Abstract
Background
Across international healthcare systems, healthcare assistant roles have proliferated, in part to decrease nursing costs and support workplace staffing. There is a lack of consensus about the professional title for healthcare assistants, and whether this group requires professional regulation. The variety of terms for healthcare assistants has resulted in confusion around their scope of practice and role within the healthcare team, which may influence patient care.
Aim
We aimed to identify the terminology used for healthcare assistants across English speaking countries and determine the international status of professional regulation of healthcare assistants.
Method
We conducted a deductive, structured search for healthcare assistant roles that were codified on English-language nursing regulator websites in each jurisdiction in Australia, New Zealand, USA, Canada, Ireland, and the United Kingdom. We assessed what terminology were used for healthcare assistant roles in each area, and whether they were regulated by a professional regulator, such as a college of nursing.
Results
Across 77 jurisdictions, we identified 37 different terms for healthcare assistants. The most frequent term was Certified Nurse Aid with 24 uses, and Certified Nursing Assistant with 13 uses. The majority of healthcare assistants are not professionally regulated. Only 12 jurisdictions have professional regulation programs for healthcare assistants, all in the USA.
Conclusion
There is an urgent need for international consensus about the nomenclature for healthcare assistants, so the healthcare assistant workforce can be supported, and their work evaluated via research studies. Regulators can consider how to engage with healthcare assistants and protect the public, as healthcare assistants provide an increasing proportion of patient care.
Keywords: Healthcare assistants, Nursing regulation, Nursing titles
What is already known:
• Healthcare assistants have been part of the healthcare workforce internationally as a supplementary role to Registered Nurses
•Naming and regulation for healthcare assistants is inconsistent, making international comparisons challenging
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What this paper adds:
• From English speaking countries, we identified 37 different terms for healthcare assistants, with the most common being Certified Nurse Aid and Certified Nursing Assistant
• Only 12 out of the 77 assessed jurisdictions had professional regulation in place for healthcare assistants
• Standardised titles and regulation of healthcare assistants are important issues for nurse leaders, as healthcare assistants become a larger portion of the healthcare workforce
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1. Introduction
The COVID-19 pandemic highlighted the shortfalls in international nurse staffing. There is a need to leverage available healthcare professionals to manage care needs, ensuring everyone is working to their full scope of practice (Griffiths et al., 2020). Population aging is a concern internationally, with more older adults requiring support with activities of daily living (The Lancet Healthy Longevity, 2021). There have been complex debates about who should provide this care and how to ensure healthcare is high quality across a spectrum of services.
Healthcare assistants are one role that has been used to supplement the healthcare workforce. Healthcare assistants have had a varied history alongside professional nursing (Stokes and Warden, 2004). Healthcare assistants, generally understood as unregulated professionals who support the work of registered nurses and assist patients with activities of daily living, have existed in some form since the outset of the modern nursing profession (Stokes and Warden, 2004). Nurses have identified that they spend notable amounts of their time completing non-nursing duties (Robert et al., 2020). Healthcare assistants can support more flexible healthcare services (Spilsbury and Meyer, 2005) and can provide assistance to registered nurses.
Internationally, there are increasing pressures to cut costs in healthcare services and a need to provide healthcare to aging populations. In the absence of a gold standard approach to nursing staffing (Griffiths et al., 2020; Prentice et al., 2021), one governmental response to these pressures has been to augment the nursing workforce with unregulated healthcare assistants, who are generally paid lower wages than their nursing counterparts (Australian College of Nursing, 2019; Duffield et al., 2019). The healthcare assistant workforce has historically grown when there are shortages of registered nurses (Stokes and Warden, 2004).These roles continue to proliferate internationally, despite evidence suggesting that introducing nursing assistant roles does not improve patient outcomes (Duffield et al., 2019; Wilson et al., 2023) and may not be cost effective (Griffiths et al., 2023). In worst case scenarios, replacing too many registered nurses with healthcare assistants can have catastrophic outcomes for patients (Francis, 2013). While healthcare assistants can provide support for the healthcare workforce, they are not direct substitutions for registered nurses.
Healthcare assistants are increasingly part of the international health workforce. The importance of healthcare assistants has gained increased prominence after the COVID-19 pandemic, but there has not been an increase in wages to reflect the additional risk of working during the pandemic (Giubilini and Savulescu, 2021). Healthcare assistants remail largely invisible in the healthcare workforce, despite their increasing role (Kroezen et al., 2018). These challenges mean that healthcare assistants have experienced a lack of professional supports in their roles.
There is also little consensus about the nomenclature for healthcare assistants (Duffield et al., 2014; Wilberforce et al., 2017) and the outcomes of healthcare assistants being regulated versus unregulated. A variety of terms are used to name healthcare assistants; for instance, the World Health Organization (2024) workforce classifications data includes the terms community health workers, personal care workers, healthcare assistants, home-based personal care workers, and personal care workers in health services. These terms could be confusing, especially for patients. The variation in naming makes it difficult to assess what proportion of the international workforce is comprised of healthcare assistants and how to conduct workforce planning in response. Additionally, it may be difficult for members of the public to understand who is providing their healthcare without consistency among healthcare assistant nomenclature and regulation (Duffield et al., 2019). To work toward addressing these issues, we mapped the terms used for healthcare assistants in a selection of English-speaking countries to understand how this professional category is being named and regulated internationally.
2. Background
The debates about the role of unregulated team members dates to the professionalization of nursing (Dewar and Clark, 1992; Hardie, 1978; Stokes and Warden, 2004). The work of healthcare assistants remains largely unregulated (Australian College of Nursing, 2019; Blay and Roche, 2020). Healthcare assistants lack a defined scope of practice as normally provided by regulatory bodies; instead, their scope of practice is established by the very employers that hire them (Berta et al., 2013). In the absence of regulation, the scope of practice for healthcare assistants has been ill defined (Roche et al., 2016). Without clear regulatory guidelines, the supervision of healthcare assistants is variable (Blay and Roche, 2020). There have been calls for regulation for many years (Duffield et al., 2014), but few jurisdictions have seen healthcare assistants join professional regulators.
Educational preparation among healthcare assistants varies, ranging from on the job training to college courses (Blay and Roche, 2020). There is some consistency among curriculum items for European healthcare assistants, including support for activities of daily living, support for administrative tasks, and communication in the healthcare team (Kroezen et al., 2018). However, there are inconsistencies in how these concept should be taught and certified (Kroezen et al., 2018). The differences in educational preparation means that it is difficult to assess whether healthcare assistants are working within their scope of practice. Healthcare assistants have expressed a desire for continuing education (Cowan et al., 2015; Wilberforce et al., 2017) and quality improvement initiatives (Tworek et al., 2019). Healthcare assistants have reported that they lacked progression pathways or opportunities for additional education or specialization (Wilberforce et al., 2017). These varied educational levels are a consequence of the lack of professional regulation for healthcare assistants.
The limited regulatory structure around healthcare assistant roles has knock on effects for healthcare teams. In most jurisdictions, registered nurse is a protected title, with a defined scope of practice. Regulators expect nurses to maintain fitness to practice and ongoing professional education. However, these regulations are often not in place for healthcare assistants. The lack of clarity around educational preparation and scope of practice means that teamwork with registered nurses can be difficult to navigate (Bellury et al., 2016; Duffield et al., 2019; Roche et al., 2016; Wilberforce et al., 2017). Healthcare assistants report that they must navigate what they understand their scope of practice to be, the expectations of their employer, and the expectations of nurses (which varied person to person) (Cowan et al., 2015; Crevacore et al., 2022; Roche et al., 2021; Wilberforce et al., 2017). The addition of unregulated workers has been found to increase the supervision responsibilities for registered nurses, which could delay care (Duffield et al., 2018; Roche et al., 2016). Healthcare assistants may receive little information about patients, and may not be included in handover or other formal communication venues (Graham et al., 2021). The success of teamwork with healthcare assistants was dependent on the local expectations and people involved, making it difficult for healthcare leaders to create system-wide supports for healthcare assistants.
Additionally, the work of healthcare assistants varies widely (Blay and Roche, 2020; Cowan et al., 2015). Healthcare assistants were found to spend most of their time providing care to patients, with the most frequent activities being personal care (Blay and Roche, 2020; Grover and Fritz, 2022; Roche et al., 2017; Spilsbury and Meyer, 2005; Wilberforce et al., 2017). While healthcare assistants may be perceived by nurses as completing tasks, healthcare assistants emphasize the person-centeredness of their role (Cowan et al., 2015; Graham et al., 2021; Wilberforce et al., 2017). As healthcare assistants are completing an increasing proportion of patient care, it is important to assess how this group is being professionalised and named internationally. Clearer naming and regulatory expectations could help to protect the public and remedy misconceptions about healthcare assistant education and scope of practice.
3. Aim
The aims of this study were to establish the terminology and nomenclature used for healthcare assistants and to determine the international status of regulation of healthcare assistants.
4. Methods
4.1. Design
We undertook a deductive, structured online search to assess the status of healthcare assistant naming and regulation internationally, illustrated in Fig. 1. We assessed the professional titles and regulation status of healthcare assistants in English-speaking, high-income countries. We adopted a systematic approach of searching online for nursing regulators, education programs, and job listings in each jurisdiction (each province, state, or nation in the identified countries). From these posts, we extracted the professional titles used for healthcare assistants, and identified whether they were regulated by a professional organization.
Fig. 1.
Overview of data collection process.
We were not aware of any comprehensive publications of healthcare assistant terminology or corresponding gray literature. The only source we could identify for this information was websites from professional organisations like The Royal College of Nursing (UK) or the Alaska Board of Nursing (USA). We used a deductive approach to searching, by identifying countries where English speaking information was available. For each country, we identified whether there were regions that would regulate nursing nomenclature independently. For example, Ireland has a single jurisdiction, while Canada has 10 provinces and 3 territories. After we listed the respective jurisdictions for the included countries, we identified each region, and searched for “nurs* regulator + Alaska” using the Google search engine.
Within the search results, we looked for a government or formal organisational website, which was consistently within the first listed Google search results. We checked the websites to ensure they were valid (such as including “.gov” in the URL). When we were confident we had identified the appropriate organization, we searched that site for policy documents, job descriptions, scope of practice documents. We tracked the names given for healthcare assistants in an Excel spreadsheet.
4.2. Inclusion criteria
We searched for evidence of healthcare assistant roles across healthcare systems in high income countries, how these roles were named, and whether staff in these roles were regulated. For pragmatic reasons, we limited our search to jurisdictions where English-language information was available. We considered a role to be a healthcare assistant when there was evidence that they would provide direct patient care, have work delegated to them or overseen by registered nurses or another nursing role, and would engage in healthcare physical labor (Jackson et al., 2021), as opposed roles exclusively for administrative work. Licensed practical nurses, registered practical nurses, nursing assistants, and other roles were excluded. To differentiate among these roles, we considered a role to be a healthcare assistant equivalent when the primary focus was supporting patients’ activities of daily living, rather than nursing interventions like medication administration or wound care. There is undoubtably variation in the work of healthcare assistants across these jurisdictions, and we focused on the role of the worker, rather than their specific duties. Where there was uncertainty about a role, the research team conferred until they reached a consensus. We found a healthcare assistant equivalent role in each region where we searched, so no regions were excluded.
4.3. Data collection and analysis
For each jurisdiction, we assessed whether the regulator included healthcare assistants in their mandate and how the roles were named. We recorded the names and regulatory status in each jurisdiction and collated the results.
We had planned initially to assess the equivalence of healthcare assistant roles by comparing education programs and scope of practice. Ultimately, this proved impossible, as the lack of regulation meant that scope of practice was loosely defined, if at all. We also planned to assess whether healthcare assistants were unionised, but the lack of consistency among groups, and even within the same jurisdictions, meant that this was not feasible for the current study.
We categorised the findings from each jurisdiction in a spreadsheet and assessed the differences between jurisdictions. We assessed whether there was consistency in terms across jurisdictions.
5. Results
5.1. Nomenclature
Healthcare assistants were part of the healthcare workforce in every jurisdiction we assessed. Overall, we identified 36 different role titles used for healthcare assistants across 77 regions, as illustrated in Table 1.
Table 1.
Role titles used by country and region.
| Country | Region | Role Titles |
|---|---|---|
| Canada | Alberta | Healthcare Aide, Nursing Attendant |
| British Columbia | Health Care Assistant, Care Aide | |
| Manitoba | Healthcare Aide, Home Care Attendant, Healthcare Support Worker | |
| New Brunswick | Personal Support Worker, Continuing Care Assistant, Home Support Worker | |
| Newfoundland and Labrador | Home Support Workers, Personal Care Attendant | |
| Nova Scotia | Continuing Care Assistant | |
| Ontario | Personal Support Worker, Patient Care Assistant, Home Support Worker | |
| Prince Edward Island | Resident Care Worker | |
| Quebec | Nurse Aides, Orderlies | |
| Saskatchewan | Continuing Care Assistant | |
| Northwest Territories | Personal Support Worker, Home Support Workers, Personal Care Aides, Resident Care Aides | |
| Nunavut | Home and Continuing Care Worker | |
| Yukon | Home Support Worker | |
| United States | Alabama | Certified Nurse Aide |
| Alaska | Certified Nurse Aide | |
| Arizona | Certified Nursing Assistant, Licensed Nursing Assistant | |
| Arkansas | Nursing Assistant | |
| California | Certified Nursing Assistant | |
| Colorado | Certified Nurse Aide | |
| Connecticut | Certified Nurse Aide | |
| Delaware | Certified Nursing Assistant | |
| Florida | Certified Nursing Assistant | |
| Georgia | Certified Nurse Aide | |
| Hawaii | Certified Nurse Aide | |
| Idaho | Certified Nurse Aide | |
| Illinois | Certified Nursing Assistant | |
| Indiana | Certified Nurse Aide | |
| Iowa | Certified Nursing Assistant | |
| Kansas | Certified Nurse Aide | |
| Kentucky | State-Registered Nurse Aide | |
| Louisiana | Certified Nurse Aide | |
| Maine | Certified Nursing Assistant | |
| Maryland | Certified Nursing Assistant, Geriatric Nursing Assistant | |
| Massachusetts | Certified Nurse Aide | |
| Michigan | Certified Nurse Aide | |
| Minnesota | Nursing Assistant | |
| Mississippi | Certified Nurse Aide | |
| Missouri | Certified Nurse Assistant | |
| Montana | Certified Nurse Assistant | |
| Nebraska | Certified Nurse Aide | |
| Nevada | Certified Nursing Assistant | |
| New Hampshire | Licensed Nursing Assistant | |
| New Jersey | Certified Nurse Aide | |
| New Mexico | Certified Nurse Aide | |
| New York | Certified Nurse Aide | |
| North Carolina | Nurse Aide I, Nurse Aide II | |
| North Dakota | Certified Nurse Aide | |
| Ohio | State Tested Nurse Aide | |
| Oklahoma | Long Term Care Aide | |
| Oregon | Certified Nursing Assistant I, Certified Nursing Assistant II | |
| Pennsylvania | Certified Nurse Aide | |
| Rhode Island | Licensed Nursing Assistant | |
| South Carolina | Certified Nursing Assistant | |
| South Dakota | Certified Nursing Aide | |
| Tennessee | Certified Nurse Aide | |
| Texas | Certified Nurse Aide | |
| Utah | Certified Nursing Assistant | |
| Vermont | Licensed Nursing Assistant | |
| Virginia | Standard Certified Nurse Aide, Advanced Certified Nurse Aide | |
| Washington | Nursing Assistant Registered, Nursing Assistant Certified | |
| West Virginia | Registered Nurse Aide | |
| Wisconsin | Certified Nurse Aide | |
| Wyoming | Certified Nurse Aide | |
| United Kingdom | England | Healthcare assistant |
| Northern Ireland | Nursing Assistant, Healthcare Assistant | |
| Scotland | Healthcare support worker | |
| Wales | Healthcare Assistant, Healthcare support worker | |
| Australia | Australian Capital Territory | Assistant in Nursing, Personal Care Assistant |
| New South Wales | Assistant in Nursing, Personal Care Assistant | |
| Northern Territory | Assistant in Nursing, Personal Care Assistant | |
| Queensland | Assistant in Nursing, Personal Care Assistant | |
| South Australia | Assistant in Nursing, Personal Care Assistant | |
| Tasmania | Assistant in Nursing, Support Workers | |
| Victoria | Assistant in Nursing, Personal Care Assistant | |
| Western Australia | Assistant in Nursing, Personal Care Assistant | |
| New Zealand | N/A | Healthcare Assistant |
| Ireland | N/A | Healthcare Assistant, Nursing Assistant |
Most terms included the words aid, assistant, or attendant, indicating a supportive role for patient care. Many role titles were only used in one jurisdiction. For the role titles that were used more once, Table 2 illustrates the frequency of each term.
Table 2.
Frequency of role titles for healthcare assistants.
| Term | Number of Times Used | |
|---|---|---|
| Certified Nurse Aide | 24 | |
| Certified Nursing Assistant | 13 | |
| Assistant in Nursing | 8 | |
| Personal Care Assistant | 7 | |
| Healthcare Assistant | 6 | |
| Home Support worker | 5 | |
| Licensed Nursing Assistant | 4 | |
| Nursing Assistant | 4 | |
| Continuing Care Assistant | 3 | |
| Healthcare Support Worker | 3 | |
| Personal Support Worker | 3 | |
| Healthcare Aide | 2 | |
Most titles were specific to a given jurisdiction, without use in other regions. At times, there were multiple names for a similar role within the same jurisdiction. The Northwest Territories in Canada had the most variation, where four terms were used: personal support workers, home support workers, personal care aids, and resident care aids. Australia had the most consistency across multiple regions, with two terms used consistently across the country: assistant in nursing and personal care assistant. In New Zealand and Ireland, we identified a single term that was used nationwide.
5.2. Regulation
The vast majority of healthcare assistants are unregulated, with most regions having no evident regulation process for healthcare assistants. The regulation that does occur happens exclusively in the United States, with 12 of 50 states regulating healthcare assistants (Table 3). In this study, regulation refers to having a protected title that is regulated by a governing body. While it is likely that regulation requires ongoing professional development, it was beyond the scope of this study to assess these requirements.
Table 3.
Jurisdictions with nursing assistant regulation.
| Jurisdiction | Term | Regulator |
|---|---|---|
| Alaska | Certified Nurse Aid | Board of Nursing |
| Arizona | Certified Nursing Assistant, Licensed Nursing Assistant |
Arizona State Board of Nursing |
| Arkansas | Nursing Assistant | Office of Long Term Care |
| California | Certified Nursing Assistant | Healthcare Workforce Branch |
| Colorado | Certified Nurse Aid | Colorado Board of Nursing |
| Florida | Certified Nursing Assistant | Florida Board of Nursing |
| New Hampshire | Licensed Nursing Assistant | New Hampshire Board of Nursing |
| Rhode Island | Licensed Nursing Assistant | Rhode Island Department of Health |
| Vermont | Licensed Nursing Assistant | Vermont Board of Nursing |
| Virginia | Standard Certified Nurse Aide, Advanced Certified Nurse Aide |
Virginia Board of Nursing |
| Washington | Nursing Assistant Registered, Nursing Assistant Certified | Washington Department of Health |
In the jurisdictions with regulation in place, only one jurisdiction (Arkansas) did not include the words licensed, certified, or registered to denote the regulatory status. The use of these indicators in the healthcare assistant names may denote a more professionalized workforce or be an effort to communicate the regulatory status to the public.
6. Discussion
We found little international consensus about the nomenclature and role for healthcare assistants, which is consistent with other studies. Wilberforce et al. (2017) identified nine different terms for healthcare assistants from nine different community mental health trusts. The varied terms to categorize healthcare assistant roles may contribute to confusion among other members of the healthcare team and the public. While the titles themselves are important for professional representation, a larger issue may be that varied role titles leads to varied scope of practice and role expectations. In turn, there may be limited support for these roles, which could negatively impact this workforce. We encourage other researchers to explore these issues further, as the proportions of healthcare that are provided by this healthcare assistants will likely continue to increase (Duffield et al., 2014).
Healthcare assistants are also present in each jurisdiction that we assessed, with relatively little regulation for the professional roles. In the absence of professional regulation, healthcare assistant scope of practice and educational requirements proved impossible to codify in the scope of this study. This challenge is likely due in part to the sheer volume and variability of such roles across healthcare settings. There have been numerous calls to examine the regulatory status and scope of practice for healthcare assistants (Australian College of Nursing, 2019; Duffield et al., 2014). There is a broad consensus that the current status of nursing assistants leads to role confusion, unclear scope of practice, and difficulty dividing care among team members (Blay and Roche, 2020; Crevacore et al., 2023; Grover and Fritz, 2022; Wilson et al., 2023). Increased role clarity and a consistent scope of practice could support the whole healthcare team to delegate and manage patient care more effectively.
At present, the lack of consistency in roles increases the workload for registered nurses, who must assess the appropriateness of delegation on a case-by-case basis (Duffield et al., 2019). Our findings support this assertion, as registered nurses may need to be familiar with the scope of practice for multiple roles, adding complexity to their delegation. Having clearer role definitions for these workers can lead to more consistent nomenclature internationally, and potential for consistent standards, scope of practice, and educational standards. It is in the interest of protecting the public to clarify these role definitions, and increase healthcare assistant professional regulation (Duffield et al., 2014). There may also be opportunities to recognize healthcare assistants as members of the healthcare team, as their contributions can be overlooked (Kroezen et al., 2018).
Developing regulations for other roles, such as nurse practitioners and physician assistants, has been a serpentine process (Gadbois et al., 2015), indicating the need for cooperation with this effort. Nurse leaders can collaborate around the regulation and professionalization of healthcare assistants to ensure that healthcare assistants have the appropriate support to protect the public, provide safe care, and follow up malpractice concerns (Australian College of Nursing, 2019). Regulation could also work towards fostering respect for the expertise of healthcare assistants, as a parallel has been seen with the registered nursing profession (Dingwall et al., 1988). The establishment of a regulated healthcare assistant role could set the stage for increased professional organizations and advocacy, through professional unions and associations.
6.1. Limitations
We appreciate that there are healthcare assistants in many jurisdictions beyond English-speaking, high-income countries. Other researchers can expand this work to the many countries that have information in other languages. Our findings are limited by these practical exclusions and can be expanded upon in future work. While we have attempted to create a comprehensive list of nursing assistant nomenclature, there may be terms at the organizational level that have not been included.
6.2. Recommendations for practice
Setting clear scope of practice guidelines for healthcare assistants is a priority in settings where healthcare assistants are present. These guidelines could reduce the work of registered nurses, by clarifying what responsibilities can be safely delegated. Clearer expectations of healthcare assistants may decrease confusion, and ultimately decrease missed care (Cordeiro et al., 2020).
6.3. Future research
There is a need for intervention studies around healthcare assistants. There are well-documented challenges around scope of practice, teamwork and delegation, and regulation among healthcare assistants. Researchers can move beyond the documentation of these challenges to assess different approaches to regulation and scope of practice definition, to identify effective paths forward for healthcare assistants and registered nurses.
7. Conclusion
We identified 37 different terms for healthcare assistants in 77 jurisdictions. There is an urgent need to develop international consensus on the terminology for healthcare assistants, to support research and professional development among healthcare assistants. Only 12 jurisdictions have professional regulation programs for healthcare assistants. There is an increasing utilization of healthcare assistants as a cost saving measure, and healthcare assistants are performing an increased proportion of patient-facing care. Expanding regulation and scope of practice standards for healthcare assistants will protect the public and strengthen patient care among nursing teams.
CRediT authorship contribution statement
Jennifer Jackson: Writing – review & editing, Writing – original draft, Validation, Resources, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Farida Gadimova: Writing – review & editing, Writing – original draft, Validation, Project administration, Investigation, Formal analysis, Data curation. Sandra Epko: Writing – review & editing, Writing – original draft, Validation, Investigation, Formal analysis, Data curation.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgments
Funding details
This work was funded by College of Licensed Practical Nurses of Alberta.
Data availability statement
Data are available upon reasonable request.
Ethical approval
Ethical approval was not required for this study, as these data were located in the public domain.
Footnotes
Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.ijnsa.2024.100200.
Appendix. Supplementary materials
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data are available upon reasonable request.