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Stephen Bach Professor of Employment Relations, King’s college, London stephen.bach@kcl.ac.uk

Occupational Boundaries In a Restructured Health Sector: The Case of Health Care Assistants in England. Stephen Bach Professor of Employment Relations, King’s college, London stephen.bach@kcl.ac.uk. Modernisation: NHS an employer of choice.

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Stephen Bach Professor of Employment Relations, King’s college, London stephen.bach@kcl.ac.uk

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  1. Occupational Boundaries In a Restructured Health Sector: The Case of Health Care Assistants in England Stephen Bach Professor of Employment Relations, King’s college, London stephen.bach@kcl.ac.uk

  2. Modernisation: NHS an employer of choice • Investment: - more staff working differently - Impact of EU working-time directive • Challenge professional boundaries:- develop user-centred services- pay modernisation • Social partnership • Waiting time targets

  3. Themes: changing shape of the nursing workforce • Professional status- boundary work and boundary disputes • Role of health care assistants: ‘those who provide a direct service – that is they have direct influence/effect on care/treatment to patients and members of the public and are supervised by and/or undertake healthcare duties delegated to them by NMC registrants’- not regulated - tasks delegated by nurses • Trade union responses

  4. Research approach • Comparison of support roles in the public services • Who enters these roles? • How are these roles performed and boundaries negotiated? • What are the consequences of these roles for HCAs and nurses? • Case study methods: - 60 Interviews (HCAs/nurses)- short biographical questionnaire (HCAs) • Acute hospital trusts – medical wards

  5. Background characteristics of HCAs (%) HCAs often had experience of caring work

  6. HCA Role • Observation:‘Well basically how I see it we are the eyes and ears of the qualified nurses’ (HCA1M) ‘They spend I think the majority of their time with patients so they’re able to spot things that sometimes if you’re a trained nurse you cant because you’re doing drugs you’re doing a million and one things…they find out things they alert the nurses to them (RGN7T) • Direct care: Some patients might be bedridden so you’ve got to keep an eye on their pressure areas …so we are constantly updating the medical teamif we notice this, that or the other (HCA2M) • Role extension - variation

  7. HCA contribution • Distinctive relationship with patients:‘.... we've had some patients who haven't had a visitor in three months, four months, we've had to try and fill up that void, so to speak, that gap and... and it's not easy at times, I mean you have to show some degree of understanding...that only comes from listening’ (HCA12T) • Nurses ‘busy’ - substantial proportion direct care undertaken by HCAs • Nurses acknowledged HCA contribution:‘without healthcare assistants…my workload would double’‘you’d be working at 50 per cent slower rate’

  8. Boundary work: HCA perspectives • Emphasis on similarity of work: ‘The only thing is that we don’t do, that’s medicine but you do everything else as a nurse’ (HCA15M)‘I work to the patient, not to the nurse, because we have our own role in this ward’ (HCA13T) • Metaphors: ‘teamwork’ and ‘mucking in’

  9. Boundary work: nurse perspectives • Emphasis on difference: ‘They are effective helpers, very effective’ (RGN2M)‘They really help us with activities of daily living’ (RGN6T) • Education credentials • Accountability • Nurses’ reasserted boundaries: ‘They do go a bit far and you have to pull up on it and go “why did you do that?”’ - induction training

  10. Consequences for HCAs • Low status • Low pay (Band 2) – mismatch between pay and competencies • Fairness:‘I was looking after a patient and there was two qualified nurses standing right there, and this guy is asking for the commode…they had to call me all the way from the top, leave the other patient and come down to get the commode. And I got really angry that morning, because I mean that was really unfair, it wasn't nice at all’ • A ‘non-person’: invisible‘you know what hurts me most…can you believe that I stopped greeting the doctors, they don't respond to your greetings…I mean over the years I've realised it and I don't say hello anymore. Now, such thing play on your intelligence’

  11. Consequences for nurses • HCAs did not understand nurses’ role:- discharge planning, audits/targets • Different criteria to gauge contribution • Nurses distanced from direct care – losing nursing • Quality of patient care

  12. Conclusions • Low status professions engage in boundary work • Modernisation: higher profile HCAs- opportunities for development- limits to workforce modernisation • Union responses:regulation of HCAs • Impact of budgetary context- skill mix

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