Recognition of the health assistant as a delegated clinical role and their inclusion in models of care: a systematic review and meta-synthesis of qualitative evidence

Authors

  • Zachary Munn BMedRad GradDipHlthSc,

    Corresponding author
    • Translation Science, The Joanna Briggs Institute, The University of Adelaide, Adelaide, South Australia, Australia
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  • Catalin Tufanaru MD MPH,

    1. Translation Science, The Joanna Briggs Institute, The University of Adelaide, Adelaide, South Australia, Australia
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  • Edoardo Aromataris BSc(Hons) PhD

    1. Synthesis Science, The Joanna Briggs Institute, The University of Adelaide, Adelaide, South Australia, Australia
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Correspondence: Mr Zachary Munn, Translation Science, The Joanna Briggs Institute, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia. Email: zachary.munn@adelaide.edu.au

Abstract

Aim

Assistants have been utilised worldwide in healthcare as a means to ensure the provision of adequate and efficient healthcare in the midst of increased pressures on health services for many years. This review aimed to synthesise available qualitative evidence regarding the appropriateness of strategies used to establish the health assistant role as a recognised delegated clinical role and to promote their inclusion in models of care. This review focused on how to make strategies appropriate for health assistants and professionals. Health assistants were defined as those who provide assistance and support to health professionals by whom they are directly or indirectly supervised in all healthcare and health education sectors.

Methods

A systematic review with meta-synthesis of qualitative studies using meta-aggregation was conducted. Types of participants considered included assistants in healthcare, including nursing and allied health assistants. The phenomena of interest was the appropriateness of strategies used to establish the assistant role as a recognised delegated clinical role and/or to promote their inclusion in models of care. Qualitative research studies including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research were considered for inclusion. Electronic searches of multiple databases including MEDLINE, AMED, CINAHL and EMBASE, limited to the English language were conducted during the period of 14 April to 13 May 2011. In addition, grey literature was also searched for, as well as a hand search of relevant journals. Assessment of methodological quality of papers prior to inclusion in the review was performed using a standardised critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI QARI). Data were extracted using the standardised data extraction tool from JBI QARI. Data synthesis using the JBI QARI approach of meta-synthesis by meta-aggregation was performed.

Results

Ten studies met the inclusion criteria. From the 10 included studies, 66 findings were identified that were organised into 11 categories by similarity of meaning. Categories were then aggregated into four synthesised findings: assistants and professionals may have good or difficult inter-professional relationships, which is dependent on a variety of factors, and can thus inform appropriate strategies to include assistants in models of care; professionals and assistants perceive the assistant role and the need for practice change in different ways, whereas the role itself and tasks performed may be influenced by a number of different factors; despite assistants feeling different levels of preparedness for training or the need for training, there are effective training programmes with certain characteristics that can result in positive training outcomes; there are concerns amongst health staff regarding responsibility in models of care using assistants, highlighting the need for appropriate supervision and mentoring of assistants.

Conclusions

Qualitative meta-synthesis was performed providing a unique perspective on the role of health assistants and strategies used to include them in models of care. These synthesised findings can be used to guide practice in healthcare organisations considering strategies for implementing the assistant role, or where assistants are currently utilised.

Background

In Australia and much of the Western world, the population is growing, living longer, and chronic disease is increasing, which all impact significantly on the health system.[1] Traditional practices in healthcare are being redesigned in order to meet the demands of the healthcare industry, particularly delivering healthcare that is equitable, accessible, efficient and effective.[2] Support personnel may allow professionals to spend more time in direct patient care activities, rather than indirect activities,[1, 2] and expanding the use of assistants may assist in reducing the demand for health professionals.[1] Health assistants can be defined as workers who provide assistance and support to health professionals by whom they are directly or indirectly supervised. Health assistants can have varied roles and may work within professions or across them. The nomenclature for allied health assistants is diverse,[3] and includes aides, support workers, support personnel, attendants, paraprofessionals or unlicensed staff.[4] For the purposes of this review, health assistants is the generic term used to describe these roles, allied health assistants is used specifically to relate to an allied health profession, whereas nursing assistants is the term used when relating specifically to nursing.

It is strongly argued across all sectors of healthcare that health assistants are able to provide effective care,[5, 6] and there are moves to change models of care to ensure that tasks are carried out by staff with the right level of skill, experience and competency.[7] There has been a long history of assistants providing care in nursing and the role of assistants is seen as essential in the modern healthcare system – even being described as the backbone of the health system.[8, 9] This assistant level of worker has since spread across the health professions, and there now exist a significant number of support workers for all of the varied health disciplines within medicine and allied health.[10]

Internationally and within Australia, the role that health assistants play varies widely and includes both clinical and non-clinical duties.[3, 11] Clinical and non-clinical roles and tasks that health assistants undertake are inconsistent both within and across the different health professions.[3, 11-13] Some of the clinical duties provided by allied health assistants include patient education, performing clinical procedures, assisting allied health professionals and a range of other tasks. Their non-clinical activities include administrative duties, preparation and maintenance of environments, record keeping, housekeeping and other duties.[11]

However, barriers to the successful introduction of assistants have been identified, including lack of clarity regarding the role of allied health assistants, confusion regarding tasks and difficulties of health professionals letting go of their work.[11] In addition, professionals may perceive the role of assistants as a threat to their practice.[14-17] This may be to the boundaries between roles in the hospital setting being seen as blurred and fluid,[17] with nursing assistants seeing little differences between their roles and nurses, other than accountability, medication administration and paperwork.[14] Similarly, this also occurs when rehabilitation therapy assistants are used.[18] To address this, strategies, such as collaborative learning,[19, 20] have been employed to include the health assistant into models of care. Education has been highlighted as essential for the successful implementation of new models of care,[21, 22] and clear role delineation appears to be an aspect of delivering successful programmes.[23, 24] These strategies have been found to be effective; however, there is little information currently regarding the appropriateness of these strategies. Appropriateness can be defined as ‘the extent to which an intervention or activity fits with or is apt in a situation’ (p. 210).[25] After searching the literature, no other systematic review was identified that addressed this issue; therefore, the authors undertook a review regarding the appropriateness of these strategies.

Aims and objectives

The aim of this systematic review was to synthesise the existent qualitative evidence regarding the appropriateness of strategies used to establish the health assistant role as a recognised delegated clinical role and to promote their inclusion in models of care. By doing this, it is hoped that we will be able to provide guidance on how to make strategies regarding the health assistant role appropriate. The objectives of the review were to

  • Determine the appropriateness of strategies to establish the health assistant role as a recognised delegated clinical role
  • Determine the appropriateness of strategies to promote the inclusion of health assistants in models of care.

Search strategy

The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilised. An initial limited search of MEDLINE and CINAHL was undertaken followed by analysis of the text words contained in the title, abstract, and of the index terms used to describe an article (Appendix III). A second search using all identified keywords and index terms was undertaken across all included databases. Thirdly, the reference list of all identified reports and articles were searched for additional studies. Only studies published in English were searched for, and there was no time limit.

The databases searched included

  • MEDLINE
  • Cochrane Library
  • JBI Library of Systematic Reviews
  • AMED
  • CINAHL
  • EMBASE
  • PEDRO
  • OTseeker
  • Web of Science
  • ERIC
  • BEME

The search for unpublished studies included

  • Mednar
  • Google Scholar
  • Current Contents
  • Dissertation Abstracts (digital dissertations).

Initial keywords used were: allied health assistants, support workers, assistants in nursing, physiotherapy assistants, health assistants, helpers, nurse aides, competency, standardised assessment, education promotion, student retention, enrolment, vocation, vocational, training, clinical training, clinical learning, local context, contextual, applied learning, training, instruction, teaching, curriculum, curricula, role redesign, models of care. Additionally, a hand search of two relevant journals (Journal of Allied Health, Internet Journal of Allied Health Sciences and Practice) was also conducted, as these were journals of particular interest, and did not want to be missed in the search. The full details of search strategy used are available from the authors.

Methods of the review

This study was developed within the framework of a broader review project investigating clinical education and training for health assistants using a systematic review methodology and methods for qualitative synthesis recommended by the Joanna Briggs Institute (JBI).[19] The full report monograph is available via the Queensland Health website.[26]

Types of participants

This review considered as types of participants allied health assistants or assistants in other health disciplines, including but not limited to physiotherapy assistants, occupational therapy assistants, podiatry assistants, speech pathologist assistants, dietician assistants, dental assistants and nursing assistants. These assistants may have been working in any healthcare sector, including acute, primary or aged care, or undergoing training. Medical/physician assistants were specifically excluded. These health assistants may or may not have undertaken formal training or have received formal qualifications.

Phenomena of interest

The review considered as phenomena of interest the appropriateness of strategies used to establish the assistant role as a recognised delegated clinical role and/or to promote their inclusion in models of care. Studies that addressed the appropriateness of these strategies, in terms of participant's perceptions of these strategies and working in models of care incorporating assistants, were specifically looked for and retrieved.

Types of studies

This review considered qualitative research studies including, but not limited to, methodologies such as phenomenology, grounded theory, ethnography, action research and feminist research. These methodologies were selected as they were most likely to include qualitative evidence of appropriateness.

Assessment of methodological quality

Qualitative papers selected for retrieval were assessed by two independent reviewers for methodological quality prior to inclusion in the review using the standardised critical appraisal instrument from the JBI Qualitative Assessment and Review Instrument (QARI) (Appendix I). Critical appraisal focused on congruity between philosophical position, study methodology, study methods, representation of the data and the interpretation of the results; biases of the researcher; the relationship between what the participants in the study were reported to have said and the conclusions drawn in analysis. No disagreements arose between the reviewers that warranted participation of a third reviewer.[19] There is considerable debate and differing opinions about the critical appraisal, or evaluation of the methodological quality of qualitative studies.[27-29] There are also different methods for the synthesis of qualitative findings.[29-31] However, it is the approach of the JBI that appraisal is a pivotal part of a systematic review of qualitative evidence, to inform reviewers of which studies to include, and that it is necessary for studies with findings that are to be used to inform healthcare to undergo a critique of their quality.[32]

Data extraction

Qualitative data were extracted from papers included in the review using the standardised data extraction tool from the JBI QARI (Appendix II). Data were extracted from each paper related to methodology, method of data collection and analysis, phenomena of interest, research setting, geographical and cultural context, and participants. Qualitative research findings relevant to the review question were extracted from the research studies in the form of themes, metaphors and concepts expressed by the study participants and/or authors. Included papers were read and reread multiple times before findings were extracted. Data extraction was performed by one reviewer, with accuracy of extraction being assessed by a second reviewer.

Data synthesis

Qualitative research findings were, where possible, pooled using JBI QARI. This involved the aggregation or synthesis of findings to generate a set of statements that represent that aggregation. Extracted findings (Level 1 findings) were rated according to their credibility based on supporting illustrations for each finding. Findings were then categorised on the basis of similarity in meaning (Level 2 findings). These categories were then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidence-based practice or informing other policy decisions.[32] A similar approach to qualitative synthesis has been used in systematic reviews to address experiential questions[33] as well as questions of appropriateness.[34] All of the studies included contributed to the meta-synthesis, despite the fact they were not all of the same stated methodology. Synthesising across primary studies of different methodologies is seen both as beneficial or as something to avoid when synthesising studies, and it requires significant interpretation.[31, 35, 36] However, it is the approach of the JBI that it is acceptable to combine findings from studies of different designs, as it is a ‘synthesis of findings and not data’ (p. 36).[32]

Findings were extracted from the primary studies and assigned a level of credibility. Findings are defined as ‘conclusions reached by a researcher after examining the results of the data analysis in their primary research, often presented in the form of themes or metaphors’ (p. 139).[37] Levels of credibility assigned to the extracted findings in JBI QARI are:[37]

Unequivocal (U) – relates to evidence beyond reasonable doubt which may include findings that are matter of fact, directly reported/observed and not open to challenge.

Credible (C) – those that are, albeit interpretations, plausible in light of data and theoretical framework. They can be logically inferred from the data. Because the findings are interpretive they can be challenged.

Unsupported (NS) – when ‘U’ nor ‘C’ apply and when most notably findings are not supported by the data.

The levels of credibility assigned to the findings were not based on the design of the study or its methodological quality, but whether or not the finding was supported by data. The approach taken by the reviewers for this review was to only assign a finding the level of ‘unequivocal’ if it was directly supported by the participant's words, in the form of a quote in the published paper, as used in other reviews of the same methodology.[33] These findings were then categorised based on similarity of meaning if they were rated unequivocal or credible; there were no unsupported findings. As all the findings were either unequivocal or credible, they were combined across the different study designs.[37]

Results

The structured search strategy was implemented during the period 14 April to 13 May 2011 (Appendix III). The results of the database searches were then combined together into an EndNote library for screening. All the results were screened for relevance based on title and abstract by two authors. After study selection and critical appraisal 10 papers were ultimately included in the systematic review (the results of this process are presented in Fig. 1): Plack et al.,[19] Hauxwell,[38] Jung et al.,[39] Jelley et al.,[40] Jung et al.,[41] Potter and Grant,[42] Nancarrow and Mackey,[43] Fronek et al.,[22] Johnson et al.,[44] Hancock et al.[45] Characteristics of the included studies are presented in Table 1.

Figure 1.

Flow diagram detailing results of literature search, study selection and assessment of methodological quality.

Table 1. Characteristics of included studies
StudyData collection methodsParticipantsStrategyAuthors' conclusion
Fronek et al.[22]Questionnaire with written open-ended questions109 interdisciplinary practitioners including allied health professionals such as dieticians, speech therapistsInter-professional trainingA combination of intensive training in professional boundaries and opportunities for ongoing professional development are important for all health practitioners.
Hancock et al.[45]Semistructured interviewsNursing healthcare assistants, patientsHealthcare assistants development programmeHealthcare assistants development programme positively influenced the role of the healthcare assistant; there was a need to invest more into preparation for the restructuring of roles.
Hauxwell[38]Structured interviewsOperating department assistants; nursesParticipants' perspective on teaching, learning and safe practice as well as working relationshipsImplementation of the national vocational qualification has brought an improvement in the relationship between the two major non-medical staff groups in the two units involved in the study.
Jelley et al.[40]Participant's kept journals; pre- and post-placement interviewsThree third-year physiotherapist students and three second-year physiotherapist assistant students; three physiotherapists as clinical instructorsA paired 5-week clinical placementThe shared model of learning in clinical placements gave the students involved an effective means to improve competencies in collaborative practice.
Johnson et al.[44]Structured non-participant observation; semistructured interviewsSenior healthcare support workersEvaluation of the introduction of support workers with advanced skills into intensive care unitsThere remains a great need to clarify the nature and lines of accountability for work done.
Jung et al.[39]Student reflective journals; students post-placement focus group discussion; student questionnaire; tutors reflective journals; preceptors post-placement focus groupSeven pairs of student occupational therapists and occupation therapists assistants; tutors; student preceptorsCombined collaborative fieldwork placementIntra-professional learning experiences prior to graduation can help prepare occupational therapy and occupational therapist assistant students for future collaborative practice.
Jung et al.[41]Journals kept by the students throughout the placement; the students also completed a post placement questionnaireEight senior student occupational therapists and eight senior student occupational therapist assistantsLearning together in fieldwork settingsIt is essential that students are prepared to have the knowledge, skills and professional attitudes to enter into the partnership relationship.
Nancarrow and Mackey[43]Focus group interviewsOccupational therapy service users and providers of North Staffordshire Combined Healthcare NHS TrustIntroduction and evaluation of an occupational therapy assistant practitionerThere is a need to clarify career structures and ensure that appropriate training is available to support staff in their new roles.
Plack et al.[19]Focus groups semistructured interviews with open-ended questions34 first-year physical therapist students and 21 second-year physical therapist assistants. Also included for comparison were 24 second-year and 22 third-year physical therapist assistants who did not partake in the same collaborative course with assistants as the first-year students. Two focus groups consisting of six assistants and five physical therapists respectivelyCollaborative learning instructional modelThe instructional model described is effective in teaching the physical therapist assistant role and provides a mechanism to foster the development of the preferred relationship between physical therapist and assistants.
Potter and Grant[42]Focus sessions (interviews)13 registered nurses; nine unlicensed assistive personnelCharacteristics of registered nurse and unlicensed assistive personnel working relationships and the care delivery practices that influence those relationshipsSuccessful registered nurse and unlicensed assistive personnel partnering allows staff to share a common patient care focus.

Most of the 10 studies that satisfied the inclusion criteria were deemed to be of generally high methodological quality (Table 2). However, no study stated a philosophical perspective (Q1), or explicitly addressed the influence of the researcher on the research, or vice versa (Q7) (Appendix I).

Table 2. Results of critical appraisal of selected studies using the JBI QARI Appraisal Instrument (Appendix I)
StudyQ1Q2Q3Q4Q5Q6Q7Q8Q9Q10
  1. JBI QARI, Joanna Briggs Institute Qualitative Assessment and Review Instrument; N, no; N/A, not applicable; U, unclear; Y, yes.
Plack et al.[19]NNYYYNNYYY
Hauxwell[38]NYYYYNYYUY
Jung et al.[39]NYYYYNNYYY
Jelley et al.[40]NYYYYNNYYY
Jung et al.[41]NYYYYNNYUY
Potter and Grant[42]NYYYYNNYUY
Nancarrow and Mackey[43]NYYYYNNYYY
Fronek et al.[22]NYYYYYNYUY
Johnson et al.[44]NYYYYNNYYY
Hancock et al.[45]N/AN/AN/AN/AN/AYUYYY

Narrative summary of studies

Fronek et al. performed a quantitative and qualitative analysis of an inter-professional training course throughout Queensland, Australia, to promote healthy professional–client relationships.[22] The 1-day course was entitled Professional Boundaries for Health Professionals, and included four topic areas: professional boundaries, ethical decision making, rigid relationships and unique issues for community settings, rural and other small communities. The 109 participants included a range of healthcare professionals and assistants across seven different sites working in various areas. Open-ended questions were used to collect qualitative data regarding the course, and thematic analysis was used to analyse the data. The authors concluded that delivery of inter-professional training courses for professional boundary training is supported by evidence of the positive evaluations, and the consequences of professional boundary violations.[22]

Hancock et al. conducted a qualitative, inductive study using semistructured interviews to determine the impact of an educational healthcare assistant development programme on care delivery and the role of the healthcare assistant.[45] The study was split in two parts; part one, which included 3 healthcare assistants, 24 of their colleagues and 9 patients, aimed to evaluate the impact of the healthcare assistant development programme. Part two, which consisted of twelve healthcare assistants who did not participate in the development programme, aimed to ascertain their current and desired roles, barriers to the new roles, and assess their preparedness to attend the development programme. The authors concluded that the development programme had a positive influence on the role of the healthcare assistant, and that there is a need to prepare for the restructuring of roles.

Hauxwell conducted a qualitative case study using structured interviews for 40 participants; only 26 were of use.[38] The aim of the study was to determine the participant's perspectives on the implementation of a National Vocational Qualification in the operating theatre, and its effects on work relationships, safe practice, and teaching and learning. The sample consisted of both nurses and assistants. The authors concluded that the implementation of the National Vocational Qualification resulted in an improvement in staff relationships, particularly noted by assistants.

Jelley et al. conducted a qualitative study to investigate the perceived impact of intra-disciplinary clinical education for physiotherapists and physiotherapist assistants.[40] Data were collected via interviews with the participants both before and after placement, and the participants also kept journals. The sample consisted of three third-year physiotherapist students, and three second-year physiotherapist assistant students, as well as three physiotherapists as clinical instructors. The clinical education consisted of a paired 5-week clinical placement, using the 2:1 clinical model of supervision. The authors concluded that the shared clinical placements can result in improvements in student's communication, consultation and assignment skills.

Johnson et al. conducted a qualitative study using structured non-participant observation and semistructured interviews to evaluate the introduction of senior healthcare support workers with advanced skills into intensive care units.[44] The sample consisted of 17 senior healthcare support workers who participated in semistructured interviews. The authors found the senior healthcare workers have an important role to play, but that it is not as yet clearly defined.

Jung et al. conducted a qualitative study to assess the impact of a combined collaborative fieldwork placement between occupational therapist students and occupational therapist assistant students.[39] During the placement, tutorials that discussed intra-professional issues were held. Data were collected using the journals of students, tutors and preceptors, as well as a post-fieldwork focus group. The authors concluded that intra-professional fieldwork and collaborative learning can assist in preparing occupational therapist and occupational therapist assistant students for working together post graduation.

Jung et al. conducted a qualitative study using reflective journals and a questionnaire to describe the process of collaborative fieldwork between occupational therapist and occupational therapist assistant students.[41] The authors concluded that there were benefits and challenges when using the collaborative learning model, and that students have the necessary preparation to work together.

Plack et al. performed a mixed methods study to evaluate a model that fosters the development of a preferred relationship between physical therapists and physical therapist assistants in a classroom setting.[19] The study used pretest/post-test questionnaires and focus groups as a way to collect quantitative and qualitative data, respectively. The study consisted of 34 first-year physical therapist students and 21 second-year physical therapist assistants. Also included for comparison were 24 second-year and 22 third-year physical therapist assistants, who did not partake in the same collaborative course with assistants as the first-year students. Two focus groups consisting of six assistants and five physical therapists, respectively, were conducted. The course that the first-year physical therapists undertook included three 2-h sessions. The first session covered various aspects regarding assistants such as their role, delegation and the preferred relationship between therapists and assistants. The second session was between the researchers and the assistants, as they discussed what would be delivered to the physical therapist students in the final session, which was a collaborative experience between physical therapist students and assistant students. The results of the qualitative component confirmed that the learning experience was valued. The authors conclude that the instructional model is an effective method to teach physical therapist assistant students about assistants and it provides a basis for forming collaborative relationships.[19]

Nancarrow and Mackey conducted a qualitative study to explore and describe the introduction and evaluation of an occupational therapy assistant practitioner in a health trust in the UK.[43] Data collection was via focus groups with assistant practitioners (five), supervising occupational therapists (five), team managers (four), and clients or carers (three). The authors concluded that career structures and accountability need to be clearly defined, and training should be available for staff undertaking new roles.

Potter and Grant conducted a qualitative study to better understand the relationship between registered nurses and unlicensed assistive personnel (UAP) and how they work together to deliver care strategies.[42] The sample consisted of 13 registered nurses and 9 UAP who did not work on the same patient care unit. The authors conclude that the successful partnering between UAP and registered nurses provides a shared common patient care focus.

From the 10 qualitative primary research studies included in review, 66 findings (Level 1) were extracted. Once the 66 findings were extracted from the included studies, they were collated to form categories based on identified similarities (Level 2).[46] This process facilitates a transfer of focus from individual studies to consideration of all findings for all studies included in the review. A total of 11 categories (Level 2) were created on the basis of similarities in meaning. From these 11 categories, four synthesised findings (meta-syntheses, Level 3) were produced.

Categories

The summary aligned with each of the categories aids to describe and add meaning to the phenomena encompassed by the category label. For each of the 11 categories listed below there is an example of a finding, rated as ‘U’, ‘C’ or ‘NS’ based on the supporting illustration extracted directly from the research text.

Category: difficult relationship

Summary

Often, the relationship between assistants and health professionals is a difficult one, characterised by an ‘us’ and ‘them’ mentality, and they may not work well with each other.

Finding and Illustration example from Potter and Grant[42]

FindingDifficult relationships (U)
IllustrationRegistered Nurse (RN): I think it is often times just checking with them and asking, ‘Oh, did you do Mr So and So's vital signs’. UAP: ‘Well yeah!’ RN: ‘OK, I'm just checking, I'm just asking. I'm just making sure that it got done’. And I think it is just a lot of times you're asking if care gets done. You know, and it's just, I guess they feel like we have authority over them and just keep questioning them, you know, did you do this, did you do that, is this getting done. (p. 21)

Category: factors affecting relationships and roles

Summary

A number of factors affect the relationships and roles between professionals and assistants, including working experience, work processes, time spent working together, the environment, staff ratios and work plans.

Finding and Illustration example from Hancock et al.[45]

FindingRelationships (C)
IllustrationRelationships between the healthcare assistants (HCA) and their colleagues influenced the HCAs' roles and appeared to be determined by the local experience of the HCA (in years). (p. 494)

Category: good inter-professional relationships

Summary

Often, the relationship between assistants and health professionals is a good one, and they are able to work collaboratively together.

Finding and Illustration example from Potter and Grant[42]

FindingGood relationships (U)
IllustrationYeah, they work with you. They know what you need. They're there doing it before you even have a chance to ask them. If you have anything special they will do it. If they can't, they will tell you they have something else that must be done and can you wait or do you have to do it yourself, which is fine. (p. 20)

Category: changing roles

Summary

The role of the health professional and assistant needs to change, develop and grow when there are changes to models of care.

Finding and Illustration example from Hancock et al.[45]

FindingRole transition (C)
IllustrationMany of the HCAs' colleagues spoke of changes to ways of working as a result of role developments. The delay between recognizing the need for change and implementing it was also acknowledged. (p. 494)

Category: different perceptions of the assistant role

Summary

Both assistants and professionals can have varied and differing perceptions regarding what the role of the assistant actually is.

Finding and Illustration example from Johnson et al.[44]

FindingThe role itself (U)
IllustrationWell I didn't know what the line was, this is what I am saying, I was sure that we shouldn't be messing with ventilators and things like that, I know that we don't actually attach a patient up, but we can set up ventilator, but we have not to do the alarms. Because we don't know what is right and wrong, we could take the blood pressure at 60 over 40 and the alarm wouldn't go off until it reached 60 over 40. You know what I mean, we are not qualified to do that so we don't do that now. Yes, yes, they were showing us everything, which was good, not that we were going to be doing everything but we were shown how to draw drugs up, although we will never touch some it was interesting to know what they were for. It helps us that way. I think if there are no guidelines for what you can and can't do I think you are open to abuse. (p. 127)

Category: factors/influences on assistant roles

Summary

A range of factors/events influences the role the assistant performs, including local priorities, current and desired roles, housekeeping duties, environmental influences, staffing levels and more.

Finding and Illustration example from Hancock et al.[45]

FindingLocal decisions about roles (C)
IllustrationDespite competencies listed for the HCAs following the Development Programme, local decisions about their roles affected and restricted their roles. (p. 494)

Category: effective training for allied health assistants to include in model of care

Summary

Training needs to be effective to successfully include assistants in models of care. The effectiveness of training can be influenced by the degree of collaborative learning, teaching methods and critical reflection amongst others.

Finding and Illustration example from Plack et al.[19]

Finding3Process (U)
Illustration

I think the scenarios [were most helpful]. The class before we learned about their roles, … but actually putting that into a scenario or practice is, I think, helpful.

It was very realistic … we are going to have to know how to communicate with the PT [physiotherapist] and how the PT is going to have [to] communicate with us and be on the same level. (p. 7)

Category: preparedness to attend training

Summary

The preparedness to attend training can vary; some assistants may be willing and want to train, whilst others do not, and may not want to undergo training not in the workplace.

Finding and Illustration example from Hancock et al.[45]

FindingPrepared to attend (C)
IllustrationThose who wished to attend the programme spoke of their desire to do more training. One HCA spoke of her desire to train more, to the extent that she was leaving to do her training. (p. 495)

Category: training outcomes

Summary

Training outcomes can be varied, and relies on the way training was delivered.

Finding and Illustration example from Jelley et al.[40]

FindingCollaborative learning (U)
IllustrationI thought it was interesting from the beginning, seeing them learning together at the same time. It [learning together] worked all the way along they learned who did what and how to organize their time and lots about communicating. (p. 78)

Category: responsibility and accountability

Summary

The inclusion of assistants in models of care raises questions regarding appropriate responsibility and accountability for tasks and patients.

Finding and Illustration example from Johnson et al.[44]

FindingResponsibility of assistants (U)
IllustrationWell if I am doing something that I have been trained to do then obviously I am responsible for my own actions, but also I suppose whoever has trained me as well and who ever supervises me is responsible to ensure that I have been shown the correct way, because if I do something and it works out that I have been shown the wrong way then obviously that person is responsible also for showing me the wrong technique or whatever. (p. 129)

Category: supervision and mentoring

Summary

The inclusion of assistants in models of care raises questions regarding appropriate supervision and mentoring of assistants.

Finding and Illustration example from Potter and Grant[42]

FindingOrientation and mentoring (U)
IllustrationI like the way I did it because mentoring with an RN, well the particular RN was very, she showed you exactly how to do it and how to do it right. You know, no shortcuts, you just did it the way it was supposed to be done. And that was good, I mean, and she just knew how to teach. (p. 22)

The 11 categories were aggregated in 4 meta-synthesised findings.

Synthesised findings

The following synthesised findings provide guidance to consider how to make strategies regarding the implementation of the health assistant role more appropriate. Due to this, they do not relate to only one (or some) of the strategies, but should be taken into consideration for all strategies.

  • Meta-synthesis 1: Assistants and professionals may have good or difficult inter-professional relationships, which is dependent on a variety of factors (Fig. 2).
Figure 2.

Assistants and professionals may have good or difficult inter-professional relationships, which is dependent on a variety of factors. This meta-synthesis derives from 17 findings formed into three categories. This synthesised finding highlights the different types of relationships that exist between the assistants and health professionals. These relationships can be tense or stressed, or may be functional and effective, characterised by collaborative practice. Different factors can influence the relationships, such as different staffing models, how the role was implemented and how they interact and work together. C, credible finding; U, unequivocal finding.

This meta-synthesis derived from 17 findings formed into three categories. This synthesised finding highlights the different types of relationships that exist between the assistants and health professionals. These relationships can be tense or stressed, or may be functional and effective, characterised by collaborative practice. Different factors can influence the relationships, such as different staffing models, how the role was implemented and how they interact and work together. These factors can be addressed when implementing strategies to improve relationships between assistants and health professionals, thereby making them more appropriate.

  • Meta-synthesis 2: People perceive both the assistant role and the need for practice change in different ways, whereas the role itself and tasks performed may be influenced by a number of different factors (Fig. 3).
Figure 3.

People perceive both the assistant role and the need for practice change in different ways, whereas the role itself and tasks performed may be influenced by a number of different factors. This meta-synthesis derives from 19 findings formed into three categories. This synthesised finding highlights the different ways that people perceive the role of the assistant, both from professionals and assistants themselves, and their role in changing practice. The role itself, and the tasks performed by the assistants, is dependent on a number of factors, including the local context and environmental issues, patient dependency and staff levels. C, credible finding; U, unequivocal finding.

This meta-synthesis derived from 19 findings formed into three categories. This synthesised finding highlights the different ways that people perceive the role of the assistant, both from professionals and assistants themselves, and their role in changing practice. The role itself, and the tasks performed by the assistants, is dependent on a number of factors, including the local context and environmental issues, patient dependency and staff levels.

  • Meta-synthesis 3: Despite assistants feeling different levels of preparedness for training or the need for training, certain characteristics of training programmes can increase positive training outcomes and programme effectiveness (Fig. 4).
Figure 4.

Despite assistants feeling different levels of preparedness for training or the need for training, certain characteristics of training programmes can increase positive training outcomes and programme effectiveness. This meta-synthesis derives from 21 findings formed into three categories. This synthesised finding highlights that assistants may or may not feel a need for training, and they may have different levels of preparedness for training programmes. However, training programmes can be effective in producing positive results; these training programmes are characterised by collaborative learning providing opportunity to learn about each other's roles, assessment of competencies and certain teaching methods. C, credible finding; U, unequivocal finding.

This meta-synthesis derived from 21 findings formed into three categories. This synthesised finding highlights that assistants may or may not feel a need for training, and they may have different levels of preparedness for training programmes. However, training programmes can be effective in producing positive results; these training programmes are characterised by collaborative learning providing opportunity to learn about each other's roles, assessment of competencies and certain teaching methods.

  • Meta-synthesis 4: There are concerns amongst health staff regarding responsibility in models of care using assistants, highlighting the need for appropriate supervision and mentoring of assistants (Fig. 5).
Figure 5.

There are concerns amongst health staff regarding responsibility in models of care using assistants, highlighting the need for appropriate supervision and mentoring of assistants. This meta-synthesis derives from nine findings formed into two categories. This synthesised finding highlights concerns amongst both assistants and professionals regarding responsibility and accountability when models of care include assistants. Adequate supervision and mentoring of assistants by professionals, with clear responsibility and accountability for roles, is required. C, credible finding; U, unequivocal finding.

This meta-synthesis derived from nine findings formed into two categories. This synthesised finding highlights concerns amongst both assistants and professionals regarding responsibility and accountability when models of care include assistants. Adequate supervision and mentoring of assistants by professionals, with clear responsibility and accountability for roles, is required.

Discussion

This review sought to synthesise the existing evidence informing the appropriateness of strategies used to establish the health assistant role as a recognised delegated clinical role and to promote their inclusion in models of care. During the search and inclusion process, 10 studies were found that addressed the aim, describing a number of different strategies utilised across healthcare disciplines including occupational therapy, physiotherapy and nursing and were deemed of suitable quality to be included in the review. The population included in the studies ranged from assistant nurses to assistants in allied health; however, as the aim was to create meta-synthesised findings that included enough data to create guidance for practice, these were combined together. The eventual meta-synthesised findings appear to be general and applicable across strategies and professions in healthcare.

The aim of this systematic review was to highlight the appropriateness of strategies used to establish and incorporate the health assistant role into models of care. From this review, analysis of the 10 included qualitative studies resulted in four meta-synthesised findings. These meta-syntheses address the relationship between assistants and professionals, what affects the assistant's role and how it is perceived, training programmes for assistants and professionals, and accountability and supervision concerns. Often, assistants are not acknowledged in trans-disciplinary models of teamwork,[18] and it can be difficult to form functioning teams when they comprise persons with different levels of education and experience.[23] The first synthesised finding, ‘assistants and professionals may have good or difficult inter-professional relationships, which is dependent on a variety of factors’, provides information regarding the influencing factors that contribute to successful relationships between assistants and professionals, and can thereby help inform how to promote good working relationships for models of care including assistants and professionals.

Alternative models of care that utilise increased numbers of assistants have been seen as a way to address the increasing pressures on healthcare systems today.[47] However, criticism of the use of UAP (personal care assistants and certified nurse's aides) exists in the literature, and there have been negative reactions to the introduction of UAP.[48, 49] The second synthesised finding, ‘people perceive in different ways the assistant role and the need for practice change, whereas the role itself and tasks performed may be influenced by a number of different factors’, highlights the various ways (both positively and negatively) that the assistant role is perceived, and describes the factors that may influence the role the assistant performs in models of care.

Currently, the training that assistants receive is often variable[14, 50, 51] and in many areas assistants may receive little or no training. Costs of training and the time taken for training vary widely, and there is often no national regulation of training, despite support for this.[52] The third synthesised finding, ‘despite assistants feeling different levels of preparedness for training or the need for training, there are effective training programmes with certain characteristics that can result in positive training outcomes’, highlights the need for effective educational and training programmes for assistants, whilst stressing the importance of preparing assistants for such training. If educational programmes are to be used as a strategy to incorporate assistants in models of care, the characteristics of effective training programmes should be considered.

The introduction of assistive personnel forces the restructure of the role of the health professionals to supervise and delegate tasks to assistants, and not perform them themselves.[49] Due to the lack of clarification surrounding the role of assistants, there are different views regarding their role, and what they can and cannot do. Health professionals are also responsible for assistants, and many worry about professional and legal risks that may arise from working with them.[49] The final synthesised finding, ‘there are concerns amongst health staff regarding responsibility in models of care using assistants, highlighting the need for appropriate supervision and mentoring of assistants’, details the concerns that exist within models of care using assistants, and provides guidance on the need to clearly outline accountability, responsibility, supervision and mentoring issues.

These synthesised findings highlight the various factors related to appropriateness that need to be considered when implementing strategies to introduce health assistants in the workplace. These can be used to provide guidance when educating assistants and health professionals, and when preparing to incorporate assistants in models of care.

Limitations of the review

Although every effort was made to ensure the systematic review was conducted thoroughly with significant methodological rigour, there are some potential limitations of the review. Despite conducting a wide-ranging systematic search, there is always potential that some relevant studies may have been overlooked. A significant limitation is that only studies published in English were included. When conducting systematic reviews, another limitation is the amount and quality of the primary literature included. Although the studies that were included in this review met the inclusion criteria and were of sufficient methodological quality, only 10 were found, and none of these stated a philosophical perspective. However, the value of a synthesis of qualitative evidence is not directly related to the number of included studies, and even 10 papers are enough for an informative meta-synthesis. Meta-synthesis by meta-aggregation is recognised as a valid approach for meta-synthesis of qualitative evidence.[32]

Conclusion

There is an acknowledged need for changed models of care within health systems, including the expansion and substitution of roles for those at the assistant level. Despite this, there are still barriers to incorporating assistants in models of care and the recognition of their place in health service delivery as a delegated clinical role. These may include lack of clarity regarding roles, and negative perceptions of assistants by health professionals. This may, in part, be due to the wide variety in the range of tasks and roles that assistants fill in current health systems across professions and areas of care. Effective strategies have been used to promote the inclusion of assistants in models of care, including education/training programmes incorporating collaborative learning. Issues with mentoring and supervision in models of care with assistants were also identified in the review. This review highlights the perceived appropriateness of some of these identified strategies aimed at including health assistants in models of care. Policymakers can, by considering the highlighted issues around the appropriateness of strategies informed by the meta-synthesised findings above, address the barriers to incorporating assistants into models of care and further ensure they are successfully recognised as a delegated clinical role.

Implications for practice

For this systematic review the JBI levels of evidence (Levels 1 to 4) and grades of recommendations (A to C) were used.[19] Level 1 of evidence refers to meta-synthesis of research with unequivocal synthesised findings.[19] Grade A of recommendations refers to strong support that merits application.[19]

  • Relationships between assistants and professionals are dependent on a range of factors (such as different staffing models, how the role was implemented, and how staff interact and work together) all of which need to be considered when incorporating assistants in models of care. (Level 1) (Grade A)
  • A number of different factors influence the assistant role, and policymakers need to be aware that people perceive the role and need for practice change differently. (Level 1) (Grade A)
  • The preparedness of assistants to undertake training programmes needs to be considered when running training courses; as do the characteristics of effective training programmes. (Level 1) (Grade A)
  • Due to the concerns of health professionals regarding responsibility in models of care using assistants, there is a need for appropriate supervision and mentoring of assistants in these models. (Level 1) (Grade A)

Acknowledgements

This research was funded under the Research and Publication Initiative 2011 of Clinical Education and Training Queensland (ClinEdQ) Queensland Health Australia.

Appendix: Appendix I

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Appendix: Appendix II

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Appendix: Appendix III

MEDLINE search strategy (via Ovid) conducted on 3 May 2011

  • 1.Allied Health Personnel/ or allied health.mp. or Allied Health Occupations/
  • 2.physical therapy.mp. or ‘Physical Therapy (Specialty)’/
  • 3.‘Physical Therapy (Specialty)’/ or physiotherapy.mp.
  • 4.‘Physical Therapy (Specialty)’/ or physical therapist.mp.
  • 5.‘Physical Therapy (Specialty)’/ or physiotherapist.mp.
  • 6.nursing.mp. or Nursing/
  • 7.nurse.mp. or Nurses/
  • 8.occupational therapy.mp. or Occupational Therapy/
  • 9.Occupational Therapy/ or occupational therapists.mp.
  • 10.Podiatry/ or podiatrists.mp.
  • 11.podiatry.mp. or Podiatry/
  • 12.speech pathology.mp. or Speech-Language Pathology/
  • 13.Speech-Language Pathology/ or Speech Therapy/ or speech pathologists.mp.
  • 14.Dietetics/ or dietitian.mp.
  • 15.dietetics.mp. or Dietetics/
  • 16.nutritionist.mp.
  • 17.Pharmacists/ or pharmacists.mp.
  • 18.Pharmacy/ or pharmacy.mp.
  • 19.Orthopedics/ or orthotists.mp.
  • 20.prosthetists.mp.
  • 21.Radiography/ or radiographers.mp.
  • 22.Podiatry/ or chiropodists.mp.
  • 23.nurse aide.mp. or Nurses' Aides/
  • 24.Nurses' Aides/ or assistants in nursing.mp.
  • 25.dental assistants.mp. or Dental Assistants/
  • 26.support worker.mp.
  • 27.Psychiatric Aides/ or Pharmacists' Aides/ or Nurses' Aides/ or aides.mp.
  • 28.helpers.mp.
  • 29.helper.mp.
  • 30.Health Education/ or Education, Nursing, Graduate/ or Education, Dental, Graduate/ or Education, Predental/ or Education, Nursing, Associate/ or Competency-Based Education/ or Education, Nursing, Baccalaureate/ or Education, Public Health Professional/ or Education, Nursing/ or Education,Premedical/ or Education, Pharmacy, Graduate/ or Education, Professional/ or Education, Nursing, Diploma Programs/ or Education, Medical, Undergraduate/ or Education, Pharmacy,Continuing/ or Education, Graduate/ or Education, Special/ or Education, Medical/ or education.mp. or ‘Education of Mentally Retarded'/ or Area Health Education Centers/ or Education, Medical, Graduate/ or Education, Pharmacy/or Education, Professional, Retraining/ or Education, Dental, Continuing/ or Nursing Education Research/ or Education/ or Education, Distance/ or Vocational Education/ or Education, Medical, Continuing/ or Education, Nonprofessional/ or Education Department, Hospital/ or Education, Continuing/ or Health Education, Dental/ or Education, Nursing, Continuing/ or Education, Dental/
  • 31.training.mp. or Inservice Training/
  • 32.vocation.mp. or Occupations/
  • 33.Learning/ or learning.mp. or Problem-Based Learning/
  • 34.instruction.mp. or ‘Instructional Films and Videos’/
  • 35.Remedial Teaching/ or Teaching Rounds/ or Hospitals, Teaching/ or Teaching Materials/ or Teaching/ or teaching.mp.
  • 36.curriculum.mp. or Curriculum/
  • 37.curricula.mp. or Curriculum/
  • 38.enrollment.mp.
  • 39.enrolment.mp.
  • 40.30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 (818332)
  • 41.assistant.mp. or Ophthalmic Assistants/ or Dental Assistants/ or Pediatric Assistants/
  • 42.model of care.mp.
  • 43.models of care.mp.
  • 44.pathway.mp.
  • 45.Personnel Delegation/ or Delegation, Professional/ or delegation.mp.
  • 46.1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22
  • 47.aid$.mp.
  • 48.Home Health Aides/ or Psychiatric Aides/ or Community Health Aides/ or Pharmacists' Aides/ or Nurses' Aides/ or aide.mp.
  • 49.23 or 24 or 25 or 26 or 27 or 28 or 29 or 45 or 48
  • 50.41 or 49
  • 51.30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 42 or 43 or 44
  • 52.46 and 50 and 51
  • 53.limit 52 to english language

Additional search following inclusions to the search strategy after feedback

  • 54.community rehabilitation assistant.mp.
  • 55.Community Health Aides/
  • 56.community health aides.mp. or Community Health Aides/
  • 57.education.mp. or Education/ or Vocational Education/
  • 58.training.mp.
  • 59.vocation.mp.
  • 60.Learning/ or learning.mp.
  • 61.instruction.mp.
  • 62.Teaching/ or teaching.mp.
  • 63.curriculum.mp. or Curriculum/
  • 64.curricula.mp. or Curriculum/
  • 65.enrolment.mp.
  • 66.enrollment.mp.
  • 67.models of care.mp.
  • 68.pathway.mp.
  • 69.role development.mp.
  • 70.role redesign.mp.
  • 71.57 or 58 or 59 or 60 or 61 or 62 or 63 or 64 or 65 or 66 or 67 or 68 or 69 or 70
  • 72.56 and 71
  • 73.69 or 70
  • 74.Psychiatric Aides/ or Pharmacists' Aides/ or Nurses' Aides/ or aide.mp.
  • 75.assistant.mp. or Ophthalmic Assistants/ or Dental Assistants/
  • 76.support worker.mp.
  • 77.helper.mp.
  • 78.Personnel Delegation/ or Delegation, Professional/ or delegation.mp.
  • 79.74 or 75 or 76 or 77 or 78
  • 80.73 and 79

Ancillary