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HCAs and immunisastion training: results of a pilot programme

Stockport PCT recently delivered a pilot programme to train healthcare assistants and assistant practitioners to administer influenza and pneumococcal vaccines to those aged 18 years and over. The background to the programme, was discussed in part one (NiP 2007;39:52-4) and this article focuses on the results

Michelle Falconer
RGN MPH BN(Hons) Nursing DN Cert
Immunisation
Coordinator
Halton &
St Helens PCT
Cheshire

David Baxter
MB ChB MSc PhD
FFPH DTM & H
Consultant in Communicable Disease Control
University Lecturer
Greater Manchester Health Protection Unit
Control of Infection Unit
Stockport PCT

Donna Davenport
RGN BSc(Hons)
Professional Development Nurse
Practice Nursing
Stockport PCT

Delivery of the pilot programme was planned as formal lectures, but with plenty of opportunity for discussion, interaction and clarification. Additionally, attendees were required to participate and demonstrate competence in adult cardiopulmonary resuscitation (CPR), reading and interpreting the information recorded on a vaccine syringe/vial, drawing up sterile water from a vaccine vial, intramuscular injection technique, subcutaneous injection technique and safe disposal of sharps postimmunisation.
Topics covered in the programme were delivered over three full days and are listed in Box 1.

[[nip 40_box1_58]]

Course content
The National Minimum Standards for Immunisation Training were published during 2005 and the core topics were incorporated into the training for the healthcare assistants (HCAs)/assistant practitioners (APs), but with a focus specifically on influenza and pneumococcal immunisation.1 This was to ensure that all attendees were trained to the same level as registered immunisers, to ensure that they were provided with up-to-date and accurate information, and to ensure that they could demonstrate confidence, competency and safe practice when administering vaccines.
Training included 17 taught sessions covering the topics listed in Box 1, two practical training sessions to ensure competence in basic life support and 13 activities to ensure competence in administering a vaccine. This included: familiarisation with a pre- and post-immunisation checklist; documentation and record-keeping; vaccine sites and injection techniques; managing anaphylaxis in the clinic; improving uptake rates and maintaining the cold chain. It was also recommended that attendees complete exercises on two evenings to ensure that they were familiar with the vaccine storage facilities in their place of work and that they could identify barriers to immunisation. Although most of the group did not complete these exercises, they felt that they would have been useful to do if they had been given sufficient prior notice.

Evaluation
As this was a pilot programme, course evaluation was completed daily and at the end of the programme.
The daily evaluation required attendees to answer questions relating to the previous taught session. This enabled the course facilitators to determine whether the content of the previous session had been understood and the necessary knowledge gained. Any gaps in knowledge that were identified were then addressed in subsequent sessions. The course evaluation revealed that participants found it beneficial that the more complex areas of immunisation were addressed more than once and explained in different ways until all felt comfortable with the concept being discussed.
Additionally, the attendees completed a pre and postcourse questionnaire. This required them to answer the same questions on the cold chain and vaccine administration (see Table 1) and on the provision of information for those receiving vaccines, routes of vaccine administration, consent and vaccine adverse events at the start and the end of the course.

[[nip 40_table1_60]]

All healthcare professionals administering vaccines must obtain informed consent before doing so. In order to do this, sufficient information must be given to the individual regarding the process, benefits and risks of immunisation.2 Individuals who are to be immunised should be aware of the vaccine they are going to receive, the diseases it will protect against, the side-effects of the vaccine and how to deal with them and any follow-up action that they need to complete. They must also then be able to communicate their decision to be immunised freely and voluntarily before the vaccine being given.
HCAs/APs were asked what information they would provide to vaccinees before giving an influenza or pneumococcal vaccine. Although a large proportion of the group recognised the importance of giving information regarding the vaccine (82%) and contraindications (64%) before they completed the training, after the course all of them recognised that they would need to give vaccine information. Additionally, 91% would give information on contraindications and 82% indicated that they would also give information about the disease (see Table 2).

[[nip 40_table2_60]]

All attendees recognised the need to obtain informed consent. However, before the course not all attendees were able to explain why this was necessary. After the course all attendees gave a brief comment as to its necessity (same respondent):

Precourse
"To give the person the right to say no and
they may have a reason not to have this"

Postcourse
"So the person receiving it has a clear
understanding of what they are receiving
and to check any underlying reasons why
they shouldn't have it"

Although all attendees demonstrated an increase in knowledge following completion of the course, some had expressed a lack of confidence when assembling a syringe and needle, and no members of the group had ever administered a vaccine or attempted to draw up a vaccine from a vaccine vial. The opportunity to practice these skills on each of the three days ensured that all attendees were able to express some confidence and less apprehension by day three:

"Went really well, felt nervous before, but
theory pitched at the right level with opportunity
to go over and ask questions"

"Good mix of theory and practical sessions"

"Mentors need to attend practical sessions to support training"

"Can't wait to get started"

When the HCAs/APs have completed their training, it is expected that they will work with their mentor under supervision to complete their assessment of competency. Only once these are signed off will the HCA/AP undertake administration of influenza and pneumococcal vaccination without direct supervision; however, it was strongly recommended that a qualified healthcare professional such as a GP or registered nurse always be available and on the premises. Protocols have also been developed in line with national standards to ensure safe practice, using the resources available from WiPP and the Skills For Health websites (see Resources).
HCAs/APs attending the pilot reported that they felt the delivery of immunisations could make their job more interesting and a practice nurse mentor envisaged that trained HCAs/APs could potentially administer around 50% of influenza vaccines each year.

Conclusion
As HCAs/APs continue to develop their skills, the requirement for them to be trained and assessed as knowledgeable and competent in the task that they are delivering is essential to ensure the confidence of those delegating tasks to them and patients receiving care from them.
The Stockport pilot programme has been successfully delivered and is currently being evaluated, it is envisaged that on completion of this there will be further roll-out of the programme.
Although there are cost and resource implications for future training, which will need to be addressed, it is expected that future delivery of influenza and pneumococcal immunisation by HCAs/APs will bring wide-ranging benefits to primary care. The HCA/AP will have the opportunity to develop competency in immunisation and to continue to focus on patient care; the practice will benefit from extra capacity as registered staff are freed up to perform more complex tasks, and the patients will benefit by having access to a flexible and responsive service.

References
1. Health Protection Agency. National minimum standards for immunisation training. London: HPA; 2005.
2. Department of Health. Immunisation against infectious diseases. London: The Stationary Office; 2006.

Resources
The MDU
W: www.the-mdu.com

Nursing and Midwifery Council
W: www.nmc-uk.org

Royal College of Nursing
W: www.rcn.org.uk

Working in Partnership Programme
W: www.wipp.nhs.uk

Skills for Health
W: www.skillsforhealth.org.uk

Royal College of General Practitioners:
Healthcare assistants
W: www.rcgp.org.uk/services__contacts/information_services/is_publications/fact_sheets/healthcare_assistants.aspx


Further reading

Department of Health. Our health, our care, our say. London: DH; 2006.

Department Of Health. Liberating the talents. London: DH; 2002.

Medical Defence Union. MDU advice on healthcare assistants giving flu vaccinations. London: MDU; 2006.

Department Of Health. The NHS plan. London: DH; 2002.

Health Protection Agency. Core curriculum for Immunisation training. London: HPA; 2005.

Department Of Health. Medicines matters - a guide to the mechanisms for the prescribing, supply and administration of medicines. London: DH; 2006.

RCN. Supervision, accountability and delegation of activities to support workers. London: RCN; 2006.

Nursing & Midwifery Council. Code of professional conduct. London: NMC; 2004.

CSP, RCSLT, BDA, RCN. Intercollegiate information paper. Supervision, accountability and delegation of activities to support workers. 2006.