the nurses' aide: past and future necessity

Journal of Advanced Nursing, 1997, 26, 237–245

The nurses’ aide: past and future necessity

Margaret Edwards BAHons MSc PGCE RGN RM RHV DNCert

Lecturer in Nursing, Department of Nursing Studies, King’s College London, CornwallHouse Annexe, Waterloo Road, London SE1 8WA, England

Accepted for publication 17 July 1996

EDWARDS M. (1997) Journal of Advanced Nursing 26, 237–245The nurses’ aide: past and future necessityPopular images of nursing, largely based on Victorian ideals, have tended toignore the role played by the unqualified nurse. Yet nurses’ aides have beendescribed as providing the backbone of health services and in many clinicalareas have traditionally performed the greater part of basic nursing care.Demographic pressures, including increased numbers of elderly people withhealth care needs and the reduction in the number of school leavers enteringnursing, together with reforms in nurse education, will mean that the demandfor nurses is likely to continue to outstrip supply. The nurses’ aide is likely toremain indispensible to nursing provision in the United Kingdom. Despite thecontribution of unqualified nurses, little attention has been paid historically totheir training needs. Studies have attempted to compare the e�ectiveness ofqualified sta� with that of nurses’ aides, even though the latter have receivedlittle or no training. The validity of such approaches is questionnable since‘unqualified’ and ‘untrained’ have been accepted as synonymous by the nursingprofession. Other studies which have looked at the caring abilities ofunqualified sta� suggest that despite their lack of training they have thepotential to deliver therapeutic care as long as trained nurses provideappropriate role models within a therapeutic unit philosophy. The value of thequalified nurse may in fact involve the organization of care rather than hands oncare alone.

Keywords: nurses’ aides, qualified nurses, e�ectiveness, therapeutic care

the desired type of nurse for the future have led to ‘a tend-INHERITED IMAGES OF NURSING

ency to indulge in fantasies about who had been nurses inthe past’. These fantasies ignored the contribution of theThe Briggs Report (DHSS 1972) contended that inherited

images of nursing, largely handed down from the nine- ‘handywoman’ class.More recently, regarding nurses’ aides, arguably theteenth century, influence not only the public, but nurses

themselves and that these images may be at variance with descendants of the handywomen, commentators haveacknowledged the view that ‘rather like sex and death,reality. One of the most powerful images is that of the lady

with the lamp at the bedside. However, it is an image that nursing assistants are essential, but that does not makethem suitable topics for polite conversation’ (Dickson &ignores the fact that for the nineteenth and well into the

twentieth century most paid caring was carried out by Cole 1987 p. 24). In contrast, this paper attempts to exam-ine the historical and present day need for the nurses’ aideuntrained ‘handywomen’ (Dingwall et al. 1988). Even

today in certain clinical areas nurses’ aides form a substan- in the light of increasing demands for health care from anageing population with unprecedented levels of chronictial part of the workforce (Thomas 1993, O�ce for National

Statistics, personal communication). Abel-Smith (1960 illness. This need is also set against the backdrop ofa diminishing pool of candidates available for nursep. 149) has suggested that professional aspirations as to

237© 1997 Blackwell Science Ltd

M. Edwards

education and training (Townsend 1989, DHSS 1987), the were not discrete activities but that in a lifetime an indi-vidual might occupy any of the first three categoriesremoval of learners as part of the nursing workforce (UKCC

1986) and a climate of explicit rather than implicit ration- depending on changing personal circumstances.Handywomen belonged to the working class and alsoing (Wells 1995). The question is asked whether the true

expertise and utility of the trained nurse involves the included those pauper nurses from the workhouse whowere on occasion permitted to nurse poor people receivingorganization of care rather than hands on delivery alone.

The historical argument presented draws heavily on the outdoor relief (Dingwall et al. 1988). The portrayal of thehandywoman in literature is typified by the unwholesomeworks of Brian Abel-Smith (1960) and Robert Dingwall

et al. (1988). Dickensian character Sarah Gamp. Abel-Smith (1960)cautioned that reformers are likely to embellish their caseand that there is evidence from the Lancet Sanitary

NomenclatureCommission (The Lancet 1866) that care given by paupernurses was not uniformly bad. Regarding care by untrainedNurses’ aides have been employed in the United Kingdom

as an integral part of the nursing care team since the incep- attendants in the lunatic asylums, Nolan (1993) describedexemplary care given to the terminally ill in the Colneytion of the National Health Service (DHSS 1987). They

have been given a variety of titles, including: nursing Hatch asylum in 1859.The private nurse was also of the servant class. Whenauxiliaries, nursing assistants, ward orderlies, ward clerks,

bath attendants and family aides. The range of titles demands for better nursing arose from advances in medicalcare, the experiences of the Crimean War and philan-reflects the diversity of roles undertaken. Tasks have varied

from domestic and clerical support only to the provision thropic and religious movements, the training schools thatwere established in the voluntary hospitals, such as atof direct nursing care (DHSS 1987). The Briggs Committee

(DHSS 1972) proposed the use of the term nursing aide to St Thomas Hospital, London, retained all the features ofthe Victorian household. Indeed, in the Nightingaledescribe nursing auxiliaries who worked within the gen-

eral sector and nursing assistants employed within mental scheme probationer nurses did not wash and feed patients.These basic care tasks were carried out by ‘under nurses’health nursing. More recently, the title of health care

assistant has been proposed (DHSS 1987, UKCC 1986). The who also carried out manual household duties such asscrubbing the floors. Abel-Smith (1960) suggested that theomission of the adjective ‘nursing’ from this new title

could arguably be seen to represent the nursing pro- Nightingale School was in practice more important as atraining school for matrons than as a training school forfession’s unwillingness to acknowledge the historical,

present day and potential future contribution of the nurses.In the community the early district nursing schemes inunqualified nurse to direct patient care.

Liverpool depended heavily on supervision of the ‘nurses’by lady superintendants. This division of labour is also

THE HISTORICAL PERSPECTIVEevident in the early health visiting schemes as ‘missionwomen’ recruited from the handywoman class were notCliches concerning the role of history as a provider of guid-

ing theory for present day action are legion (Santayana trusted to work on their own. They were again supervizedby a lady volunteer (Dingwall et al. 1988).1922, Foucault 1977). It is nonetheless true that history

o�ers interesting insights into the past roles of trained anduntrained nurses which are highly relevant to many of the

Mythology of nursingdebates within nursing today, particularly those relatingto skill mix and the extended role of the nurse (Hunt & It was, seemingly, the organizational and supervisory skills

of Florence Nightingale and her companions that had beenWainwright 1994). To revisit the past and discuss the evol-ution of the trained and untrained nurse, particularly most useful in the Crimea in the face of military incom-

petence. The image of the lady with the lamp at the bedsidein the context of inherited nineteenth century images,therefore seems worthwhile. at Scutari forms part of the mythology of nursing. Some

contend that the majority of nursing care during theCrimean War was given as it always had been by the ward

The advent of the trained nurseorderlies and wives of soldiers (Dingwall et al. 1988). Thehistory of nursing in the Crimea has largely ignored theIn pre-industrial England most nursing care appears to

have been given by other members of a sick person’s house- role played by Mrs Mary Seacole, the Creole nurse, whosecontribution, in the eyes of certain commentators, equalledhold, which was likely to mean the servants (Dingwall

et al. 1988). These authors identified three other broad that of Florence Nightingale (Alexander & Dewjee 1984).However as Abel-Smith (1960 p. 20) related, ‘in the eyescategories of providers of nursing care: two types of paid

helper (the handywomen and the private nurse) and treat- of the British people Florence Nightingale, an upper classwoman, had saved the British army and this was a firstment assistants who were men. They pointed out that these

238 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 237–245

The nurses’ aide

step towards making nursing respectable and… if it could (VADs) sharpened the argument within the profession fora register so that nursing could retain its aspirations as abe made respectable it could provide an outlet for the

social conscience and frustrated energies of the Victorian suitable career for educated women. The e�ects of regis-tration were in fact to concentrate trained nursing in thespinster’.

Advances in medicine required careful bedside obser- voluntary hospitals and on the district (Abel-Smith 1960).Unqualified nurses continued to plug the gap, sta�ng thevations and were an important influence in the growth of

professional nursing. However, the advent of the trained mushrooming number of nursing homes and, as AbelSmith (1960) acknowledged, whilst the care of the acutelynurse could also be seen to result from two other distinct

trends; that of the humanistic desire to improve the lot of sick was undoubtedly improved, the fate of the chronicsick may have been made worse. The dependence onthe sick and in particular the poor sick, coupled with the

need for a suitable profession for middle-class women. An untrained nursing labour has certainly been an enduringfeature of care of elderly people (Davies 1992). Studies ofapparent tension between these two aspirations contrib-

uted to ensuring the survival and exponential growth of nursing activity in units providing care for this group ofpatients persistently reveal that the majority of direct carethe paid untrained nurse.is provided by nursing auxiliaries (Adams & Mcillwraith1963, Wells 1980, Phillips 1988).

The move for registration and the untrained nurse

With training schools established in many of the voluntaryThe division of labour in health care

hospitals and provision made for training in selected poorlaw asylums under the Metropolitan Poor Act 1867 (sec- It was in the voluntary hospitals that the need for the more

educated type of nurse was most keenly felt. Medicaltion 29), the disappearance of the handywomen andpauper nurses might have been the expected consequence. advances made the need for careful observation vital.

Experienced and skilled nursing made delegation andTheir continued survival can be explained by two phen-omena: the first being the enduring fact that the demand consequent medical consultant status possible

(Gamarnikow 1991). It has been pointed out (Dingwallfor nursing care outstripped and continued to outstripsupply (Abel-Smith 1960). Although the Athlone et al. 1988 p. 164) ‘that one of the fundamental processes

of the division of labour in health care is the making ofCommittee (Ministry of Health 1939), whose brief it hadbeen to investigate the recruitment and retention of nurs- innovations by doctors which once routinized are then

delegated to nurses or other paramedical sta�’.ing sta�, was disbanded at the outbreak of the SecondWorld War, figures provided in the interim report illustrate Resistance to this process, very much evident today in

the debate over the extended role of the nurse and substi-the di�culties many hospitals were experiencingrecruiting not only trained but also untrained sta� (Abel- tutions of role (Hunt & Wainwright 1994), does not take

into account the historical fact that nursing tasks such asSmith 1960). Secondly, whilst the lady probationers wereunlikely to seek employment in the Poor Law institutions, dressing wounds and urine testing were in the Victorian

hospital the exclusive domain of the physician or phys-even those recruits to the Poor Law asylum trainingschools were keen to seek their fortunes elsewhere (Abel- ician’s assistant. These tasks are now so much part of nurs-

ing routine that they are jealously guarded, as they onceSmith 1960), particularly engaging in private work caringfor the rich sick. were by medical sta� (Gamarnikow 1991), and often

auxiliary sta� cannot be trusted to perform them (RyeThe Poor Law institutions catered for the chronicallysick and incurable, whilst nursing in the voluntary hospi- 1978, Mersey RHA 1989). Yet according to Dingwall et al.

(1988) divisions of labour are not static but rather liketals provided more opportunity for the exercise of skills.A cachet of respectability was attached to working within cities take on new forms to adapt to changing social press-

ures. In the past physiotherapy constituted just such aa voluntary hospital and the argument could therefore beupheld that nursing was a suitable profession for middle development and it may be that in the nursing support

worker a new division of labour is evolving in response toclass women. The same argument could not be made fornursing the chronic sick within the poor law institutions, social pressures.where matrons were few and far between and nurseswould have been in the employ of workhouse masters who

THE PRESENT DAY PERSPECTIVEwere their social inferiors. Nevertheless, the workhouseinfirmaries had to be sta�ed and this was achieved by There are persuasive arguments on both sides concerning

the development of ancillary sta�, including the nurses’employing ever larger numbers of untrained nurses (Abel-Smith 1960). aide in nursing (Hockey 1978, Hardie 1978, Thomas 1992,

McKenna 1995). Eloquent arguments have been putThe numbers of untrained sta� in all areas of nursingincreased particularly during the First World War. The forward for having a qualified only workforce by those

whom Thomas (1992) has described as professionalizers orinflux of women from the Voluntary Aid Detachment

239© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 237–245

M. Edwards

proselytizers. On the other side of the divide, demographic responsibilities. Even if su�cient numbers of potentialcandidates were to be available it is not every person whoand economic considerations constitute a pressing case in

favour of the nurses’ aide. Commentators have noted that is equipped psychologically and emotionally to be a nurse(Abel Smith 1960), a point illustrated by the historicallyin the course of history demographic and economic argu-

ments have always prevailed against the aspirations of the high level of attrition from nurse training (AthloneCommittee, Ministry of Health 1939).profession (Dingwall et al. 1988). With the wage bill for

nursing having always represented a considerable pro- This ongoing problem with recruitment and retention innursing exists against the backdrop of an increase in theportion of NHS expenditure (Hockey 1978) it is unlikely

that the profession’s call for an all qualified and preferably numbers of the old elderly people (Central StatisticalO�ce 1996). Some hold optimistic views about the healthall graduate work force (Day 1994) will be heeded, particu-

larly in today’s world when cost containment of health status of this population, believing that improved stan-dards in living will contribute to a compression of mor-care is a national and international goal (International

Council of Nurses 1993). Hockey (1978) argued in the bidity, i.e. disabling illness will feature only for a shortperiod prior to death (Fries 1980, 1996). There is, however,1970s that any public service which is not self-limiting

must find ways to control expenditure and that nursing is an opposing view which sees this generation as rep-resenting the failures of medical success (Moody 1995),an economic activity. This fact has been overlooked by

some historians in their obsession with professionalism. i.e. elderly people in whom death has been postponed bymedical advances but who consequently live for long per-iods with high levels of chronic disease, reduced quality

The demographic positionof life and increasing demands on health and social ser-vices, with some evidence existing for this latter viewIt has already been noted that the greater part of the twenti-

eth century has been marked by the demand for nursing (Bowling et al. 1993).care exceeding supply. Nurse shortages are again on theagenda, with reports of Trusts having to provide material

Meeting the needs of those with chronic illnessenticements to recruit sta� (Leifer 1996). Di�culties inrecruitment vary but a shortfall of 12–14% has been found Indeed the highest admission rates from heart failure in a

London hospital are amongst those 75 years of age andin some areas (Boulton 1996). Without ‘an independent,robust systematic and independent review of nurse sta�ng over and are most marked in the over-85s (Majeed 1993).

North American studies suggest that as many as one-levels’ (Seccombe 1996 p. 25), it is di�cult to disentanglewhat has been reported as ‘a little local di�culty’ in third of recurrent hospitalizations could be prevented

(Hawthorne & Hickson 1993). Studies do not distinguishrecruitment from any wider trend.In the past responses to the problem were not those most between progression of the disease and lack of compliance

but Hawthorne and Hickson (1993) have suggested thatpalatable to the profession, i.e. the creation of a secondlevel nurse in 1943 (Abel-Smith 1960) and the reduction inadequate symptom management may be the precipitat-

ing factor in many hospitalizations. Symptoms includein the educational entry requirements. It is estimated that50% of the 18-year-old population with five GCSE grade weight gain, oedema, dyspnoea (Masiello Millar 1994).

Close monitoring of both the signs and symptoms of con-Cs or above or with 2 A levels will need to be recruited inorder to meet the requirements of the NHS to ensure a gestive heart failure is held to be essential to long-term

follow-up once the diagnosis of congestive heart failure issu�cient supply of qualified health-care practitioners(Townsend 1989). The traditional recruitment pattern to established (Masiello Millar 1994). In the UK, with increas-

ing numbers of ‘old’ elderly people living on their ownnursing, together with known demographic trends, isalready producing a shortfall of entrants to nursing which (Central Statistical O�ce 1996), the question of who will

be monitoring for acute-on-chronic exacerbations ofwill continue well into the next century (DHSS 1987,Waite 1989). Price Waterhouse, on behalf of the UKCC, diseases such as congestive heart failure or chronic

obstructive airways disease needs to be explored.have estimated that the cumulative shortfall of entrants bythe year 2004 will be in the region of 10 000 (UKCC 1987). The Value for Money Unit study of district nursing skill

mix (NHSME 1992), although criticized for its task-An increasingly competitive employment market anddoubts as to the desirability of the NHS as an employer oriented approach (Cowley 1993), does provide infor-

mation on the nature and frequency of diagnostic taskshave also been cited as possible reasons for this trend(Townsend 1989). It will be di�cult for nursing to compete such as weighing and blood pressure monitoring based on

a total of 5721 visits by all grades of district nursing sta�with other employers, e.g. financial institutions in the pri-vate sector, who have already been providing child-care across three Community Trusts. Blood pressure measure-

ment took place on 0·07% occasions and weighing 0·01%.facilities at the workplace (Waite 1989) without a radicalchange in recruitment and retention policies which None of these tasks were undertaken by auxiliary sta�.

If the results of the Value for Money study in terms ofmake it easier for women to combine family and career


The nurses’ aide

monitoring of patient condition can be generalized it education of ‘nursing aides’ to be a matter of considerableurgency. The Committee commented on the fragmentaryseems unlikely that the monitoring needs of an increasing

chronically sick population can be met within existing nature of education for unqualified sta� and the lack ofany general regulation of provision for training. The surveyresources or methods of working. Pearson and Wistow

(1995) have noted that long-term care has historically been carried out for the Committee on Nursing found that inover 50% of hospitals no training at all, induction or laterassociated with inappropriate institutional arrangements

and inadequate provision in the community. instruction was o�ered to nursing aides. Half the auxiliar-ies in their representative sample agreed that they hadThere is evidence in the literature, and particularly in

the literature concerned with lay carers (Nolan & Grant received no training at all. The Committee’s recommen-dations for in-service training seem to have been largely1989, Pearson & Wistow 1995), that the district nursing

service has never adequately succeeded in meeting the ignored.Other surveys of training provision for untrained sta�needs of all the old and sick in the community (Skeet &

Crout 1977, Heslop & Bagnell 1988). In their survey of 250 consistently demonstrate a lack of training for unqualifiedsta� (Hardie 1978, Thomas 1992). Hardie (1978), in apatients Skeet & Crout (1977) found that 22% of long-stay

patients and 15% of short-stay patients needed help with national study of auxiliary usage (response rate 88·6% ofall districts), found that 70% of districts o�ered orientationbasic care such as washing and dressing when they

reached home and were not receiving it. Carers of old days and/or in-service training. Hardie found, however,that the time devoted to training was only partially quanti-people who were sick needed information on pressure area

care, the management of constipation and incontinence fiable. In approximately one-third of the 30 pilot inter-views carried out with auxiliaries it was revealed that evenand how to change a soiled drawsheet. Skeet (1978) con-

cluded that the members of the primary health care team, though the hospitals concerned did o�er some instructionon a formal basis, the individual interviewed had notas it was then composed, could not give the help as often

as it was required and that what was needed was indeed received the training for one reason or another. In only31% of the districts was the instruction o�ered under theskill mix which included teaching preparation for an

auxiliary, providing support for the nurse responsible for auspices of the nurse education system.More recently Thomas (1992) in her thesis comparingoverall care. Heslop and Bagnell (1988) in their inter-

vention study of patients with disabling chest disease (n= the work of qualified nurses and nursing auxiliaries inprimary, team and functional nursing wards, found that75) found that most of the elderly and disabled partici-

pants were not being visited by a district nurse or health her sample of auxiliaries su�ered from the same lack oftraining. In a study examining the role of the supportvisitor.worker in the health care team Robinson et al. (1989)described how, despite considerable length of employ-

Skill mixment, systematic attention to training had not apparentlybeen paid to any of the traditional support worker roles.The Audit Commission (1992) found enormous variation

in the numbers of qualified and unqualified sta� compris- While and Barribal (1994) had similar findings. Carr-Hillet al. (1992) in their study of nursing skill mix found that,ing district nursing teams across the country. Other

researchers have commented that the establishment of apart from wards on which primary nursing was practised,sta� generally received very little training and unqualifiedcommunity nurses has been based on historical factors

rather than on any rational assessment of population need sta� had enjoyed the least amount. This lack of traininghas implications for the quality of care given to patients(Coomber et al. 1992). Whilst it is important to keep in

mind the distinction between grade mix and skill mix, the but also raises doubts about the validity of those skill mixstudies that attempt to compare the quality and e�ective-latter being concerned with needs, skills and outcomes,

(Cowley 1993), some commentators have assumed that a ness of qualified versus unqualified nurses, a point whichwill be re-visited later.particular grade brings with it particular knowledge and

skill so that one might reasonably infer the other (Carr-Hill et al. 1992). That Carr-Hill et al. (1992) were able to

Qualified versus unqualified sta�attribute skills to grades is a likely reflection of the natureof nurse education and in particular the training or lack Leaders of the nursing profession point to studies emanat-

ing from the USA, and in this country the Carr-Hill et al.of it of unqualified sta�.study (1992), to demonstrate that qualified sta� are bothcost-e�ective and cost-e�cient (Seymour 1992). McKenna

The training of unqualified sta�(1995), in a review of studies relating to skill mix, hasnoted that transatlantic studies are not easily translatable.The Briggs Committee on Nursing (DHSS 1972), recogniz-

ing the dependence of the nursing and midwifery system In testing out assumptions about skill mix, McKenna cameto the conclusion that a su�cient number of studies areupon nursing auxiliaries and assistants, believed the


M. Edwards

available which can be used to support the retention of a (Thomas 1992). It has been suggested that therapeutic careoccurs when nurses understand their primary caring func-large number of qualified nurses although few demonstrate

the necessary rigour for lobbying purposes. The problem, tion and have a positive approach to patients’ health(Kitson 1991).however, with studies such as the much quoted Carr-Hill

et al. study (1992) is that the researchers make compari- Thomas (1992) compared the contribution to patientcare of nursing auxiliaries with that of qualified nursessons between nurses who have undergone formal edu-

cation and training and sta� for whom training is likely to using a qualitative indicator, nurse–patient interaction.Di�erent grades of nursing sta� were also compared inhave been sparse if not non-existent. A more valid

approach would be to compare qualified (trained sta� ) terms of activities performed and perceptions of their workenvironment. The study showed that nursing auxiliarieswith unqualified but trained sta�.

Further the Carr-Hill study is problematic on other are capable of providing therapeutic care for elderlypatients within a pattern of ward organization which facili-counts. The authors claim their convenience sample of

seven hospitals was representative. However, they selec- tates sustained nursing sta� allocation and appropriatesupervision and direction in the form of qualified nursested their subjects for observation purposively even though

randomization could have been used and indeed would working with nursing auxiliaries. Thomas found a greateramount of therapeutic communication regardless of sta�have been desirable since one of the instruments used

(Qualpacs, Wandelt & Stewart 1975) requires randomiz- grade in wards where primary care nursing was the organ-izational mode. Carr Hill et al. (1992) also found supportation of patients for observation. The researchers chose to

use high dependency patients in the hope of securing a for the benefits of primary nursing but questionnedwhether elements contained within particular organiz-high number of observations. In selecting these patients

the study was immediately likely to disadvantage ational modes also a�ected care delivery. In earlierresearch Kitson (1991) implicated the therapeuticuntrained sta� as many of the tasks under consideration

were not those traditionally undertaken by auxiliaries, e.g. approach of the ward sister as an important variable. Otherresearchers (Norman et al. 1994) were unable to fully repli-monitoring the rate of intravenous infusions and arranging

discharge. cate Kitson’s findings (1991), possibly because changes inthe organization of nursing work had superceded many ofthe issues addressed by Kitson’s original data collection

The e�ectiveness of the nurses’ aideinstrument. One of the organizational changes has beenthe spread of primary nursing.The less than e�ective performance of nurses’ aides (nurs-

ing auxiliaries) in studies such as that of Carr Hill et al.(1992) is therefore likely to reflect their lack of training.

Primary nursing and the nursing auxiliaryThere has been a long-standing tendency for nurses todefine their role by what they may do and what others Primary nursing has been defined as:may not do in terms of technical tasks (Hardie 1978), thus

a mode of nursing organisation at the unit level in which onerestricting the work undertaken by auxiliaries. The UKCC

registered nurse is designated as the primary nurse for a small(1992), in its document Standards for the Administration

number of patients upon their admission and for the duration ofof Medicines, is explicit in its disapproval of adminis-

their stay in that unit; the primary nurse takes responsibility fortration of medicines by any other than a qualified prac-

planning and evaluating all aspects of their nursing care.titioner for dependent patients, particularly in acute care

(Giovannetti 1981, cited by Thomas 1993 p. 45)settings, although it does concede that informal carers may

From the literature Thomas (1993) described two oppos-accept delegated authority, a responsibility not a�orded tothe nursing auxiliary. This ignores the fact that anyone ing viewpoints on the role and function of the nursing

auxiliary in primary nursing. According to the first, auxili-else outside institutions is free to give medications.Dingwall et al. (1988) have claimed that throughout the aries should not be involved in direct patient care but sup-

port qualified sta� in preparing equipment and performingoccupation’s history a professional segment has sought tosqueeze out the ‘handywoman class’ from the care of the domestic non-nursing duties (Pearson 1988, Macguire

1989, MacMahon 1989). Others such as Pembrey (1985)sick. There is a professional ideology which involvesclassifying work so that nursing care is only given by conceded that there is a role for the auxiliary in direct

care for the patient whose condition is stable, under thenurses with a statutory qualification (Thomas 1993).Exponents of this view consider that holistic care can only direction of the qualified nurse.

The professional has been described as a decision-makerbe delivered by qualified nurses who possess the necessaryeducation and skills to be ‘therapeutic’ (Pearson 1988, and the auxiliary as an implementer (Hockey 1978). In this

analysis, patient condition, in terms of stability and theMacMahon 1989). However, evidence exists to show thatdespite their general lack of training auxiliaries are able frequency of need for reassessment, would determine

input from di�erent grades of sta�. Thomas (1992)in certain circumstances to deliver therapeutic care


The nurses’ aide

suggested a ratio of one qualified sta� member to one therapeutic care for elderly people as long as qualifiednurses provide appropriate role models within a thera-auxiliary for the wards for elderly people in which her

study took place. Hockey (1978) described the need for peutic unit philosophy. Hawker and Stewart (1978) ident-ified the need for professionals to acknowledge that theirclinical areas to work out the level of sta�ng required by

delineating a danger zone which would signal the point skills lie in knowing what to do rather than doing it. Afterall, Florence Nightingale was herself an organizer of otherat which the level of responsibility for decision-making

was passing from qualified to unqualified sta�. peoples’ labour!Eighteen years ago, when learners still made up a large

part of the workforce, Hockey (1978) asserted that a fullyReferences

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the nurses' aide: past and future necessity

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