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Influenza clinics: a case study for training HCAs

Francina Hyatt
RGN Practice Nurse Specialist
NVQ Assessor
Clinical Nurse Trainer
Croydon PCT
E:Francina.Hyatt@croydonpct.nhs.uk

Sue Cressey
RGN Practice Nurse Specialist
NVQ Assessor
Clinical Nurse Trainer
Croydon PCT
E:Sue.Cressey@croydonpct.nhs.uk

The influenza (flu) season has arrived and as usual will increase the already heavily burdened workload of primary care nurses. It is possible that some nurses will take advantage of the patient contact and offer the pneumococcal vaccine to those aged 65 or over who have not yet attended for the immunisation.
Influenza is an infection caused by the influenza virus, which is spread by respiratory droplets from sneezing, coughing, talking and on contaminated hands. It is responsible for considerable morbidity and mortality each year and is prone to minor changes (point mutations) to one or both surface antigens during replication, and it results in seasonal epidemics, hence the yearly vaccination recommended.(1)
With the arrival of primary care trusts (PCTs) and a modernised NHS, there is a much greater emphasis on skill mix and a flexible team approach to ensure both patients' and the service delivery needs are met.(2) The appropriately trained, assessed, supervised and supported healthcare assistant (HCA) is already playing a key part in delivering care to patients. Many HCAs have succeeded in obtaining an NVQ in care qualification, and some are undertaking advanced skills such as:

  • Spirometry measurement.
  • Smoking cessation.
  • Basic wound care.

The GMS contract has created more opportunities for nurses to take on new clinical roles.(3) Is there now a place for suitably qualified HCAs to be trained in the advanced role of giving injections, such as influenza and pneumococcal vaccination, thus giving nurses more time to spend on advanced nursing skills?

Croydon PCT HCA injection pilot
Croydon PCT has an established HCA workforce, in both general practice and community settings. The PCT provides robust, ongoing training opportunities and support to the HCA and delegating practitioner.
The expansion of nurses' roles means that they are becoming more responsible for care traditionally undertaken by medical practitioners.(4)
In Spring 2005 the PCT nursing directorate responded to an enquiry from a general practice regarding HCAs giving injections such as influenza and pneumococcal vaccines in the practice.
A review of current literature revealed that a small minority of other PCTs are already training HCAs to give insulin to stable patients in the community; however, there is very little information about the training packages available.
 
Training and assessment package
A training and assessment package was compiled using existing resources, guidance from professional bodies such as the Royal College of Nursing (RCN), Nursing and Midwifery Council (NMC) and Medical Defence Union (MDU), and current evidence-based literature.
The training was delivered as a small pilot with two out of the three HCAs in the practice participating. The third HCA was not included as she had not yet completed the PCT's Community HCA 10-week development programme and postcourse competency assessment framework. An NVQ level 3 in care qualification is cited as desirable in the course handbook; however, evidence of completion of the PCT core development programme or equivalent is essential before training for this advanced role.
The aim of the training was to teach the underpinning knowledge and skill that promotes high-quality, safe, holistic care for patients (see Box 1) and clearly identifies roles and responsibilities through written competencies and protocols. The clinical nurse trainers for practice nursing worked with the participating practice staff to agree the training content, assessment process and audit methods. It was agreed that the HCAs would be assessed using the PCT competency framework administering 20 injections and complete an unseen multiple-choice paper.

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Legal and professional aspects of HCAs administering injectables
Many nurses are used to delegating care to others who are not registered nurses or midwives, such as student nurses, and do so according to clause 4.6 of the NMC Code of Conduct.(5) The team working on this pilot project recognised that nurses may have concerns about recruitment, patient safety, competence, accountability and supervision of HCAs. Practice nurses should take leadership of the supervision and delegation of nursing tasks to HCAs.(6)
It is the experience in Croydon that HCAs who are welcomed into the nursing team were delegated roles based on individual competence and a nurse's assessment of the patients' needs, to become skilled and highly effective members of the team.
The RCN have written guidance on employing HCAs in general practice, where the principles of delegation are defined as:

  • Primary motivation for delegation is to serve the interests of the patient.
  • The needs of the patient are always assessed - their needs define who does what.
  • The level of experience and competence to whom the task is delegated is appropriate.
  • The level of supervision is appropriate.
  • Rigorous protocols clearly define the HCA's role within a clinical activity.
  • The competency of the HCA to deliver specific delegated clinical activities must be assessed before delegation and reviewed at regular intervals (6-12 monthly).(6)

Due to current lack of regulation and national standards defining scope of practice, competence and education, the Director of Nursing for Croydon PCT has produced a professional liability policy for nurses, therapists and HCAs, including a code of conduct for HCAs and nursery nurses.
Other useful resources and initiatives already provided by the PCT to address the above issues include a HCA employment handbook, HCA nurse mentor workshops and monthly, lifelong learning sessions for HCAs. Four clinical nurse trainers also go out to the clinical environment to support and assess HCAs and nurses.
Meanwhile, the government is currently working collaboratively to achieve regulation of support workers by late 2006,(7) and the RCN has lobbied for HCAs to be regulated by the same body that regulates nurses.
Apart from the accountability issues raised by nurses, there is also often the misunderstanding of indemnity insurance cover for HCAs. The MDU will look individually at each practice's request for vicarious liability indemnity cover under group scheme arrangements; this is dependent on factors such as evidence of the HCA's job description, arrangements for supervision, competence and training.
The MDU has said it is always happy to discuss individual circumstances with members. Nurses must be aware that the NMC may also hold any delegating nurse to account should a claim be made against a HCA. Clear and concise documentation of training and assessment is therefore recommended as evidence of the level of competence. Those HCAs employed by the PCT are indemnified by the organisation as it provides NHS indemnity for employees. The RCN will allow any HCA who has completed an NVQ level 3 in care to join its union.

Medicines Act 1968
HCAs are not covered to work under the guidance of patient group directions (PGDs); only registered practitioners usually identified on the policy may administer the direction. Therefore the Medicines Act 1968 must be adhered to when supplying prescription-only medication (POM), such as influenza and pneumococcal vaccination, requiring a prescribing practitioner to individually prescribe the vaccine to be given before administration. Nurses may, however, use the guidance supplied in the PGD to write practice protocols for the HCAs to follow.(8)

Influenza clinics - the future
The HCAs involved in this pilot will initially be allocated 15 minutes per consultation once they begin working without direct supervision. This will ensure standards of care are safeguarded and allows the HCA to work from novice to expert in conducive working conditions.
It is not envisaged that HCAs new to the skill of administering injections will make much impact on the service delivery this year, requiring nurses to tackle the majority of the work. HCAs in training, however, can still provide excellent assistance to the smooth running of flu clinics by undertaking administrative, stock rotation and ordering tasks, as well as recording information on the computer. On successful completion of the pilot and positive audit outcomes/patient user feedback, Croydon hopes to roll out the training across the trust, and is currently investigating the possibility of producing a training CD-Rom to share the learning with other PCTs.
Croydon is in no doubt that many of its HCAs are ready for the challenge to progress their roles, and with the support and mentorship of the nursing staff, patients will gain the benefits of improved access to healthcare and a greater choice of who provides that care.

Treatments for flu
Treatments for flu do not eliminate the virus; they only make the severity and length of time spent unwell more tolerable. Self-help advice for patients that can be displayed in practice booklets, electronic messaging systems or as health education information is illustrated in Box 2.(9) Antiviral medicines active against the flu virus A and B may be considered on an individual basis by doctors but need to be commenced within the first 48 hours of symptoms occurring. Antibiotics may occasionally be necessary to control complications such as chest infection and pneumonia.

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Conclusion
Nurses currently have a pivotal role in helping to prevent epidemics of influenza by administering vaccinations to the vulnerable patient groups. This can put added demands on an already busy service. Nurses in primary care have the opportunity to take the lead in developing the nursing team to work in new ways, delivering a quality, individualised service to patients. Nurses can be assured of working within existing legal frameworks if adequate training, supervision and assessment are given to HCAs who are appropriately selected to undertake advanced roles.
For more information regarding the Croydon pilot please contact the clinical nurse trainers.

References

  1. Prodigy. Prodigy guidance: influenza. Available from URL:http://www.prodigy.nhs.uk/guidance.asp?gy=influenza
  2. Department of Health. Liberating the talents: helping PCTs and nurses deliver the NHS plan. London: DH; 2002.
  3. Department of Health. The new GMS Contract. London: DH; 2003.
  4. Stokes J, Warden A. The changing role of the health care assistant. Nurs Stand 2004;18(51):33-7.
  5. Nursing and Midwifery Council. Code of professional conduct 2002. Available from URL: http://www.nmc-uk.org/nmc/main/publications/CodeOfProfessionalConduct.pdf
  6. Young L. HCAs in general practice. Practice Nurse Association Newsletter Spring 2005. Available from URL: http://www.practicenurse.org.uk/ci.htm
  7. Department of Health. Enhancing public protection: proposals for the statutory regulation of healthcare support staff in England and Wales. London: DH; 2004.
  8. Department of Health. Forthcoming legislation on the safety, quality and description of drugs and medicines. London: DH; 1967.
  9. NHS Direct. Treatment for flu. Available from URL: http://www.nhsdirect.nhs.uk