Title: Can Health Care Assistant training improve the relational care of older people?: A development and feasibility study of a complex intervention
Funder: Department of Health (England)

Abstract: BackgroundPeople aged 75 years and over account for 23% of all hospital admissions an increase of 66% in the last decade (The Information Centre for Health and Social Care 2010). There has been increasing recognition of problems in the care of older people particularly in hospital care (Cornwell 2012). Evidence suggest that older people judge the care they receive in terms of the relational and values-based aspects of care such as kindness compassion and respectful communication (Maben Adams et al. 2012). Healthcare assistants (HCAs) deliver an increasing proportion of direct care to older people yet their training needs are often overlooked (Bach Kessler et al. 2012). The proposed study has the potential to provide a testable form of training package for HCAs in an area of particular concern to older people (Goodrich and Cornwell 2008; Tadd Hillman et al. 2011; Maben Adams et al. 2012). AimsThe proposed study aims to:1.Understand the ‘values-based’ training needs of HCAs in maintaining the dignity of and affording respectful care to older patients in acute NHS settings.2.Develop a ‘values-based’ training intervention for HCAs designed to address the identified needs of older patients for high quality relational care.3.Assess the feasibility of a study that can formally test the performance and cost effectiveness of the developed training intervention for HCAs against current training in improving the care of older patients in acute NHS settings.SettingSelected wards within three acute NHS Trusts in England. Wards will be selected according to the proportion of older people (aged 70+) typically cared for within them.Methods (see flow diagram at end of document)The study will be conducted in two disticnt but related phases using mixed methods. Phase 1 will address aims 1 & 2 and Phase 2 will address aim 3:Phase 1: We will conduct a scoping exercise of current education/training/induction for HCAs across the three acute trusts. This exercise will consist of a (i) telephone survey of the lead NHS trainer at each acute NHS Trust in England (ii) qualitative interviews with HCAs (n=30 n=10 per Trust); (iii) qualitative interviews with other staff groups (e.g. nurses and managers) (n=24 n=8 per Trust); and (iv) focus group interviews (n=3 groups) with established community groups of older people. From (i) the scoping exercise and analysis of the qualitative interviews and (ii) current evidence we will undertake development of a brief ‘values-based’ training intervention for HCAs. As the evidence suggests that (i) respectful communication practices and (ii) ‘seeing the person behind the patient’ (Bridges Flatley et al. 2010) are key for older people we anticipate forming a brief and interactive intervention that specifically addresses these areas of concern; the former through the development of a ‘customer focus’ package with input from non-healthcare sector retail organisations (with established reputations for good customer care) and the latter through a modified life story approach.Phase 2 (Aim 3): We propose to conduct a feasibility cluster randomised controlled trial of a ‘values-based’ training intervention for HCAs developed in Phase 1 versus HCA ‘training as usual’ to inform the design and viability of a future definitive trial.OutcomesPhase 1: On completion of Phase 1 we will have gained a national picture of HCA training provision and variation across acute NHS trusts in England and an indepth view of (i) HCA training experiences preferences and needs from the perspective of HCAs other staff groups and older people. We will have a designed a training package for HCA trainers that will be based on Phase 1 outputs and rooted in current evidence regarding older people’s care experiences and the learning styles of staff groups such as HCAs. At this stage we will have a package that is ready to move to an early stage of evaluation (feasibility RCT).Phase 2: On completion of Phase 2 we will have conducted a feasibility cluster randomised controlled trial that will inform the design of a definitive cluster RCT in relation to the viability cost acceptability of the intervention itself and the acceptability of particular design considerations of the trial such as recruitment randomisation and outcome measures. The outcome measures we will be field testing in this phase of the study is will be at ward (observation) HCA (empathy and attitudes to older people) and patient level (evaluation of care).AnalysisThe qualitative data generated from the qualitative interviews and focus groups will be analysed thematically using framework analysis (Ritchie and Spencer 1994). We will use data from the feasibility cluster RCT to estimate parameters that are needed to design a future definitive trial including the acceptability of the training intervention and randomisation the willingness of ward managers HCAs and older patients to participate in the study the acceptability and discrimination of outcome measures an estimate of costs for both HCA training intervention and HCA training as usual. Main benefits and potential impact to the NHSDeveloping HCA training in key aspects of relational care for older people has the potential to improve care quality by targeting the section of the workforce with the greatest level of direct contact with older patients. Although much is known about what older people perceive as the shortcomings of care in hospital the lack of robust evaluations of HCA training interventions suggests important feasibility work is needed before knowing if and how a definitive cluster randomised controlled trial is viable.ReferencesBach S. I. Kessler et al. (2012). Nursing a grievance? The role of healthcare assistants in a modernized national health service. Gender Work and Organization 19(2): 205-224.Bridges J. M. Flatley et al. (2010). Older peoples and relatives experiences in acute care settings: systematic review and synthesis of qualitative studies. Int J Nurs Stud 47(1): 89-107.Cornwell J. (2012). The care of frail older people with complex needs: time for a revolution. London The Kings Fund.Goodrich J. and J. Cornwell (2008). Seeing the person in the patient: the point of care review paper. London The Kings Fund.Maben J. M. Adams et al. (2012). Poppets and parcels: the links between staff experience of work and acutely ill older peoples experience of hospital care. Int J Older People Nurs 7(2): 83-94.Ritchie J. and L. Spencer (1994). Qualitative data analysis for applied policy research. Analysing qualitative data. A. Bryman and R. Burgess. London Routledge.Tadd W. A. Hillman et al. (2011). Dignity in practice: an exploration of the care of older adults in acute NHS trusts. London HMSO.The Information Centre for Health and Social Care (2010). Hospital Episode Statistics: Admitted Patient Care - England 2009/10. http://www.ic.nhs.uk/pubs/hes0910.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE