3.3 More carers: still deeper in the shadows?
What can be said of the others who work on hospital wards? There are, as you heard on the audio cassette, care assistants, there are domestic staff, and sometimes too there are nursing auxiliaries and clerical assistants whose role is to take some of the paperwork away from the nurses, to enable them to get on with the business of giving direct patient care. You have already seen that the division of labour between doctors and nurses is not always clear-cut. You will now see that there are important overlaps between nurses and those who assist them in the work of patient care. What a care assistant does, and also what a domestic or a clerical assistant does, rather like what a nurse does, can depend on who else is available, varying from ward to ward or even varying on the same ward depending on what time of day it is. This can lead to frustration all round, with the qualified nurse feeling that she is not doing the work she is trained for and wants to do, and others feeling that no one is acknowledging the skills of the work they do.
‘On the wards’, the offprint you will read for Activity 9, is an excerpt from an account by anthropologist Liz Hart of the time she spent working as one of over 200 domestic staff on the wards of a large teaching hospital in the West Midlands. Her method was open participant observation – that is to say she had permission to carry out the research, and staff and management knew that she was a researcher. But she worked shifts alongside the others, doing the same work and sharing breaks with the domestic staff.
Click to read: On the Wards
Activity 9 Hidden contributors to care
Patient care in a hospital is not restricted to care by doctors and nurses – it includes care provided by staff who are not professionally qualified.
Read the offprint now and try to set out the different ways in which Hart's findings support this statement.
Hart shows that in the case of a teaching hospital domestic staff do many activities that can be classified as care.
Domestics carry out a range of tasks for patients (fetching things, finding things in the locker, helping them to drink, even sometimes lifting) in response to patient requests and in the absence of nursing staff.
Domestics converse with patients in an ordinary and everyday way which they, and some nursing commentators, claim is helpful to the patient and can be therapeutic. Relatives also sometimes turn to domestic staff for information and advice. Domestic staff can sometimes even be an ‘anchor’ in a setting where staff changes are rife.
Often domestics have long years of experience in a particular ward, and wish to and successfully do build up knowledge and relationships that mean an extension of their role.
Patient contact can be a source of job satisfaction for domestic staff, some of whom intend moving into care assistant work.
There are plenty of other examples that could be given to show that caring work is not the exclusive province of those who are qualified and registered as nurses. A great deal of care for elderly people in residential homes, for example, is carried out by care assistants. This can be true in hospital settings too. Qualified nurses plan, assess and supervise the work, delegating to others. This was clear when James described his role as a primary nurse on the audio cassette and when Ann, the care assistant, gave an account of her day. Care assistants and auxiliaries, however, are likely to have had some training for their face-to-face responsibilities for patients. Domestics are not. One of our course testers argued that Liz Hart's account was too positive -without careful training and supervision, the interventions of the staff that she describes could risk sometimes doing harm.
One of the members of the course team, Jan Walmsley, interviewed Val, a care assistant in a psychiatric setting, and then shadowed her as she worked for a day – recording what she did and what she had to say about her work. Val said that she was ‘unqualified but not untrained'; she had had a lot of experience as a care assistant, and in practice she found that she was ‘training’ the junior doctors, the student nurses and the nurses with much less experience than herself. In a hospice, the sister admitted that care assistants were the ‘backbone of the unit’ and that she was sometimes ‘a tinge jealous’ of how close some were to the patients. A staff nurse from the same hospice went further and recognised that some of the care assistants possessed skills that she herself did not. Remembering one particular incident she said:
At the time I just didn't know how to cope. And luckily the older auxiliaries were there. If Maggie hadn't been on that day I don't know what would have happened. I just didn't know what to do with this poor woman. She just completely broke down and collapsed in front of me. And I went to get Maggie, and said ‘come and help me, please’. And Maggie was very firm with her, but very sympathetic at the same time.
(Quoted in James, 1989, p. 36)
Can we ever generalise about what different grades of staff do? Can we get neat job descriptions? The answer, from workers at least, seems to be no – there is too much variation across the settings and in day-to-day resourcing. One care assistant summed it up neatly:
I think of myself as polyfilla. Filling in the gaps, doing things the nurses haven't got time for, or making it easier for the nurses, or talking to patients when no one else has got the time to talk to them. Really just anything and everything.
(Quoted in Ahmed and Kitson, 1993, p. 27)
There is considerable debate over what training should be provided for workers such as care assistants, by whom, and for how long. But over the last decade there has been growing recognition of the contribution made by non-qualified and non-clinical support workers. Substantial Department of Health funding has been made available to enable trusts and other health care organisations to develop education and training for these groups. National Vocational Qualifications (NVQs) and Scottish Vocational Qualifications (SVQs) are available to help staff in training for their important role in patient care.
Care assistants, and others who are sometimes not formally qualified or registered, carry out much hands-on care on hospital wards.
Their work can overlap with that of registered nurses, and boundaries can be hard to draw.
Although care assistants can play a key role for the patient, their training and responsibilities are not always well defined.
New opportunities are emerging, however, which enable support workers to be formally and vocationally prepared for their roles.