understanding the roles of registered general nurses and care assistants in uk nursing homes

NURSING AND HEALTH CARE MANAGEMENT ISSUES

Understanding the roles of registered general nurses and care

assistants in UK nursing homes

Michelle Perry MSc

Research Assistant, Centre for Health Services Studies, University of Kent, Canterbury, Kent, UK

Iain Carpenter MD FRCP

Associate Director and Reader in Health Care of Older People, Centre for Health Services Studies, University of Kent and East

Kent Hospitals NHS Trust, Canterbury; and Senior Lecturer, GKT School of Medicine and Dentistry, London, UK

David Challis PhD

Professor of Community Care Research, and Director, Personal Social Services Research Unit, University of Manchester,

Manchester, UK

and Kevin Hope PhD

Lecturer in Nursing, School of Nursing, Midwifery and Health Visiting, University of Manchester, Manchester, UK

Submitted for publication 15 May 2002

Accepted for publication 4 February 2003

Correspondence:

Michelle Perry,

Centre for Health Services Studies,

George Allen Wing,

University of Kent at Canterbury,

Canterbury,

Kent CT2 7NF,

UK.

E-mail: [email protected]

PERRY MPERRY M., CARPENTER ICARPENTER I., CHALLIS DCHALLIS D. && HOPE K. (2003)HOPE K. (2003) Journal of Advanced

Nursing 42(5), 497–505

Understanding the roles of registered general nurses and care assistants in UK

nursing homes

Background. The recent government decision to fund the costs of Registered nursing

time in long-term care facilities in England through the Registered Nurse Contribution

to Care renders the need to distinguish the role of Registered General Nurses (RGNs)

from that of Care Assistants (CAs) in nursing homes increasingly important.

Aim. The objective of this qualitative study was to obtain an in-depth understanding

of the main differences between the roles and functions of RGNs and CAs working in

nursing homes in the United Kingdom (UK).

Design. Data were collected through interviews with nine RGNs and 12 CAs

employed in four different nursing homes across England.

Findings. Our findings suggest that RGNs have difficulty defining and limiting their

roles because they have all-embracing roles, doing everything and anything within the

home. By contrast, CAs define their role in terms of what they are not allowed to do.

This difficulty in limiting their role, in addition to their sense of professional ac-

countability for residents’ care, leads RGNs to experience difficulty in delegating tasks

to CAs. Both RGNs and CAs agreed that an increase in the number of assistive staff is

needed to provide residents with good quality care and suggested that a measure of

resident dependency would be a good method by which to determine staffing levels.

Conclusions. We recommend that job descriptions that clearly define the roles and

responsibilities of both RGNs and CAs are developed so that caregivers at all levels

understand each others’ roles and work together to co-ordinate, plan and provide

residents’ care.

Keywords: nursing home, roles, Registered General Nurses, Care Assistants

� 2003 Blackwell Publishing Ltd 497

Background

The need to distinguish clearly the role of Registered General

Nurses (RGNs) from that of Care Assistants (CAs) in United

Kingdom (UK) nursing homes has become increasingly

important in light of the proposed changes to the long-term

care payment system in the UK. The Department of Health

CM 4818-II (2000) proposed that in the future the costs of

RGN time spent on providing, delegating or supervising care

in long-term care settings would be met by the publicly funded

National Health Service through the Registered Nursing

Contribution to Care (RNCC). However, this statement left

unanswered the question of how the RGN role could be

differentiated from the CA role, making the exercise of

quantifying and reimbursing RGNs for their time difficult.

Care Assistants have been widely employed in various

settings to help improve efficiency and reduce health care

costs. This reflects the view that personal care tasks, such as

bathing, dressing, and bedmaking could be more appropri-

ately allocated to care assistants, thereby increasing the time

available to nurses to perform tasks deemed to be in the

domain of Registered Nurses, such as assessment, drug

administration and wound care (Capuano & Kinneman

1989, Manthey 1989). In practice, however, there still

appears to be some overlap between the two roles, with

CAs performing tasks deemed to be the domain of the

Registered Nurse and RGNs continuing to engage in

activities considered to be the responsibility of CAs (Chang

& Twinn 1995, Thornley 2000).

Perhaps the reason for the overlap between the two roles is

the difficulty in defining the nursing role (Hunt 1990,

McKeown 1994). Much of this difficulty stems from the fact

that most studies have used workload sampling techniques to

measure how much time nurses spend doing specific tasks and

thus to understand the nature of nursing (Hendrickson et al.

1990, Bridel 1993, Fagerstrom & Rainio 1999, Flynn et al.

1999, Freeman et al. 1999, Leppa 1999, McGillis Hall &

O’Brien-Pallas 2000). While these studies reveal interesting

findings about how trained and nontrained nursing staff

spend their time, critics argue that these work sampling

techniques present an over-simplified view of nursing care

because much of what a nurse does cannot be observed and

therefore cannot be quantified (Endacott & Chellel 1996,

Hunt 1990, Procter 1992, Needham 1997, Hughes 1999).

Several studies have used qualitative methods of analysis to

understand better the essence of RGN and CA roles (Leppa

1999, Reeve 1994, Workman 1996, McLaughlin et al. 2000,

Schirm et al. 2000, Thornley 2000). While most of these

studies were based in hospital settings, they nonetheless

confirmed the ambiguity surrounding both roles and stressed

the need for clarification of what nursing work entails (Reeve

1994, Workman 1996, Thornley 2000). Only two studies

could be found that examined the roles of RGNs and CAs in

nursing homes (Leppa 1999, Schirm et al. 2000). While the

Leppa (1999) study revealed interesting findings about the

role of an RGN in a nursing home, it did not provide any

insight into the differences between RGN and CA roles. In a

similar vein, the study by Schirm et al. (2000) provided

insight into RGNs’ and CAs’ perceptions of caregiving in a

nursing home, but still left unanswered how the two roles

could be clearly delineated.

What is already known about this topic

• Ambiguity exists about the roles of RGNs and CAs in

UK nursing homes with CAs performing tasks deemed

to be the domain of the RGN and RGNs continuing to

engage in activities considered to be the responsibility of

CAs.

• To understand the nature of nursing most studies have

used workload sampling techniques to measure how

much time nurses spend doing specific tasks. This may,

however, present an over-simplified view of the nursing

role because much of what a nurse does cannot be

observed and therefore cannot be quantified.

• Studies that used qualitative techniques to examine the

roles of RGNs and CAs in nursing homes revealed in-

teresting findings about perceptions of care but still left

unanswered how the two roles could be clearly delin-

eated.

What this paper adds

• RGNs’ sense of professional accountability means that

they have difficulty defining and limiting their role and

in delegating tasks to CAs. Consequently they under-

take everything and anything within the home.

• By contrast, CAs typically define their role in terms of

what they are not allowed to do.

• Both RGNs and CAs agreed that an increase in the

number of assistive staff is needed to provide residents

with good quality care and suggested a measure of

resident dependency would be a good method by which

to determine staffing levels.

• The Resource Utilisation Groups Version III (RUG-III)

case mix classification system is a suggested method by

which to measure resident dependency levels and as a

result determine the Registered Nursing Contribution to

Care (RNCC).

M. Perry et al.

498 � 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 42(5), 497–505

The study

Aim

We undertook an exploratory qualitative study to obtain an

in-depth understanding of the main differences between the

roles and functions of RGNs and CAs working in nursing

homes in the UK.

Design

This study formed part of a larger quantitative project funded

by the Joseph Rowntree Foundation to develop a methodology

to determine the RNCC for residents admitted to nursing

homes (Carpenter & Perry 2002, Carpenter et al. 2002).

Qualitative methods were chosen for this component of the

study because we were seeking to understand better percep-

tions of the care assistant and nursing roles from the perspec-

tive of the participants themselves (Morse & Field 1996).

Sample

The study was conducted in four nursing homes in England:

two ‘chain’ nursing homes in the north of England and two

other not-for-profit homes, one in the north and one in the

south-west. These homes had a total of 200 residents. Given the

aim of the study, a purposive sample was chosen to ensure

that participants could appropriately provide useful insight

into the topic (Morse & Field 1996). Participants were

recruited through contacts with the nursing home managers,

who placed an information sheet on a notice board in each

home asking for volunteers to participate in the interviews. To

maximize participation the nursing homes were reimbursed for

an extra member of staff to be present on the day of

interviewing to cover the duties of the staff participating in

the interviews.

Four of the nine RGNs were sisters and held administrative

positions in addition to their direct caregiving responsibilit-

ies. Of the 12 CAs, two held senior positions and were

trained to National Vocation Qualification (NVQ) level 3,

two had level two NVQ training, and the remaining eight

were trained according to the policies of the nursing home.

The NVQ award in Care is used throughout Great Britain as

the standard qualification for working with adults who

require care.

Data collection

Data were collected through semi-structured interviews with

nine RGNs and 12 CAs from the four homes. Individual

interviews were held in a private meeting room in each

nursing home, making it convenient for participants to

attend. Given the potentially hierarchical working relation-

ship of RGNs and CAs, conducting the interviews separately

in a private meeting room helped to ensure that participants

had a neutral, nonthreatening environment in which to

express their views (Denscombe 1998).

The interview schedule was developed after a review of the

nursing literature describing the role of RGNs and CAs.

Nursing researchers were also consulted throughout the

development of the interview schedule and revisions were

made accordingly (Morse & Field 1996). The interview

questions were designed to encourage participants to describe

their role in the nursing home both independently and in

relation to the other’s role (see Appendix).

All the interviews were conducted by one of the authors

(MP). Discussions were tape-recorded and transcribed by the

interviewer so that verbatim quotes could be analysed

thereby enhancing the trustworthiness of the data (Kvale

1996, Morse & Field 1996, Denscombe 1998). The inter-

views lasted from 30 to 90 minutes, the longest interviews

were with senior RGNs, due in part to their administrative

role.

Ethical considerations

Ethics approval for the project was received from the local

ethics committee representative of the ‘chain’ nursing

homes and the participating nursing home managers. All

participants consented to participate and to be tape-

recorded, and were identified according to a code to ensure

confidentiality.

Data analysis

As the study was exploratory and descriptive in nature, the

analysis was primarily guided by the interview questions

rather than by a specific theoretical paradigm (Morse & Field

1996, Polit & Hungler 1999), and thus content analysis was

the method used (Morse & Field 1996). The transcripts and

tapes were reviewed repeatedly by looking for patterns of

consistency and variability in the content of the text until

broad categories emerged (Morse & Field 1996). Manual

methods of data analysis were employed, including colour

coding of categories and cutting out relevant quotes and filing

them under specific categories (Morse & Field 1996). As

analysis continued the views expressed by the RGNs and CAs

became repetitive, with no new information being presented,

and thus saturation of the categories was attained (Morse &

Field 1996).

Nursing and health care management issues Role of caregivers in nursing homes

� 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 42(5), 497–505 499

Contextual factors limited the data collection period,

making it difficult to do member checking. However, the

preliminary analysis of the interviews was reported to a

consultancy panel of individuals interested in the nursing

home sector. Feedback provided by this panel was incorpo-

rated into subsequent analysis and the final report was

modified accordingly and received acceptance by the panel,

thereby increasing trustworthiness of the data (Polit &

Hungler 1999).

Findings

The following is a list of the categories that emerged from the

analysis of the interviews:

• RGNs do anything and everything

• Knowledge, training and experience

• Allocation of care activities to CAs:

– Policies and procedures

– National vocational qualifications

– Sense of accountability

• Staffing levels – enough RGNs but more CAs needed.

RGNs do anything and everything

The RGNs interviewed felt as although they had many

different roles and would act as Administrator, Manager,

Supervisor, Nurse and carer during the course of a single

shift. As managers and supervisors they allocated work to

CAs at the beginning of each shift and felt responsible for the

smooth running of the unit during that shift. If CAs then

needed their help an RGN would also act as a carer,

providing personal care to residents.

As trained nurses, RGNs felt that anything ‘medical’ was

solely their responsibility. CAs also used the term ‘medical’ to

define those areas of care that were the role of the RGN.

Unlike RGNs, who hesitated when trying to define their role,

CAs were quick to list aspects of care that were strictly

outside their domain of responsibility. As one CA said,

‘Anything to do with the medical side (like) dressings,

enemas, catheters, pressure sores, medications (and) blood

pressures we get the trained staff’. In fact, all CAs interviewed

commented that when they noticed a change in a resident, no

matter how slight, they would notify the nurse in charge

immediately. Another CA said, ‘Even if we know what’s

wrong with them, we call the trained staff and just stay with

them and comfort them until someone comes’.

All RGNs interviewed seemed to have difficulty identifying

areas of care that were outside their domain of responsibility.

One said, ‘We can and do anything and everything. If it needs

to be done, we just get on and do it. Including hovering’.

Most CAs also had difficulty thinking of areas that were

solely their responsibility. As one said, ‘Nothing really,

because RGNs help when we need it’. The only area of care

that CAs could claim as their own was escorting residents to

appointments and hospitals because an RGN must be present

on the unit at all times. This appeared to be a definition of

spheres of responsibility by administrative default, rather

than an effective role function.

Knowledge, training and experience

RGNs’ knowledge, training and experience also appeared to

factors in differentiating the RGN role from that of the CA.

As one RGN said, ‘I think you’re monitoring and assessing all

the time. This is the area where your knowledge comes in’.

Several of RGNs stressed this difference between their role

and that of CAs. One said, ‘They (CAs) just head straight to

the lounge (when they arrive for their shift, the RGNs) look

at every resident…we’re monitoring all the time’. The RGN

further suggested that, although they felt the CAs they

worked with were competent and knew the residents well,

they lacked the training and skills to pick up on subtle

changes. For example, one RGN described a situation with a

resident with diabetes:

…if she ate very little for breakfast no one else would notice it –

only I would notice it…they (CAs) wouldn’t think about the effect

of her not eating on maintaining blood sugar. They wouldn’t pick

up on it.

The CAs seemed to recognize their limits and acknowledged

and respected the years of training and experience of RGNs.

In a discussion about what a CA would do if they found a

resident who had recently had a fall, a CA said, ‘That’s it –

you can’t (do anything) because there’s always trained staff

around – you know they’re superior because of they’re

qualifications and knowledge than anyone else.

Allocation of care activities to CAs

The ambiguity in role expectations increased the difficulty of

delegation of tasks to CAs and so in press was also explored

in the interviews. From the comments of both RGNs and

CAs, there appeared to be three factors that dictated when a

nursing task might be handed to a CA, namely policies and

procedures, the level of NVQ training of the CA, and the

RGN’s sense of accountability.

Policies and procedures

When asked if their home had policies and procedures that

defined what activities CAs could and could not do, most

M. Perry et al.


RGNs and CAs both responded quickly with, ‘Oh, yes’.

Comments made by all participants seemed to demonstrate

that these policies and procedures took priority when deci-

ding what activities could be allocated to CAs. For example,

when asked if there were activities that were ambiguous with

regard to whether a RGN or a CA would perform them, one

CA said, ‘Like what? There isn’t anything! There are clear-cut

rules’. When asked the same question an RGN said, ‘There

are some strict boundaries where they are just not allowed to

do it at all. It’s mainly to do with medications, controlled

drug injections, insulin, administrative care plans, all those

sorts of things’. CAs seemed to like having policies and

procedures in place: one said, ‘You know where you stand.

There are no grey areas’. RGNs were divided on this issue,

with some agreeing that policies and procedures were good

because ‘there’s no grey area’, while others seemed to feel

that the sheer volume of policies and procedures prevented

them from ‘know(ing) what they can and can’t do within the

company’.

National vocational qualifications

The CAs level of NVQ training was another factor involved

in determining whether or not a RGN would delegate a

nursing task. One RGN said, ‘Only if they’ve had proper

training for the job, that they’ve been assessed as being

competent for the job and that they feel competent for

the job’. Not all RGNs appeared comfortable with

allocating certain elements of care to CAs with NVQ

training, however. One CA said, ‘Some trained nurses

don’t like NVQ3. So I never do it unless I ask them first.

Because I know there’s a grey area’. Comments from an

RGN echo this:

Senior CAs can re-dress (a wound or ulcer) and this is a very personal

thing, that if they do a dressing I always like to see it because when

I’m handing over – so I can say I have done this dressing and it looks

like this and it may be improving, not improving – whatever. Just so

that I have seen it. I wonder if that’s part of our training – part of the

nursing bit. I just need to see it because that is what I’m here for. I see

that as part of my role.

Sense of accountability

Although both RGNs and CAs felt a sense of accountability

for the care they provided, they seemed to experience it in

different ways. Most of the CAs felt that the RGN in charge

had ultimate legal and ethical responsibility for residents,

whereas they felt responsible themselves more narrowly for

their job performance. One said, ‘I mean we have a respon-

sibility for residents – it may not be legal, but we have a

responsibility in the sense of…from a job point of view as in

we’ve got stuff to do for the residents and it’s our responsi-

bility to ensure it gets done’. Most of the RGNs, on the other

hand, seemed to feel responsible to the UKCC (United

Kingdom Central Council for Nursing, Midwifery and

Health Visiting – now the Nursing and Midwifery Council) in

a professional sense. This sense of ultimate accountability for

the residents in their care seemed to be a factor in determining

who provided a particular aspect of care, as this response

from an RGN illustrates:

Well, we debate this sometimes, don’t we? I, as an RGN, am

accountable for the residents when I am the RGN on duty. The

Matron is the registered person for the nursing home, so she is

accountable. But I am accountable to the UKCC for me and my

practice.

Staffing levels – enough RGNs but more CAs needed

In addition to understanding better the roles RGNs and CAs

play in nursing homes, we were also interested in learning

about their perceptions of the current staffing levels in their

homes, particularly in the context of the proposed RNCC

funding system. Curiously, most of those interviewed felt that

they had enough RGNs but needed more CAs or that staffing

levels were fine ‘under normal circumstances’. The main

reason cited for needing more CAs was that dependency

levels had risen in recent years. As one RGN said:

We’re working on staffing levels from 1992 to and I worked here in

1992 and there’s a big difference now, because a lot of them used to

be on long-stay for the elderly wards – so they have high dependency.

I can honestly say that around 3 or 4 o’clock in the afternoon I can

guarantee that if I haven’t got all my paperwork done and up-to-date,

then I’ll be staying late because after 4 o’clock I just consider myself

to be a carer.

The CAs commented on not having time to provide

adequately for the emotional side of the residents’ care. As

one said, ‘We don’t have time to look after the social side or

their emotional care. We’re just doing our basic personal

care. We need more CAs to give the whole package of care

not just personal care’. RGNs expressed concern that CAs

were overworked and overwhelmed because they did not

have the appropriate number of staff.

When asked which method would be best for determining

future staffing levels, both RGNs and CAs agreed that staff

numbers should be based on the dependency levels of

residents. One CA said:

I don’t think we have enough CAs. I think their policy is one carer to

five (residents). But I think they need to look at the resident as what



their state or what their ability or what their situation is. I think we

should look at what each individual resident is and what they are and

what care they need, and let that determine the numbers of CAs.

Discussion

A nursing home is a facility that aims to provide care and

support to chronically ill older people. In order to provide

care of a high standard it is imperative that caregivers at all

levels understand their own role and those of other’ and work

together in a co-ordinated fashion. In this study, we sought to

gain an in-depth understanding of the different roles RGNs

and CAs play in providing care to residents in nursing homes.

The most notable difference was that, compared with RGNs,

CAs seemed to find it easier to define their role. Whereas

RGNs felt as although they did anything and everything in

the home, CAs defined their role in terms of the tasks they

were not trained to do, such as administering medication or

applying dressings. CAs in Workman’s (1996) study also

found it easier to define their role by identifying what they did

not do. This inability of RGNs easily to define their role

because of a perceived responsibility for doing anything and

everything is common and was not wholly unexpected, given

that it is found throughout the nursing literature (Flynn et al.

1999, Hendrickson et al. 1990, Bridel 1993, Fagerstrom &

Rainio 1999, Freeman et al. 1999, Leppa 1999, McGillis

Hall & O’Brien Pallas 2000).

The RGNs, we interviewed highlighted the holistic nature

of their work and described how they constantly monitored

and assessed the residents under their care. They further

suggested how these skills differentiated them from the CAs,

who were unable to pick up on subtle cues and differences in

residents. This sentiment is echoed by Crump (1992) who

says that ‘nursing is a constant process of learning and

relearning’, whereas to the untrained carer ‘nursing is a set of

unconnected tasks to be achieved before the end of the

working day’ (p. 49). Hughes (1999) argues that this ability

constantly to monitor and assess patients under their care is

an integral component of the nursing profession. Davies

(1992) further suggests that untrained staff are unable to

respond to patients’ cues or to guide or encourage patients

appropriately. From these accounts, it appears that the CA

role, and not the RGN role, may be more suited to workload

analysis as it seems task-related when compared with the

RGN role. On the other hand, as the nature of the RGN role

appears all-embracing, there is clearly room for at least

prioritizing and understanding better the way RGN time is

spent. This finding could have important implications for

current policy in the UK in defining nursing care compared

with personal care (Heath 2000). Perhaps the answer is not in

defining what nursing is, but rather should be in defining

what being a CA is not.

The difficulty in defining and limiting the nursing role may

also help explain, in part, why RGNs in this study had

difficulty deciding which tasks could be delegated to CAs. If

RGNs are able to do anything and everything that CAs can

do within the home, then it must be difficult to place

boundaries on their role and know when to use these

support workers appropriately (Reeve 1994, Workman 1996,

Thornley 2000).

A CA’s level of NVQ training sometimes influenced when

an RGN would delegate activities, but this seemed to be a

very personal decision on the part of the nurse. Some CAs

even suggested that RGNs disliked NVQ training. This is in

direct contrast to a study by McLaughlin et al. (2000), in

which it was found that UK nurses were more satisfied with

the CA role than their United States of America (USA)

counterparts. It was suggested that this could be partly

explained by the greater clarity of role expectations outlined

in the NVQ training. Clearly more research is needed to

explore how RGNs feel about NVQ training.

An RGN’s sense of professional responsibility for resident

care also seemed to influence which activities were delegated

to a CA. This sense of professional accountability may help

explain why the RGNs interviewed were divided on how they

felt about policies and procedures and NVQ training. This

feeling of accountability may reduce the amount of tasks

delegated to a CA and lead RGNs to undertake personal care

tasks, as they may be concerned that they would be held

responsible for the actions of a CA if a resident was put at

risk (Gardner Huber et al. 1994, McLaughlin et al. 2000).

Therefore, it appears that RGNs may continue to engage in

personal care activities until job descriptions are developed

that clearly define the roles and responsibilities of both

themselves and CAs within nursing home settings (Krapohl &

Larson 1996). These issues are, however, likely to be

complicated by the size of the home in which care is

provided. Many nursing homes are in essence small-scale

organizations, in which role differentiation is inevitably less

fixed than in a larger more bureaucratized organization such

as a hospital or large home (Weber 1964). Further research

could investigate whether there is differentiation of RGN

roles according to the scale of homes.

With respect to staffing levels, both RGNs and CAs felt

that they had sufficient numbers of RGNs but required more

CAs. This finding was somewhat unexpected because it is in

direct contrast to most of the research on roles performed in

hospitals, where there has been an outcry against the

increased use of CAs because they may compromise the

quality of care (Gardner Huber et al. 1994, Huston 1996,

M. Perry et al.


Krapohl & Larson 1996). This difference in findings may be

due in part to the acute nature of care in hospitals compared

with the chronic nature of resident care in nursing homes.

Nonetheless, RGNs in this study recognized the contribution

of CAs to completing hands-on tasks, and said that they were

continuing to engage in personal care tasks because CAs were

overburdened. Therefore, appeared that RGNs were acting as

assistants to the CAs instead of CAs doing the job for which

they were introduced. According to both RGNs and CAs, this

lack of staff resulted in residents receiving care of a poorer

quality. This finding was echoed in a recent study that

investigated the views of RGNs and CAs about quality of

care in nursing homes, in which CAs felt that inadequate

staffing levels greatly reduced the quality of care they could

provide (Schirm et al. 2000).

These interesting dynamics can be illustrated as follows

(Figure 1). The left hand image represents the apparent view/

desire of CAs and that which policy in the homes seems to

direct (i.e. distinct and differentiated roles), and the position

that national policy strives for. The right hand image

encapsulates the issues from RGNs’ point of view, with their

overall control and responsibility (anything and everything)

for maintaining and sustaining an equilibrium between the

two roles, while being influenced by accountability for

patient care and professional knowledge. This image also

illustrates the permeability of the interface and takes CAs’

abilities into account. The middle image conveys the situation

we describe in this study. This reflects what appears to be

happening in practice as described by our participants, with

overlap and boundaries, and could be considered as the

‘negotiated’ reality as a consequence of the tension between

the two other perspectives.

The notion that the answer may lie in defining what being a

CA is not aligns with the left hand model. A Registered Nurse

would be likely to argue the difficulties, sensitivity, politics,

legality and, perhaps, dangers of professional boundaries

being established externally. However, we may need to

recognize the professional model emerging on the right,

which does not readily align with the allocation of resources

but perhaps helps to explain the request for more CAs. This

also clearly highlights the need for a very careful examination

of how RNCC reimbursement for residents in nursing homes

can be fairly determined.

In the context of the RNCC, participants were asked which

method would best determine the number of nursing staff

needed, and both RGNs and CAs suggested looking at the

dependency levels of residents. Other researchers (Endacott

& Chellel 1996, Needham 1997) also suggest assessment of

patient dependency as a method by which need for nursing

time can be measured. The Resident Assessment Instrument/

Minimum Data Set (RAI/MDS) is one such method whose

validity has been demonstrated (Fries et al. 1994, Carpenter

et al. 1995). Following an MDS assessment, residents are

grouped into a group associated with the Resource Utilization

Groups Version III (RUG-III) case mix classification system.

This grouping determines the amount of payment nursing

homes receive for providing care. A recent study by Mueller

(2000), based in American nursing homes, demonstrated the

utility of the RAI/MDS for identifying residents’ clinical

needs and the validity of the RUG-III case-mix classification

system for making staffing decisions. In our wider study for

the Joseph Rowntree Foundation, RGNs provided more care

to residents with complex medical and nursing conditions

when compared with residents with less complex conditions

(Carpenter & Perry 2002, Carpenter et al. 2002). This study

demonstrated that RUG-III could be used to determine the

RNCC, and is supported by the views of RGNs and CAs here

that resident dependency levels could form the basis of a fair

and equitable method of determining staffing levels and in

turn a payment system.

Conclusions

Given the limitations of using a small convenience sample of

nursing home staff, and the exploratory and descriptive

nature of the analysis, the role descriptions identified by

RGNs and CAs in this study should not be seen to reflect

relationships in other contexts such as hospitals or commu-

nity care, and therefore they cannot be broadly generalized.

However, they may well be applicable to most nursing homes

and illustrate the all-embracing nature that RGNs have of

their role in these settings. Understanding the roles and

responsibilities of these two caregiver groups can be a first

step towards reorganizing their work patterns, particularly

with reference to the time spent in personal care tasks by

RGNs. CAs were originally introduced to carry out personal

care activities so as increase the time available to RGNs to

perform those activities deemed to be within the domain of a

Registered Nurse. However, given the responses from both

RGNs and CAs in this study, it appears that RGNs continue –

perhaps appropriately – to perform some personal care

activities. One reason for this may be that they have difficulty

limiting their role and feel ultimate responsibility for the

CACACA RGNRGNRGN

Figure 1 The role of the care assistant as seen by care assistants, left;

RGNs, right; and the position that national policy strives for, centre.



residents under their care. Therefore, job descriptions must be

developed that clearly define the roles and responsibilities of

both RGNs and CAs. However, the capacity to devise

suitably differentiated roles between staff types is likely to be

determined by the context in which care is provided, and in

particular the scale of the home. There is a need for research

in this area to examine the relationship between effectively

differentiated roles of staff related to the scale of the home

and unit of management within it.

Staffing levels must also be investigated so that adequate

numbers of support staff are available to allow nurses time to

perform skilled tasks. As was suggested by the participants in

this study, assessing resident dependency levels may be the

best method by which to determine staffing needs. The RUG-

III case-mix system has been suggested as a valid tool for

assessing these dependency levels and determining staffing

levels.

As long-term care becomes more complex, it is essential

that caregivers at all levels understand their roles and those of

others, and work together to co-ordinate and plan resident

care. However, further research is necessary to distinguish

clearly between the roles and functions of RGNs and

CAs and their relationship to other factors in the care

environment.

Acknowledgements

This study formed part of a larger project funded by the

Joseph Rowntree Foundation in May 2001 to develop a

methodology for identifying the level of Registered Nursing

Contribution to Care (RNCC) for residents of nursing homes.

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Appendix

Interview schedule

Are there specific areas of care that you perceive to be definitely within your domain of responsibility? Are there specific areas

of care that you perceive to be definitely outside of your domain of responsibility?

Under what circumstances would a RGN or a CA consider that delivery of a specific element of care be handed to the other. For example,

what conditions would need to be met from the RGN’s perspective to safely allow care to be undertaken by a CA. Conversely, under what

conditions would a CA expect or request that the activity be undertaken by a RGN?

Are written policies and procedures in place that help in this decision-making process?

What is it about your role as a RGN that is different from a CA?

What is it about your role as a CA that is different from a RGN?

Who has ethical and legal responsibility for residents?

How does this influence whether a RGN or CA provides care to the residents?

Do you have enough RGNs and CAs in this home?

If yes, why?

If no, why do you need more?

If no, how many more do you think are needed? How would you determine how many members of staff are needed?



understanding the roles of registered general nurses and care assistants in uk nursing homes

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