A review of the clinical assistant workforce at a district general hospital during the COVID-19 pandemic

Discussion

Our results have demonstrated the benefits of the NGH CA programme for the CAs themselves, the clinicians they worked with and, potentially, the patients in their care. They have also highlighted important areas of improvement, should such a programme be implemented again in the future.

The first notable benefit of this programme was the potential to improve medical students’ preparedness for practice. CAs showed significant improvements in confidence with practical procedures and ward-based administrative tasks after working at NGH. These results may have been expected, as confidence levels are known to improve post-intervention. However, clinicians also believed that CAs had become more competent in performing practical skills, as well as developing their communication skills, understanding of the junior doctor role and of how the NHS works. These results are consistent with literature evaluating final-year student assistantships, a placement following the medical apprenticeship model, in which the focus is on learning through participation and involving medical students in practice as much as possible.⁶ A review of the student assistantship at Queen's University Belfast found that it significantly improved students’ perceptions of preparedness in almost all clinical and practical skills; improved communication with patients, relatives and colleagues; and helped students’ understanding of the work environment.⁷ Similar results have been found at the University of Bristol; students reported increased confidence in practical, communication and documentation skills, assessing and managing patients, prescribing and understanding the roles of staff members following their assistantship.⁸ When discussing why their assistantship had improved confidence and preparedness, students at The University of Sheffield Medical School discussed the importance of having a sense of responsibility and a clear role.⁹ This is unlike normal medical school placements, in which the role of a medical student is undefined, with students feeling like a ‘spare wheel’ and therefore adopting an overly passive approach to learning.^10,11 Much like final-year assistantships, CAs at NGH were provided with specific responsibilities and expectations, perhaps aiding the shift from passive observer to active team member, and therefore providing CAs with many opportunities to practise practical and administrative skills. It is unclear whether pay was somewhat accountable for CA engagement, but the fact that similar results were found from unpaid final-year assistantships suggests that this is unlikely.

Despite significant improvements in preparedness since the introduction of the student assistantship, 33% of UK graduates in 2019 still did not feel prepared for practice, leading to calls for longer periods of ‘hands-on’ experience.^12,13 Assistantships are currently only offered to final-year students, but our results suggest that medical students of all years can fulfil this role, and making this available to students in earlier years of study would provide them with the practical experience they need. The majority of respondents in this study agreed with this proposal; 68% of medical student CAs and 47% of clinicians wanted to see the integration of a CA role into the first- to fourth-year medical school curriculum, and an additional 25% of clinicians wanted the CA role to become a part-time job for medical students. Overall, it is clear that the CA role helped students prepare for many of tasks expected of them when they qualify, and that prolonged exposure to such experience, whether in an unpaid medical student placement or in a paid NHS trust role, is desired by both students and clinicians.

The active engagement of CAs seemed to positively impact clinicians too, with 90% of those surveyed reporting reduced workloads, despite staffing pressure caused by the pandemic. Even before COVID-19, the strains placed upon NHS junior doctors were well documented. The 2019 national training survey revealed that over 45% of trainees regularly worked over their contracted hours, and almost 40% reported excessive workloads.¹⁴ These pressures have been shown to negatively impact patient care and clinician wellbeing, and are only set to increase as the NHS attempts to deal with the growing backlog of work (such as elective surgeries) caused by the pandemic.^15,16 There may, therefore, be a role for CAs within the NHS even as COVID-19 cases start to fall. The ability of CAs to reduce clinician workload may be why they were regarded as valuable colleagues by almost all clinicians. CAs, in turn, felt significantly more integrated into the clinical team when they worked at NGH, compared with when they were medical students on placement. This is consistent with other studies, in which medical students reported feeling like anonymous bystanders during their clinical placements, while students completing their final-year assistantships reported feeling both professionally and socially accepted by colleagues.^11,17 Teamwork is a cornerstone of the NHS, linked to improved patient outcomes, productivity and mental wellbeing of healthcare professionals, as well as being a GMC requirement for medical students.^18,19 Hence, integration into clinical teams should be a key aspect of medical education and, unlike traditional medical school placements, the CA role has shown to be an effective way to do this.

As well as helping clinicians, CAs were also perceived to benefit patients by providing continuity of care. Like many trusts, junior doctors at NGH were redeployed to COVID-19 rotas during the pandemic, sometimes covering different wards on a daily basis.^20,21 In contrast, CAs tended to work on the same wards. Continuity of care has been linked to improved clinician–patient relationships, more efficient management of patients and reduced mortality rates, again demonstrating the multiple beneficiaries of this programme.²²

The concept of students spending additional hours on the wards (either as part of their placement or as a job outside of medical school hours) may lead to questions about time for academic study. Although 93% of the medical student CAs were able to balance at least one academic commitment during their time at NGH, the possibility that CAs were studying for fewer hours per week than they would at medical school cannot be excluded. However, the vast majority of clinicians were able to provide informal teaching to CAs on a regular basis, and almost 80% of CAs felt as though their assistantship made up for lost time at medical school, suggesting that this programme did provide some opportunity for CAs to learn. Moreover, 52% of medical students already manage studies alongside a part-time job in order to finance their degree, so allowing this job to complement their studies could help to promote equality among medical students and encourage widened participation within medicine.²³ Introducing a new paid role within the NHS would, of course, require funding, and whether this would come from medical schools or NHS trusts needs to be addressed.

The most important area for improvement was CA access to support. The pandemic brought added stressors to doctors, and had a significant effect on their mental health.²⁴ CAs were not exempt from this: 24% self-isolated with COVID-19 symptoms, 35% witnessed traumatic events and some worked up to 50 hours per week. Although CAs felt able to access support from colleagues, a third were unaware of how to access the hospital's support service. Even without the pressures of COVID-19, the poor mental health of doctors and medical students is well known.²⁵ Therefore, for a workforce that was potentially naive to the mental impact of working in the NHS, let alone during a pandemic, access to support was essential. Future CA programmes should provide an easily accessible, well-advertised support service, with a cap on the number of hours a CA can work. Another aspect for improvement was formal teaching. Although a high proportion of CAs were able to attend at some point during their time at NGH, few attended regularly. Perhaps this was due to the fact that only 60% found the teaching consistently useful, or perhaps they felt unable to leave their ward duties. This could be improved by providing protected teaching time for CAs, and by allowing them to request certain teaching topics.

Our study's limitations include our small sample size, limited to one district general hospital, the potential for recall bias (as some CAs were no longer working at NGH at time of data collection), the use of self-assessed confidence instead of objective competence to measure practical and administered competence, and that not all respondents answered all the questions. However, our accessible questionnaires resulted in a high CA response rate. Our clinician data collection, despite being small, consisted of clinicians at every medical grade who had worked alongside CAs and represented our target population. Additionally, supplementing the CA data with input from clinicians allowed us to more reliably assess the improvement in CAs’ skills levels.