Dilemma: Can you train health care assistants to syringe ears?
Can you train Health Care Assistants (HCAs) to syringe ears? If not, are there other ways to train people in this role to do more?
Dr Paula Varma: Yes, but HCAs are not clinicians
Health care assistants are a valuable resource for a financially challenged health care system. However, it is most important that they are employed to perform tasks for which they have been effectively trained and that they are supported by the whole of the health care team to ensure patient safety.
It must be remembered that HCAs are not clinicians. Ear-syringing is a practical task that can be performed by HCAs so long as the clinical decision regarding the need to syringe has been made by a clinician.
As registered professionals, doctors are legally accountable for the care provided by delegated, non-registered staff. The patient must be made aware that the HCA is not a registered professional. Defence organisations support “reasonable delegation” within the field of the HCA’s expertise, ensuring that they are fully trained, competent and follow a robust protocol: the patient should be over 16, have been seen by a GP or practice nurse who have assessed the clinical need and safety to delegate the procedure, the patient should have no contraindications and should have had the procedure performed before with no complications.
There are many validated training courses available to HCAs for training in ear irrigation. They require the HCA to have a mentor who monitors and supports them in their practice. It is essential to inform the defence organisation of the duties of the HCA to ensure that adequate cover is provided and to perform regular audit and feedback on patient satisfaction.
HCAs can be employed in many technical tasks so long as the above criteria regarding training, monitoring and support are met. These include alcohol screening tools, Vitamin B12 injections, flu vaccination, contraceptive depo injections.
Dr Paula Varma is a GP in Pontyclun, South Wales
Dr Tanis Hand: It’s not appropriate for the HCA to make the initial assessment
Health Care Assistants are valued members of nursing teams in every setting and their role in GP surgeries has developed considerably in recent years.
Registered nurses routinely irrigate ears for but it is an activity that can be delegated to a trained and competent HCA providing certain criteria are met.
The HCA must not be put in a position where they have to make a stand-alone clinical judgement. They should always be working under the supervision of registered nurses and within clear protocols. If they are unsure of any aspect of care they must be able to refer to a registered practitioner for further advice.
It’s not appropriate for the HCA to make the initial assessment of the patient prior to irrigation. They should, however, have been trained to double check for contra-indications.
The HCA role in ear care should be limited to simple inspection and irrigation to remove wax or debris in otitis externa – and only when the patient has no pain. They should not attempt any more complex procedures such as removal of foreign objects or manual removal of wax. They would need written evidence of their competence using recognised standards and should maintain this competence through CPD.
Tanis Hand is the Royal College of Nursing’s adviser for HCAs. For more information about accountability and delegation to HCAs visit www.rcn.org.uk/hcaaccountability
Dr Rachael Birch: There is no definitive list of tasks for HCAs
Many practices are keen to extend the role of their HCAs. There is no definitive list of tasks that HCAs should undertake and practices vary in what their HCAs do. The Royal College of Nursing (RCN) offers advice on roles and training in ‘First steps for HCAs’.1
If delegating a task, doctors and nurses must ensure that the HCA is trained and has the necessary skills, knowledge and competence to perform that task. The General Medical Council and Nursing and Midwifery Council offer guidance on delegation.2,3 Accountability must be clear, although employing partners remain vicariously liable for the acts and omissions of the HCA.
HCAs should not be expected to assess patients and therefore it would be inappropriate for the HCA to decide if syringing is required but restrict their role to carrying out the syringing at the request of the assessing clinician.
If the above principles are followed, there is no reason why HCAs shouldn’t be trained to perform ear-syringing. They should follow a robust practice protocol, be competent and fully trained. Training should be validated and include theoretical and practical work. The practice should also have a system to monitor performance.
The employing partner should inform their Medical Defence Organisation of any work that the HCA undertakes to ensure they have adequate protection.
Dr Rachel Birch is a medicolegal consultant at the Medical Protection Society
1 RCN. First steps for HCAs. http://rcnhca.org.uk/
2 GMC. Good Medical Practice (2013). Para 45. http://www.gmc-uk.org/guidance/good_medical_practice.asp
3 NMC. The Code: Standards of conduct, performance and ethics for nurses and midwives (2008). Paras 29-31. http://www.nmc-uk.org/Publications/Standards/The-code/Introduction/