You’ve worked hard to gain a position on the Trainee Nursing Associate (TNA) apprenticeship course: prepared for your interview, revised the NMC Code of Conduct, familiarised yourself with the Standards of Proficiency, and possibly taken extra courses in Maths and English. Then on shift you’re asked if you are a HCA or a TNA today? It can feel very frustrating. If you are further into training, you’ve probably been on a few placements, participated in some medication rounds (under direct supervision of course), completed care plans and starting to feel more confident and knowledgeable about your future role. To be allocated as a Health Care Assistant (HCA) when working in your base area can often feel very limiting with additional worries about missing out on learning.
Most TNAs that I have spoken with experience this situation, some a lot more than others. It is very dependent on the policies of your employer, the understanding of your manager and colleagues about the apprenticeship, and of course staffing levels. Shortages of staff are the main reason TNAs find it difficult to be anything other than a HCA in their base area. Student nurses have longed raised issues about lack of training in clinical areas and of being used as unpaid support workers so as TNAs we are not alone in this situation.
Many trainees that I have spoken with often take being allocated as a HCA as an insult. Some will say that did not join the programme in order to wash and feed patients. Many trainees, even at the start of the course worry they are not gaining enough experience in medication rounds. Others become disillusioned with their base area and resentful of managers and colleagues. Still others leave the training programme – often destined to spend their time telling everyone that the course is a waste of time and trainees are just being used to support staff shortages. Some that persist with the course develop a dislike for their base area and the people they work with. Personally, I would always take the diplomatic route. Often, managers and the nurse in charge are constrained by staffing levels. It is usually just not feasible to pay a TNA to be at work and then pay for a HCA to replace the TNA for a whole shift. I am not even sure if this would be allowed by most health care employers. The majority of TNAs are on the apprenticeship route and paid at Agenda for Change band 2 or band 3 while training. As we are being paid – we are expected to be working while learning.
The NMC requires that at least 20% of the training programme to be protected learning on external placements and studying at university. Employers must still be able to provide learning opportunities during training, however I believe that the majority of learning opportunities must be actively sought out by ourselves as trainees. We are the ones who are best placed to understand where are knowledge and experience is lacking and so we are the ones best placed to look for ways to fill those gaps. My advice, and my work ethic from the start of training, as been to ‘Think Like a TNA‘ at all times. My page on protected learning gives some examples. I have spent the majority of my time in my base area allocated as a HCA. However, I do not view this in a negative light. Many of my HCA colleagues are some of the most experienced and compassionate nursing staff I have worked with. Many health care assistants have years of patient care experience and some of the best instincts I have seen. Some health care assistants I have had the pleasure to work with are my personal role models.
No matter what abbreviations are next to my name on the staff board, I am constantly observing and evaluating my patients in everything they do and every interaction I have with them. This is what a good, experienced HCA will do – and it is the basics of what we should be doing as a TNA.
Communication:
How does this person like to speak? Do they like a little bit of banter or are they a little more formal? Adapting my style of communication for each patient allows them to feel comfortable and possibly open up about any concerns they have. Good communication builds trust and trust is the basis for a positive therapeutic relationship.
Emotional State / Mental Health:
Communication and trust are also essential to evaluating a patient’s mental health or emotional state. You can learn so much – which might have not been picked up if that person had felt closed off from the staff caring for them.
Activities of daily living:
Observing a patient eat or drink and observing or assisting with mobilisation are basic skills that tell us so much about our patients. Often, these basics are the foundation for the rest of the patient’s care. As a trainee nursing associate it is important to understand our patients; to be able to escalate concerns, monitor changes, and to work with colleagues such as dieticians, speech and language therapists and physio and occupational therapists.
Observations / Vital signs:
As a HCA, I would complete a set of obs. If something was wrong I escalated to the nurse and moved on. As a TNA, I always try to link theory into practice. Why potential reasons are there for new hypotension, new confusion, or pain. Is there anything I can do about it now? (of course always escalate to the nurse or medical team). If a patient is deteriorating I always ask myself what would I do in this situation after I have qualified.
If a relative asks for an update, as a HCA I would always go and get the nurse. As a TNA (and if confident and I understand the situation) I would provide an update myself. This is not an all or nothing situation. Sometimes I would give a brief summary and inform the relative that further information is outside my competency and understand as a trainee and I would find someone who could provide that information. Every situation is specific.
Medications:
This is the big one for many trainee nursing associates. Lack of opportunities to participate in medication rounds on base area is a legitimate concern in my opinion. As drug rounds tend to occur at the same time as patient washes and mealtimes – it can be very difficult to be able to participate and practice medication administration. Most TNAs will have 7.5 hours per week in an external setting – even then this time is usually shared with student nurses and other trainees so opportunities to participate in medication rounds are often slim even on placement. Some areas and nurses do prioritise student nurses over TNAs when it comes to medication which can limit opportunities even further.
My advice for this is to take any opportunity to understand and familiarise yourself with medications. If you are completing a care plan – check what medications the patient is taking and look up details on the BNF? The actually task of administering medications on a typical drugs round is fairly simple. However, understand the rationale for different drugs, knowing indications and contraindications and typical doses is essential knowledge. Being able to explain to a patient in terms they understand what their medications are for is an important communication skill to have. Making your own opportunities to learn and expand your knowledge whenever you can will help you to learn while working. It is important to remember that as a TNA we must always work within our scope of practice. Even when pushing ourselves and practicing new skills or improving confidence in communication it is important to judge each situation and patient individually. If something is outside your scope then do not do it.
Finally, I believe that the role of a HCA is not something we should look on as some kind of demotion. Health care assistants are an absolutely essential part of the nursing workforce. The backbone of patient care and the foundation on which all other care is provided. Registered nurses and register nursing associates, doctors, physiotherapists, occupational therapists, dieticians, and every other member of the multidisciplinary team simple cannot perform their duties without healthcare assistants. My parting advice when asked if you are working as a HCA today is to say yes, and be proud of that. Be proud of the fact that you are providing essential care on which the patient and the entire team relies upon. However, always think as a TNA and try to learn from every situation, interaction, conversation and experience.
