Health care assistant and registered nurse dyads, working together and apart – a qualitative study

Background: This study was undertaken to understand the role of the Health Care Assistants and how they negotiate roles and responsibilities with Registered Nurses in adult acute hospitals. Methods: The qualitative approach of focused ethnography used non-participant observation and interviews with staff from four acute wards. Field notes and interview data, analysed using NVIVO10, moved data from description through explanation, interpretation and identification of themes. Results: 148 h of observations and 108 interviews were conducted in dyads comprising 22 Health Care Assistants and 33 Registered Nurses. Health Care Assistants worked non-dependently from, and inter-dependently with Registered Nurse dyad partners. Dyads relied on demarcation of responsibilities by task, established and reinforced by ward culture. Demarcation enabled Registered Nurses to oversee care but could create false divides between observing and recording patients’ conditions and interpreting findings. Interdependent working only happened when two staff members were needed for care. Involvement in fundamental care by the Registered Nurse was unpredictable and discretionary. There was limited evidence of how dyads supported person-centred approaches. Conclusion: The physically-boundaried, close working of the Health Care Assistant and Registered Nurse had an isolating, task driven impact on Health Care Assistants’ work. Recognising the dyad did not foster shared goals, learning or review of care.