Characterising support and care assistants in formal hospital settings: a scoping review

Reporting is guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA–ScR) guidelines [29].

This review aimed to map evidence for the characterisation of lower-skilled support and CAs in formal hospital settings. We note that there is a lot of inconsistency and substantial variation in the terms or titles for CAs, their training, the scope of practice, and regulatory mechanisms within and across the reports included from 15 countries. Moreover, we note that the two commonly used terms “assistant” and “support worker” do not align with the ILO’s ISCO 5132, 5133, and 3231 descriptions [92] that use “Institution-based personal care workers” or “nursing aid” to refer to the titles and roles ascribed to CAs. Thus, our synthesis points out the need to review the ILO’s ISCO nomenclature for this occupational group.

Our evidence mapping indicates a substantial amount of empirical literature on task-shifting/sharing between nurses and CAs in high-income countries but largely understudied in LMICs. However, overall, some evidence suggests CAs may contribute to improved quality of patient care by availing nurses time to concentrate on high-acuity and critical care activities [11, 12]. There is, however, contrary evidence suggesting the involvement of CAs in patient care may pose a risk to patient safety and quality of care [26, 48, 93, 94]. In addition, the evidence for CAs’ ascribed roles is generally mixed and their role boundary with professional nurses is even more blurry from the patients’ perspective.

Importantly, this review reveals that CAs take up a range of roles in clinical and care settings some of which are informally negotiated based on competency levels, years of experience, confidence, or supervision effort required. These insights are similar to observations by Just et al. [63] while examining the role of CAs in end-of-life care and McKenna et al. in their review on how CAs’ roles affect patient safety and care quality. The majority of the CAs’ assigned tasks are direct patient care activities, including vital signs monitoring, assisting with patient hygiene and elimination needs, and support with patient medication—all of which help to meet essential patient care needs. This suggests that with good mentorship, competency-based training, and appropriate supervision, such tasks could be progressively assigned to lower-cadre assistive personnel. Interestingly, we also note that there are higher-level extended roles undertaken by the CAs, namely, basic life support, giving injections, wound care, ECG monitoring, catheterisation, and sample(specimen) collection. However, in support of other studies elsewhere [63, 95], these tasks are mostly informally negotiated, setting-specific, and would require a higher level of skills and training. Notably, the extended roles were common in USA, Canada, UK, and Australia, which could be attributed to deliberate staff upskilling incentives and/or the availability of good on-the-job competency development programmes in these settings. More importantly, clarity of role boundaries and accountability mechanisms that avoid role conflict with the qualified nursing workforce appears to be missing. Overall, the nature of pre-service, and on-the-job training requirements determine the roles and depth to which tasks are assigned and executed by the CAs [24, 40, 45, 60, 64, 81, 96, 97].

How CAs are recruited and deployed in formal care settings has the potential to affect patient care outcomes and shape nurses’ experiences of care delivery. We infer that hospitals choose between two strategies of integration of CAs in the hospital setting: a substitutive model [50, 73] where the CAs are employed to cover the shortage of nursing staff and a supplemental model where the CAs are added as a layer to an existing proportionately ‘optimal’ staff. However, these strategies have only been explicitly reported in the UK and Australia [50, 73, 98]. Still, the choice of either approach is very much inconsistent or unclear across and within most care settings [50, 73]. This could be explored further in future research. Supplementation of nurses with CAs creates an incremental effect on skill-mix and is generally linked with positive patient outcomes and clinical staff experiences, including promoting continuity of quality and effective care through fewer work interruptions, reduced waiting time, and overall, reduction in the risk for missed care. On the other hand, the substitutive strategy is associated with a reduced nurse–patient contact time, leading to concerns about patient safety [14, 69, 71], role deprivation, loss of professional identity, reduced job satisfaction, and unclear accountability lines for actions [53, 63, 95]. Noteworthy, as illustrated in Table 3 and Table 4, a few papers had impacts and experiences that conflict with others. For instance, patient safety is not only viewed in a positive sense (i.e., reduced patient injury [48, 54] but equally in a negative sense (i.e., heightened risk to patient safety [42, 50, 68]. Similarly, job satisfaction among nurses has both negative [54] and positive[59, 79] sentiments from different settings. Understandably, as reported elsewhere [99, 100] the effects related to patient safety and satisfaction present potential for medical–legal issues, although this implication was not observed in the current review.

With the ever-increasing strain on healthcare globally, many healthcare systems have been pushed to adopt mechanisms to optimize care delivery amidst limited workforce capacities [43]. Coupled with the slim evidence on specific safe staffing mix ratios, CAs have become a norm in healthcare systems albeit, largely informally in most countries. Although a few studies reported some form of regulatory or clinical governance mechanism, the general picture is a lack of standardised regulatory frameworks for training, employment, degree of task-shifting/task-sharing, the delegation of duties, and supervision and accountability of the CAs. In LMICs, this cadre of staff remains marginalized and or unofficially recognised. Effective management and utilisation of this workforce in healthcare remains disjointed and could lead to either exploitation or underutilisation [43, 73, 85]. Moreover, the lack of clarity on their contribution to patient safety and quality of care begs further investigation. In essence, the adoption and use of CAs in healthcare require a careful approach to sustain professional accountability and avoid over-dilution of skill-mix [42, 94, 97, 101].

The synthesis of the finding of this review is cognisant of some limitations. First, since this is a review, its methodology is unable to make causal inferences on how CAs affect patient care outcomes. However, our findings help to highlight gaps that could be addressed by robust empirical study designs. Second, our eligibility was limited to records in English-language only. However, despite adopting an open search period and across multiple databases and registries, we only retrieved and synthesised literature from 15 countries. This could imply this topic remains under-studied in the countries with no available literature.

In summary, the nomenclature for CAs is largely inconsistent and variably used. Second, the application of task-shifting strategies in hospitals is fragmented and this is observed both within and across countries. Third, the effect of CAs on patient care outcomes or nurses’ experiences remains unclear as both positive and negative sentiments have been reported in equal measure. Consequently, the synthesis of these findings has several implications. First, we provide evidence that the 2008 version of the International Labour Organization’s International Standard Classification of Occupations [ILO’s ISCO] [92] and related national occupation classifications should be updated for a more clear and more meaningful nomenclature for CAs and other related assistive personnel. Second, collating and mapping empirical evidence on regulatory and clinical governance mechanisms for CAs and their impact on patient care as well as nurses’ experiences present an opportunity to advance conversations on future research on HRH for assistive personnel. For instance, the amount of net savings or costs incurred relative to gains on service delivery and efficiency from assistive personnel in healthcare facilities. Third, these findings bring to the fore, a need for the operationalisation of context-specific policy guidelines and strategies for task-shifting/sharing, including the training of CAs, within a larger framework for norms and standards for HRH management. Such guidance will need to accommodate a diverse and changing landscape of CA roles in hospital settings.