy these key staff felt able to access medical support in order to maintain patient safety when needed. Nurse Managers need to ensure mandatory training requirements are adhered to in order to ensure optimal patient safety. Scenario-based learning/ongoing bedside teaching and clinical supervision is suggested in order to develop a more comprehensive approach to the development of these key ward staff. The present study has provided further insight into barriers to providing optimal care for acutely ill patients. The patient remains the priority within healthcare, and the HCA makes a vital contribution to this. Careful consideration of expansion of the HCA role needs to take place in light of the proposed changes to registered nurse education.

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