This chapter defines healthcare as assessed by PISA-VET and elaborates the framework for this occupational area that has been designed for the Development Phase of the project, including descriptions of the competencies and constructs to be assessed. It presents and explains the processes, content knowledge and contexts and provides several sample items with descriptions of task characteristics. The chapter also discusses how performance in healthcare is measured and reported against proficiency levels and scales.
PISA Vocational Education and Training (VET)
Assessment and Analytical Framework
PISA
Abstract
This chapter identifies and defines a medium-skill occupation within the broad “healthcare” occupational area for the purpose of assessment by the PISA-VET project. It elaborates the framework for the occupation for the Development Phase of the PISA-VET project, including descriptions of the competencies and constructs to be assessed. It presents and explains the processes, knowledge, and contexts reflected in the occupation and provides several sample items with descriptions of task characteristics. The chapter also discusses how performance in initial VET healthcare programmes can be measured and reported against proficiency levels and scales.
The rationale for the inclusion of a healthcare occupation in this Development Phase is strong considering its large economic and societal importance and its continued relevance in ageing societies. As a sector, healthcare is in widespread demand, with a large student population in formal VET programmes worldwide (Bjornavold and Chakroun, 2017[1]). While the scope of healthcare provision varies in national and regional cultures and settings, there is also a significant common core of competencies across the world (WSI, 2022[2]). Highlighted as the third UN Sustainable Development Goal (ensure healthy lives and promote well-being for all at all ages), demand and need for good healthcare will require constant evolution in the partnership between the healthcare provider, the circumstances, and the technologies to hand (UN Department of Economic and Social Affairs, 2022[3]).
The purpose of the PISA-VET framework is to “encompass VET learners on a trajectory to become skilled professionals able to make well-rounded judgements and decisions,” in healthcare in this instance (OECD, 2022a, p. 6[4]). Therefore, the aim of this section of the chapter is to:
a) Use the availability of global and international classifications to help define healthcare as an occupation and in this instance the equivalent of the healthcare domain.
b) Identify the trajectory through which learners may become skilled professionals, together with their intermediate destinations and milestones.
c) Build on the lessons of the last 15 years regarding the opportunities for and challenges of international comparative assessments and judgements in healthcare occupations.
While the classifications are occupational, as a minimum they indicate the extent of learning required to fulfil each role. The literature search and analysis that follows discusses qualifications and their relationship with occupational requirements as required in the context of this project.
The healthcare occupational area comprises many different types of occupations at various levels of qualification requirements. Given that the focus of PISA-VET is on VET programmes at ISCED levels 3 to 5, healthcare occupations that typically require bachelor’s, master’s or doctorate qualifications are excluded, and the focus is instead on medium-skill healthcare occupations. Within the 2008 International Standard Classification of Occupations (ISCO-08) medium-skill healthcare occupations most closely fall within Unit Group 5321 “Healthcare Assistant”. Unit Group 5322 “Home Based Care Assistant”, is also partially relevant since a Healthcare Assistant may work in the home as well as other settings.1 Health care assistants are defined as providing direct personal care and assistance with activities of daily living to patients and residents in a variety of health care settings such as hospitals, clinics and residential nursing care facilities. They generally work in implementation of established care plans and practices, and under the direct supervision of medical, nursing or other health professionals or associate professionals. Home-based personal care workers provide routine personal care and assistance with activities of daily living to persons who are in need of such care due to effects of ageing, illness, injury, or other physical or mental condition in private homes and other independent residential settings.
Based on international occupational classifications, there appears to be a broad role, referred to as healthcare assistant, and a role of nursing assistant which may be more specifically focused on nursing rather than nursing and caring. Since both roles sit within the pathway to registered nursing occupations, and in some instances nursing assistant is regarded as a subset of healthcare assistant, it is appropriate to embrace both within the definition of the occupation. As a result, the term ‘healthcare/nursing assistant’ will be used from this point onwards where it relates directly to the focus of the occupation for OECD’s PISA-VET.
The role of the healthcare/nursing assistant, which is classified as a service worker, is accessed by certification or recognition following structured preparation of different types and lengths. Table 5.2 provides an overview of the main VET qualifications for these roles in several countries. Through the length and quality of the preparation, some national systems extend their entry arrangements to incorporate preparation for healthcare associate professional roles. This is particularly the case where there is mixed mode (work and study) delivery. Therefore, given the purpose of the PISA-VET framework, while focusing on initial entry programmes associated with ISCO 5321, account has been taken of the fluidity of the relationship with associate professional roles (ISCO 3221 – Nursing Associate Professionals) in the scoping of this domain.
The VET-LSA Feasibility Study (Baethge and Arends, 2009) was designed to learn if there was a common basis for comparing four selected vocational programmes in each of eight participating European countries. The comparison was focused on a “medium level of proficiency, that is, initial VET programmes at ISCED level 3 and corresponding to occupations requiring medium or considerable vocational preparation” (Baethge and Arends, 2009: 7). As one of the four programmes, social and healthcare programmes were found to have distinct characteristics within each country “due to differing political, historical, and cultural backgrounds” (Baethge and Arends, 2009: 85). The relationship of each programme to health on the one hand, and society on the other, was an identifiable factor. Although the Study initially excluded social care and “half-nursing,” ultimately it derived a frame of reference from several O*NET occupational profiles, including social care. The “work object” featured in the Study as “a person in a situation needing help” may indicate the greater breadth of the programmes studied, relative to this chapter’s remit (Baethge and Arends, 2009: 85), which is understood to relate to health needs rather than needs more generally. Notwithstanding variations across the selected vocational programmes, the LSA-VET expert group identified five core areas of commonality, amenable to evaluation across the eight participating European countries (Baethge and Arends, 2009, p. 120[5]).
WorldSkills International (WSI) has a WorldSkills Occupational Standard for “Health and Social Care” that has been updated biennially since 2012 (WSI, 2022[2]), and seeks to comprise the competencies that represent medium-level occupational mastery across its membership of 85 nations and regions.
Between 2015 and 2017, a project led by Cedefop and UNESCO analysed and documented the use of learning outcomes from the perspectives of the education and training sector and labour market stakeholders (a) within the European Union (Auzinger, Broek and Luomi-Messerer, 2017[6]), and (b) worldwide (Bjornavold and Chakroun, 2017[1]). Ten VET qualifications were reviewed in 10 EU countries, and four were reviewed in 26 countries worldwide, looking at the existence, content and comparability of the qualifications – including medium-level healthcare qualifications. Findings included that healthcare qualifications were newer than qualifications in other occupational areas covered by the analysis and not always present; that relevant qualifications were rated at ISCED 3; and that the relationship between healthcare qualifications and the skills included in the European Skills, Competences, Qualifications and Occupations (ESCO, 2020[7]) classification was relatively weak.
These findings were supported by an overview of healthcare assistants in EU Member States (Kroezen et al., 2018[8]), which noted:
“It is shown that most learning outcomes for healthcare assistants across Europe are defined in terms of knowledge and skills, often at a basic instead of more specialized level, and much less so in terms of competences. While there are many differences between member states, there also appears to be a common, core set of knowledge and skills-related learning outcomes which almost all healthcare assistants across Europe possess.”
To conclude: the evidence for a common core of knowledge, skills, and competences relating to the domain of healthcare/nursing assistant is well supported by the literature. The diversity that exists for historical and cultural reasons does not undermine this evidence; it does, however, call for continuing awareness of factors that may have a bearing on assessment. Attitudes to pain, the family, women, the rights of particular social or ethnic groups, and cultural norms, all vary across the world, and may impact on teaching, learning, and practice. Awareness of this will therefore be essential when making comparative judgements.
Given the diverse understanding and practice of medium-skill healthcare occupations across the world (Bjornavold and Chakroun, 2017[1]), to organise the domain for international comparative assessment, the contexts, processes, and knowledge are required to be:
universally recognised as core
amenable to interpretation, assessment as well as evaluation at several levels
culturally neutral.
Using the above principles for selection, this section deals with processes, content knowledge, and contexts. Considerable material exists to draw upon and retain, while excluding material that is specialist, culturally or historically determined.
The choice of healthcare strategies, plans, and interventions is highly dependent on context, which is wide-ranging. To discuss context, five aspects or categories are considered, each of which is relevant to the role of healthcare/nursing assistant.
The place or location.
The client or patient.
The illness, injury, and disability.
The situation in which care and treatment are needed.
Regulatory and organisational requirements.
Each of these has a lesser or greater importance in determining the healthcare/nursing assistant’s actions; they may also impact on one or more of the others. When under instruction, for example in a hospital, the range of choice may be very limited; in other circumstances, a client’s home, in normal circumstances the range of choice may be considerable.
While there is a top-level distinction between a hospital and a home-like environment, in practice, there is a complex web of settings, the number and purpose of each depending on each nation’s and region’s healthcare system and history. The menu of settings is wide:
Hospitals: inpatient or outpatient facilities, specialist or general.
Clinics for specific purposes and conditions (e.g. psychiatric, geriatric).
Residential nursing care.
Hospices for terminal care.
Clients’ and patients’ own homes.
For the healthcare/nursing assistant, there is a gradient of formal care plans and supervision from established and high for inpatient care to more diverse and open in clients’ own homes. This reflects the reason for the client or patient being in a particular place or setting.
Within this chapter both ‘client’ and ‘patient’ are used to denote the person using healthcare services. According to context, client’ is used in relation to wellbeing and preventative services, and ‘patient’ is used in relation to medical services and treatments.
Numerically, the population most in need of the healthcare/nursing assistant’s role will be the elderly. However, depending on context, a health need may occur at any point from before birth to after death. Across the lifespan, needs associated with specific ages and stages may lead to specialisation, for example in the needs of the child, or the elderly. For international comparative assessment, while care of the elderly is generally seen as a core part of the role, care of the child lies outside this role’s compass.
The age range is therefore proposed to be:
adolescence
adulthood
old age.
A healthcare/nursing assistant may encounter patients/clients with a range of temporary, permanent, or deteriorating conditions, separately or in combination. Their response will depend upon the purpose of their visit, within the care or treatment plan, and the regulatory framework in place. The conditions can be grouped in illnesses, injuries, surgeries, and disabilities.
There are multiple dimensions to the situations. A situation may be planned or unplanned from the outset, as with responding to a fall at home by a frail client. A routine visit may give rise to unexpected challenges during treatment: for example, a client refuses care.
There are many planned transitions in the care and nursing cycle for the healthcare/nursing assistant to respond to, as the client or patient recovers, or stabilises, or deteriorates. For a number of these, for example, arranging transport for a patient moving to hospice care, the role of the healthcare/nursing assistant may be administrative and logistical as much as directly supportive of the client or patient.
Situations also entail a range of people representing both the client or patient, and the web of professions that represent the healthcare sector.
Legal, regulatory, and administrative requirements are a constant feature of healthcare assistance. Healthcare is a regulated profession at all levels, included intermediate roles. This feeds into its administration, which is the foreground of regulation. Regulation normally includes a framework for audit and quality: compliance, acceptable practice, and improvement.
The healthcare/nursing assistant has a personal responsibility to know and work within their national legal framework and operational regulations. This ranges from ensuring the health and safety of clients, patients and themselves, to striving for best professional practice in life enhancement. In line with operational standards, they manage consumables and agreed medicines, and keep apparatus and furniture operational. They use resources with purpose, efficiency, and environmental consciousness, and dispose of materials according to legal, organisational, and ecological good practice. They are expected to stay up to date with the law and regulations, and to raise non-compliant incidents and practice without hesitation.
Maintaining the focus on the client or patient, and their illness, injury, or disability, which are inseparable, items most closely focused on these should have the highest proportion of items, followed by the situation, which is closely associated to the person and their health need. Place and formal requirements are significant determinants of actions; however, since this are not the purpose of the actions, they rate lower.
Five occupational processes have been identified that meet the criteria for international comparison, are balanced in their significance to the role and, when taken together, require all the capabilities looked for following initial vocational education and training to equip individuals for roles as healthcare/nursing assistants. The five proposed occupational processes are:
Work in professional teams.
Identify needs and collaborate in healthcare planning.
Support and enhance clients’ quality of life.
Provide and support treatment and medical processes.
Review and evaluate care.
While other taxonomies exist, for the scope of determining occupational capabilities related to these processes, Cedefop’s discussion of universal descriptors, drawn from the Educational Research Institute (Cedefop, 2022, p. 25[9]), is used. Bloom’s taxonomy for cognitive, psychomotor, and affective domains, as set out in Cedefop (2022, p. 62[9]), offers more detail and creates a link with level descriptors for ISCED purposes (see Figure 5.1).
Source: Cedefop (2022: 62)
The following ten capabilities resonate with the five processes and Bloom’s taxonomy:
collaboration with others to achieve optimal healthcare
open mindedness throughout the healthcare process
engagement with others for therapeutic relationships
communication as a therapeutic instrument
emotional regulation to achieve optimal healthcare
access to and use of evidence and information to support healthcare solutions
management of self, time, tasks and workspace to optimise healthcare solutions
coordination of mind, feelings, and movement for dextrous, respectful healthcare
contribution to healthcare solutions
reflective practice for healthcare.
The five processes and underlying ten capabilities are described in detail below.
Healthcare is a purposeful social undertaking, requiring teams of similar and different contributors drawn from many disciplines, cultures, and groups. The healthcare/nursing assistant has therefore both to present and maintain a professional demeanour and recognise and respect difference and diversity. According to their role, status, and specialisms, the healthcare/nursing assistant must contribute to the healthcare team formally and informally. Formally they receive, gather, provide, and retain information, fulfil their obligations, and meet deadlines. They understand interdependencies, follow instructions, raise concerns promptly, and act as advocates when needed. Informally they earn respect and trust through their foresight and insight, discretion, and consideration. When issues and conflict arise, the healthcare/nursing assistant responds openly but with discretion, calmly, and rationally, notwithstanding the pressure on them and others.
Healthcare/nursing assistants contribute to the nursing process – which is managed mostly by qualified nurses- by identifying changes and needs and adapting measures in collaboration with the nurses. According to the status of the healthcare/nursing assistant, and the context, aspects of planning may be delegated, under the superision of the nurse, who retains this responsibility.
Healthcare is about the care of people with health-related needs and covers wellbeing and life enhancement. The healthcare/nursing assistant will support the health and wellbeing needs of individuals of all ages and with a wide range of challenges for health reasons and which are closely associated with the medical profession. Owing to the nature of the needs, and the situation of each client, the range of needs, individuals, and settings will be very wide-ranging. Within those settings, the healthcare/nursing assistant manages health, physical, and psychosocial well-being, supports growth and development, caring and rehabilitation. The support provided follows a planned and reflective process, always taking full account of the nature and limitations of the environment to ensure the safety of the client and others, to avoid the risk of infection, and promote good hygiene. Great care is taken in the transportation, use, storage, and disposal of material and equipment.
The healthcare/nursing assistant takes a strong interest in the client in order to develop a deep understanding of their biography, character, and medical condition, and to win their trust. They respect clients’ autonomy, beliefs, norms, and right to refuse care. They use therapeutic communication techniques to establish rapport and communicate with clients who have disabilities in communication and understanding. They use coaching techniques to enable clients to develop or restore life skills and establish positive relations with clients’ families and other supporters. Maintaining a realistically open and positive outlook, they will organise educational and rehabilitative activities in an age- and culturally- appropriate way.
In hospitals and other healthcare settings where professional nursing roles are required, the healthcare/nursing assistant may have a significant support role during clinical investigations, interventions, and treatment.
Here they perform quality nursing care within the scope of their permitted practice, such as hygiene care, first aid, wound care, and breathing exercises. They monitor and report on different health parameters, such as blood pressure, temperature, pulse, respiration, blood sugar, pain score, and weight. They take precautions to avoid common risks for sick patients, such as infection, pressure ulcers, falls, pneumonia, and contractures. They record and update patients’ medical information and identify and report on problems that require referral. They collaborate with patients, families, nursing colleagues, other healthcare professionals, and the community to ensure continuity of care.
They may be expected to prepare rooms, sterilise instruments, provide equipment or supplies, and ensure that the stock of supplies is maintained. They provide a safe environment for patients and staff including implementing infection control procedures.
Healthcare/nursing assistants help to optimise patients’ conditions by encouraging their independence through mobilisation, use of mobility devices and nutritional wellbeing. They may advise patients on the administration and storage of common drugs and medication, and their potential side effects. Within the limits of their authority, they plan and schedule their assigned tasks to avoid rushing patients or disrespecting their needs. In hazardous and potentially hazardous settings, the healthcare/nursing assistant uses resources efficiently and effectively and discards waste safely and ecologically.
Review and evaluation are a recurrent, almost continuous, process, at a basic level, and for the healthcare/nursing assistant are most complex in formal settings. Reviews must be grounded in a context and purpose because what is “worth doing” may vary from providing palliative care, through to recuperation and discharge, or the maintenance and enhancement of a life limited for health reasons. Ongoing review may be as simple as continuously encouraging feedback from clients through careful discussion, to enhance the therapeutic relationship. In some settings, the healthcare/nursing assistant may seek feedback from clients’ families and other supporters, and from their own colleagues and related professionals. In these instances, the outcome may be continuous improvement through small changes.
More formal reviews and evaluation will be information- and data-led, which underscores the need to good record keeping and storage. Given the organic nature of healthcare, review and evaluation may be 360° in nature, entailing critical self-review for the healthcare/nursing assistant. Irrespective of the formal requirement, they are expected to be reflective practitioners who seek and act on feedback from a range of trusted sources. This carries with it the responsibility to maintain and update their knowledge, understanding, practice, and compliance with new regulations. For the reflective healthcare/nursing assistant, review and evaluation is the opportunity for innovation and creative solutions in a complex service occupation.
The goal in constructing the assessment is to achieve a balance in the weighting that reflects the primary focus of the processes described above. The distribution in Table 5.3 reflects the prime focus on the client and patient that runs through this chapter. They represent the core purpose of the role, which the other three processes serve and enable.
The role of healthcare/nursing assistant is holistic as well as diverse. The provision of care to clients and patients is based on a mutual understanding of their physical, psychological, emotional, and spiritual dimensions. To varying extents, the formation of healthcare/nursing assistants is a process of professional socialisation, particularly where the learning contains a work-based element.
Nominally, a number of underlying capabilities for healthcare/nursing assistants resemble the OECD’s Survey for Social and Emotional Skills. Where this is the case, the essential differences between the SSES and the underlying capabilities for the healthcare/nursing assistant are in context, application, and extent, as befits a professional healthcare role. Healthcare/nursing assistants deal with clients and patients who depend upon them, whether they are temporarily or continuously impaired, and when, for whatever reason, their ability to communicate is likely to be restricted or lacking. Often, healthcare/nursing assistants are in situations the client’s or patient’s condition cannot improve. At the same time, they must articulate themselves in a professional medical and health environment, using appropriate terminology and structures, while generally being at the lower end of the professional hierarchy.
The purpose of collaboration is to expand the available resources to overcome a problem. Given the complexity of human health, collaboration is a defining feature of healthcare. At its most basic, there must be collaboration between the provider of healthcare and the recipient, who for therapeutic reasons is better regarded as a partner in their recovery or stabilisation. In the community, collaboration may also embrace family and friends. When healthcare needs become more complex, collaboration may be more planned and structured, involving new resources and agencies. The healthcare/nursing assistant is an essential member of larger professional teams, with a support role in the immediate or midterm service of clients and patients.
In their professional role, the healthcare/nursing assistant must keep in mind the purpose of the collaboration, and their position within it. Irrespective of the need, they must demonstrate trustworthiness, dependability, and empathy, while at the same time maintaining their professionalism, which requires objectivity, emotional regulation, and discretion. These attributes will serve them well when complexities arise, as they normally will. As part of the collaborative team the healthcare/nursing assistant should have the ability to give and take feedback, acknowledge the experience, ideas, and contributions of others, and take account of their feelings, concerns, and opinions.
The management and treatment of ill health is complex. Health needs take many forms and may impact on people at all and any points in life. Clients and patients vary by age, gender, ethnicity, culture, lifestyle, and other factors, united solely through a need for professional support for health reasons. The natural material world, with which healthcare interacts, is in constant flux, often defying certainties and requiring open mindedness in response. A further complexity is the diversity of values which requires an objective awareness of context, norms, relativities, and absolutes.
The healthcare/nursing assistant requires an informed understanding of, and respect for, human diversity, especially where a health need creates vulnerability for the client or patient. Notwithstanding that vulnerability, the client or patient is a partner in their recovery or sustainability, to the extent that their personal agency may be the key to their recovery or wellbeing. This provides an opportunity to explore new approaches, advance, adapt, or delay certain treatments in consultation with others or under the authority of the healthcare /nursing assistant, who may be a partner, mediator, advocate, or restraint, drawing on their underpinning knowledge and understanding to maintain or restore the client’s or patient’s equilibrium.
In the healthcare context, the term “open mindedness” refers to learned professional behaviours, which are explored under “communication” and “emotional regulation”. It connects with open mindedness as a generic social and emotional skill, but occupationally is realised through specific professional capabilities.
Where there is a client or patient, healthcare is inherently social. The healthcare/nursing assistant requires a sociable disposition which is mediated through their professional attributes and behaviours. The ability to engage with the patient or client, to respect them and empathise with their situation and condition, is a positive attribute for recovery and wellbeing. A therapeutic relationship needs to be established with all contributors to health, including the client or patient. However, the healthcare/nursing assistant has a distinct role with its own agency in the healthcare process, and the exercise of that agency by taking initiative, injecting energy and optimism, is a significant contribution to healthcare. The healthcare/nursing assistant may be the most regular or frequent contact for the client, and in some instances the most approachable. Therefore, a consistently sociable demeanour, requiring in some circumstances considerable resilience, is a key attribute of the healthcare/nursing assistant.
Ill health and/or disability make a client/patient vulnerable. This both restricts their ability to communicate effectively and increases their need for effective communication by the healthcare team. Outside the hospital environment, the healthcare/nursing assistant may be the individual upon whom the client/patient most depends, to inform, interpret, and explain their health need and situation. The inability to communicate and be understood may cause deep distress and worsen health conditions.
Where due to age or infirmity the client/patient is unable to initiate, respond, or understand verbal communication. The healthcare/nursing assistant must show empathetic perception, by using each of their own senses, and communicate empathetically. They must seek or create alternative forms of communication to the spoken or written word, potentially using facial expression, signs and gestures, pictures, and/or assistive technology. They may require imagination and creativity in order to listen, interpret, anticipate, encourage and reassure the client/patient.
The healthcare/nursing assistant is the person who retains control of their emotions in order professionally to support others in emotional and stressful situations. The healthcare/nursing assistant works in emotionally charged situations, with clients, patients, their family and friends who have cause for distress and will respond in diverse ways. Their role is to provide supportive environments for the expression of grief or distress; to keep distressed people safe; and make referrals as required. This constitutes emotional labour for which high levels of stress resistance need to be developed, together with the ability to recognise when they should or must seek help. Self-monitoring helps the healthcare/nursing assistant to understand the causes of their own concern and distress, their personal emotional capabilities, and the need to sustain their own wellbeing.
At an intermediate level, the healthcare/nursing assistant constantly monitors, assesses, and makes small and nuanced decisions generally regarding recovery and wellbeing, but also terminal care. They must be alert to clients’ and patients’ conditions such as distress and pain, recognise or infer causes, report on and alert others to clients’ and patients’ conditions. Their role is rooted in the natural material world, for which they need to understand scientific concepts and theories and have a working knowledge of scientific procedures and practices. These are the foundation on which their expertise is built. Since measurement and estimation are constant elements of client and patient care, the role also requires an equivalent grounding in mathematics and the natural sciences. Linked to this is the ability to use equipment correctly, record, and interpret data. Since digitalisation and automation has an increasing presence in healthcare, the healthcare/nursing assistant must have ICT skills and be a conscious, discriminating user of ICT and social media.
Healthcare requires human decision-making, in which context, emotion, bias, and capacity are factors. With the welfare of the client and patient at stake, healthcare/nursing assistants need to know and understand what is normal, and what is within and outside given ranges. Data rationality is a vital learned professional skill irrespective of circumstances and pressures.
Healthcare requires effective management of self, time, tasks, other people and workspace to optimise health outcomes. The role of healthcare/nursing assistant is complex in these respects. In many circumstances quality of care may clash with priorities and pressures of time. With a caseload of clients and patients, the calls upon underlying knowledge and experience may be far-reaching. Limitations of the environment and access arrangements may distract or worse. To manage these factors requires an unerringly methodical approach, with a high level of awareness of self, clients/patients, and settings, such as a hospital ward.
Health and safety considerations are constant features of task performance, with many factors at play relating to the client/patient, the environment, equipment, and materials. Risk assessments, plans, and reports are regulatory requirements and essential for both the client/patient’s and the healthcare/nursing assistant’s safety and wellbeing.
Psychomotor skills epitomise the professional client/patient relationship in action. Often referred to as “head, heart, and hands”, the ideal healthcare/nursing assistant’s movements combine cognition, empathy, and dexterity, for example in respectful touching. Coordination, grace, strength, delicacy, and speed are learned behaviours that engender trust and confidence in clients/ patients, ease discomfort and pain, and aid recovery. Psychomotor skills are muscular actions based on mental processes, which develop from imitation and ultimately become naturalised. As an underlying capability, they epitomise the client/patient-facing core of the healthcare/nursing assistant role.
The purpose of being a healthcare/nursing assistant is to respond to a health-related need or problem within a regulated and managed organisation or structure. In their intermediate role they may have limited autonomy to solve problems, their role being to implement their share of a solution, such as to support the post-operative recovery of a patient in hospital. In other settings, such as a care home, they may have greater autonomy and responsibility to identify and define problems, come up with possible solutions, evaluate the options, choose and implement the solution, and evaluate the outcome. Depending on the problem, the solution may be found through collaboration, referral, or individual creativity and initiative. Examples of problem solving in the home or care environment may include identifying and reporting a pattern of concerning behaviour suggesting deterioration, organising with others a series of recreational activities, or acquiring and setting up a bird table outside an immobile client’s window.
Underpinning problem solving are several other capabilities, including data rationality, empathy, and well-founded achievement orientation.
The purpose of the healthcare/nursing assistant’s role is to have a positive bearing on individuals’ and groups’ health, according to their conditions and situations. Given the nature of the natural world and human beings’ interactions with it and inside it, the way in which their role is fulfilled is bound to keep changing. This requires reflective practice as a learned habit within the larger review and evaluation systems to which their role is accountable. The focus of review and evaluation includes the client or patient, for whom report structures and systems are normally provided, the context, which may or may not be included in formal reports, and themselves. Self-reflection and learning are essential attributes, and an underlying capability. It underpins self-efficacy, which for the role of healthcare/nursing assistant must include self-care.
Across the world, wherever there is a distinct healthcare/nursing assistant role, its core purpose is to help meet the health and care needs of clients or patients, who are living organisms with personal health needs, circumstances, and rights. Beyond this, there is considerable diversity in the scope and limits of the role, and the preparation of young people and adults to fulfil it. As noted above, each nation’s and region’s healthcare system are a historical, cultural, social, and economic artefact, as are the VET arrangements designed to serve it (Bjornavold and Chakroun, 2017[1]). To accommodate this, this chapter focusses on the competencies that are (a) universally recognised as “core” to the occupation, (b) amenable to interpretation, assessment, and evaluation at several levels, and (c) culturally neutral. To add to these, effective role execution by a healthcare/nursing assistant requires a blend of social, emotional, physical, mental, and intellectual maturity.
At the heart of PISA-VET is the acknowledgement that an understanding of healthcare content, and the ability to apply that knowledge to the solution of meaningful contextualised problems is fundamental for success in the healthcare occupation. That is to solve problems and interpret situations in occupational contexts, there is a need to draw upon certain healthcare knowledge.
The five content categories selected reflect the categories explored by the literature discussed above and cross-referenced to international skills classifications like ESCO and O*NET. The categories are:
Multi-professional collaboration.
Communication and relationship building.
Medical and related sciences.
Client/patient care, service, and assistance.
Administrative and legal frameworks.
In an experiential, iterative and holistic learning model, each knowledge category contains its own hierarchy, with curricular and pedagogical choices, or opportunism, determining its position and prominence at any one time within a VET programme. In keeping with this, and based on Maggioni and Alexander (2010[10]), Cedefop (2017[11]), and the OECD’s definitions of learning (OECD, 2019[12]), the span of each knowledge category is set out as an introduction to 16 cross-cutting knowledge clusters which vary according to their knowledge type: in OECD terms (OECD, 2019[12]) disciplinary, interdisciplinary, epistemic, and procedural. This is to make a bridge between the more disciplinary origins associated with PISA and the distinctive conceptualisation of knowledge in VET. To reflect the specific nature and demands of healthcare, strategic and conditional knowledge are also considered to be essential knowledge types. Details about the 16 cross-cutting knowledge clusters are provided in the Annex to this chapter.
Healthcare is a collaborative process in which the healthcare/nursing assistant combines their expertise with others in multi-professional teams. While each member of the team brings a different perspective and expertise, they must also have inter-disciplinary knowledge and understanding, to apply and combine the contributions of each specialism to resolve given problems. Depending on context, collaboration in providing services will have a prominent role. Within the formal and informal boundaries set nationally and locally, administration and legal frameworks are also determinants for collaboration, as are formal and informal norms, hierarchies, and networks. To fulfil their own role in multi-professional teams, the healthcare/nursing assistant needs to be both literate and numerate to find, absorb, interpret, and work with technical information, both textual and numerical. Tacit knowledge is also essential both to provide good service and to create and sustain mutual trust and confidence with and across teams.
Communication is at the heart of the healthcare/nursing assistant’s role and is intrinsic to all their learning and knowledge requirements. It is both a focus for disciplinary knowledge, and a means of unlocking and using other forms of knowledge. There is an extensive new vocabulary to understand and apply, while (re)conceptualising communication as a mode of behaviour and being. Communication is core to the transfer of information, support, and treatment in a therapeutic context, and to the socialisation of intending healthcare/nursing assistants into their professional role. Communication can show respect, create trust, and form a therapeutic relationship upon which recovery or sustainment may be based, both with clients/ patients, and colleagues. Where, for whatever reason, the client/patient is unable to initiate, respond, or understand verbal communication, the healthcare/nursing assistant must know and use create alternative forms of communication, potentially using facial expression, signs and gestures, pictures, and/or assistive technology. In patient care, the registered nurse may be the healthcare/nursing assistant’s closest colleague, mentor, and role model, from whom most epistemic knowledge is gained. Beyond inpatient care, the client’s or patient’s relationship with the healthcare/nursing assistant may be the most important factor in preserving their sense of identity and agency.
Medical science covers many subjects which try to explain how the human body works. Starting with basic biology it is generally divided into areas of specialisation, such as anatomy, physiology and pathology with some biochemistry, microbiology, molecular biology and genetics. For an intermediate role, such as healthcare/nursing assistant, the extent to which medical sciences are taught, may vary widely, often determined by the status afforded to the role itself, and where the programme sits in the hierarchy of qualifications and career paths. Good practice suggests that a minimum of anatomy, physiology, and pathology would form an irreducible part of the healthcare/nursing assistant’s knowledge and understanding, both for immediate use, and as a foundation for continuing learning. This knowledge is largely disciplinary and relates most directly to client care, service, and assistance. It also influences the quality of communication, relationship building and collaboration.
Being mindful of the diversity of VET for healthcare/nursing assistants, which reflects the diversity of the occupation itself, the knowledge in this category is largely epistemic and procedural. The disciplinary knowledge underpinning this category may be regarded as the essentials of the role, irrespective of other divergences. These include (the principles of) person-centred care, health and safety, hygiene, nutrition, first aid, and information handling. This category is quintessential: it is the place where, in various combinations, the healthcare/nursing assistant’s grasp of the other content categories is tested.
To a greater or lesser extent worldwide, healthcare is a regulated sector with strict norms and administrative requirements. In their intermediate role, the healthcare/nursing assistant is more personally accountable for what they do than in many equivalent occupations, because the consequences of error and neglect may be severe. This category comprises largely disciplinary content, which needs to be embedded into practice from the start of professional formation.
The 16 cross-cutting content topics that are presented in Annex 5.A vary in their relationship with the three types of knowledge: disciplinary, procedural, and epistemic, required for the role. While the order of the topics broadly relates to the sequence of the five content categories above, each has a different relationship with practice, as befits VET with its distinctive heuristics and significant reliance on conditional knowledge. In broad terms, 12 topics have a strong disciplinary content, and four stress procedural and epistemic knowledge. In keeping with its frequent conditionality, across these topics the knowledge requirement may be presented as applied.
Although most healthcare programmes include healthcare for babies and children, pragmatically the care of individuals below the age of 16 years has been excluded from this framework, due to the complexities of assessment for international comparison. For the same reason, mental illness other than that associated with ageing and the secondary effects of other illness has also been excluded.
The table below presents the desired distribution of items in the assessment over the five content knowledge categories. The rationale for this distribution is the same as for the healthcare processes (Table 5.3), namely the primacy of the client or patient, and what most directly serves their needs.
This section of the chapter outlines the approach taken to apply the elements of the framework described in previous sections to PISA-VET. This includes the response formats, item scoring, and the proposed reporting healthcare proficiency. This section also includes examples of test items.
Though related here to medical practitioners,
Figure 5.2 is applicable to and valid across the entire work spectrum. While knowledge and understanding are vital, they cannot replicate or replace the evidence gained from actual performance in real or simulated work settings. To “know about” is different from “can.” For VET assessment, each are essential. A key objective for this section is therefore to propose an approach which includes each layer of
Figure 5.2’s pyramid of performance. For national purposes, summative assessment for VET generally comprises live tests of practice plus tests of knowledge and theory. In so doing it covers actual performance while indicating the extent to which that performance is underpinned, generalised, and built upon through disciplinary, procedural, conditional, and epistemic knowledge and understanding.
The case for live performance assessment within the mix of assessment types is strong, and particularly so for testing procedural knowledge. However, for comparative assessment, testing conditional knowledge will be challenging. The scope and limitations of live performance testing for PISA-VET are worthwhile topics to explore during this development stage of PISA-VET. As explained in Chapter One, limited time is available to assess the employability and occupation-specific skill. For validity at scale, the model developed should be viable for the facilities in which VET programmes have been offered.
Source: (Miller, 1990[13])
The main purpose of the healthcare/nursing assistant’s role is to serve the client or patient within a therapeutic framework. Due to the holistic nature of the healthcare/nursing assistant’s role, a focus on the client or patient also draws on teamwork, planning, frameworks, and review, each of which are means to an end. In keeping with many national assessment systems’ practice, the focus on the client and patient leads to scenarios as the starting point and enabler of “knows, knows how, shows, does.” These are the hook on which to hang processes, underpinning capabilities, knowledge, and context. To position scenarios for assessment, a template has been created; see Table 5.6.
For two of three assessment types, scenarios should be developed either as a “highly immersive” basis for digitally simulated assessment tasks, as for example the assessments from the ASCOT+ initiative, or for actual live (or video recorded) performance assessment followed or preceded by additional assessment tasks. The aim is to create a menu of scenarios to enable a pair of assessments, one for immersive questioning, and one incorporating live performance, to be used for each assessment cycle. The below template shows a scenario which may be developed further for either immersive questioning, or live performance with live judges, followed by questions.
Note: A list of additional scenarios, with their potential for assessment and achievement range is given in the Annex of this chapter.
Based on practical experience elsewhere (WSI, 2022[2]), effective assessment of live performance takes around 30 minutes. Two scenarios, each incorporating 25-30 scores, possibly one based on immersive questioning and one live performance, would each comprise one third of the available assessment time (if the proposed 90-minute assessment of occupational-specific skills is maintained, see Chapter 1). There would also be opportunity for additional questions that may not flow naturally from the scenarios: for example, mathematics used for medication and testing. The package would therefore look like this.
Ideally, these three assessments would form a coherent package, which flows easily for the candidate. One means of achieving this would be to limit the basis of material to one client and one patient, with different health conditions: that is, to have fewer clients/patients, with more complexities.
Package design would require coordination, the immersive questioning and live performance being designed in tandem, and the separate Q&A testing then designed to achieve completeness and balance, relative to the needs of the work role. The assessment methods depend on the types and purposes of the competency being assessed:
Immersive questioning would assess disciplinary and procedural knowledge and understanding, using open and closed constructed responses, and selected responses, to cover know, know how, and to a limited extent, show.
Live demonstrations would both measure and judge performance against assessment criteria with detailed descriptors. These would be recorded as yes/no or 0-2/3 scales by moderated live markers. Reflective questions would mainly use open constructed responses.
Q&A testing would mainly use multiple choice and/or constructed response items.
The following questions lend themselves to multiple choice:
Key factors influencing dignity/rights/privacy/confidentiality of patients/colleagues (e.g. age, gender, beliefs) (tick all that apply).
The rights of patients regarding giving informed consent for treatment when required.
Which of the following blood pressure readings would cause concern regarding a woman who is 60 years old and without known health issues?
Before using a sterile package what should you do? (Tick all that apply).
The functioning of protection equipment (surgical mask, protective respirator). Tick correct answers.
Assessment will be by measurement and judgement, the former mainly being dichotomously scored, and the latter graded according to correctness or quality. The ratio of dichotomous scoring to grading is expected to be around 2:1. Taking the meaning of “item” to be an individual mark or score, however derived, it is known at live performance over 30 minutes would generate 25 to 30 items. It is surmised that immersive scenarios would generate items at a broadly similar rate. Supplementary questions may generate items more quickly. Therefore, over 90 minutes, 90 to 100 items may be expected.
The standard formats of learning outcomes, Bloom (Figure 5.1), and the available vocabulary banks for determining levels of achievement have been referenced to guide assessment criteria. This scale is derived from EQF and ISCED level descriptors across levels 3 and 4. It is expressed as situated learning outcomes, derived from knowledge and skill combined to create competence and capability graded against levels of autonomy, responsibility, and complexity. The essential knowledge and capabilities listed are simply examples. For the design of assessment, a fuller, detailed tabulation is required. The lower score limits will be determined with data in the second stage of the Development Phase according to the standard PISA scaling procedure.
For the design of assessment, account can be taken of the “natural” limits and scope of each scenario, which can then be adapted and selected or not, to ensure coverage of the full achievement range. As an illustration, the scenario Mr Peterson has had a bad fall (Table 5.6) enables achievement at the upper half of achievement but may be limiting for the lower half. The scenario concerning Mrs Garcia (Annex 5.C) may favour the lower half but limit differentiation.
The scenario in Table 5.6 shows planned differentiation. It covers a routine visit to help a client self-medicate for a new health condition. There are 23 items, each of which is individually well within what a healthcare/nursing assistant should know at EQF equivalent level 3. This scenario assesses the assimilation and naturalisation of competencies, in addition to each competency category individually. This live performance reflects a visit scheduled and is budgeted for 30 minutes.
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As noted in Chapter 5, the 16 cross-cutting content topics that follow vary in their relationship with the three types of knowledge: disciplinary, procedural, and epistemic, required for the role. While the order of the topics broadly relates to the sequence of the five content categories above, each has a different relationship with practice, as befits VET with its distinctive heuristics and significant reliance on conditional knowledge. In broad terms, 12 topics have a strong disciplinary content, and four stress procedural and epistemic knowledge. In keeping with its frequent conditionality, across these topics the knowledge requirement may be presented as applied.
Although most healthcare programmes include healthcare for babies and children, pragmatically the care of individuals below the age of 16 years has been excluded from this framework, due to the complexities of assessment for international comparison. For the same reason, mental illness other than that associated with ageing and the secondary effects of other illness has also been excluded.
Although the healthcare/nursing assistant’s professional relationships will generally be with nurses, they should understand the scope and boundaries of their and others’ roles more widely, and the conventions for acknowledging and addressing others in mixed professional settings. Their interdisciplinary knowledge should be sufficient to enable them to understand the perspectives, boundaries, and terminology used by allied professions, and to check their understanding and its relevance to their role if they are uncertain. They should know and adhere to the conventions for presenting, informing, and recording information, together with the distinctions between formal and informal speech and writing. They should recognise and clarify as necessary the explicit and tacit expectations of their role, including individual and collective ethics, accountabilities, and protocols.
As an adjunct to multi-professional collaboration: whichever setting the healthcare/nursing assistant is in, it is fundamental to know and apply set procedures for record-keeping, handovers, and emergency responses. According to the context, the healthcare/nursing assistant may work alone or in a team. If working in clients’ homes, they may be the only link between the client and healthcare services, thus being depended upon to transmit information and advice both ways, and to raise concerns if the client’s health or circumstances deteriorate. In nursing homes and clinical settings, they will be part of a larger team with set timetables and routines which they must be fully aware of.
The ability to communicate is a vital attribute of the healthcare/nursing assistant, requiring an advanced understanding of what communication comprises, and its role in creating and maintaining a therapeutic relationship. The healthcare/nursing assistant must learn and correctly employ an extensive new technical vocabulary, and several new speech registers. Thoughtful speaking and listening are important transmitters of information, emotion, and empathy. However, in many instances the client’s or patient’s communication skills (speaking and/or hearing) may be impaired, thus requiring alternative forms of communication, some of which may be based in new technologies. Culture and diversity also have a bearing on the extent to which communication can be verbal and oral. In these situations, body language needs to convey meaning, including showing insight and respect. Each of these abilities is a learned skill based on principles of practice.
The healthcare/nursing assistant should know and be able to use measurement, estimation and calculation, proportions, and formulae. They should be able to recognise and work with different numbering systems common to healthcare. They should be able to read, understand and use data in different formats, and communicate using mathematics. They should understand and be able to interpret basic patterns, trends, and risk, and know how to check for validity and accuracy.
The healthcare/nursing assistant should be able to identify and describe the various parts and functions of the systems of the human body. They should recognise the major physical and physiological changes of the human body as the individual grows and develops across a lifespan. They should understand the importance of appropriate nutrition. They should know the effects of pathological micro-organisms on the human body, and the use of common pharmacological products in healthcare settings. They should understand the healthcare needs of clients with alterations of various body systems requiring different methods of treatment.
The healthcare/nursing assistant requires a sufficient understanding of human actions to be able to anticipate and manage people’s behaviour, including their own. Behavioural science relevant to their role may be sociological, cultural, economic, psychological, and biological. The more the healthcare/nursing assistant can understand and objectify their clients’ and patients’ behaviours, the better they will be able to support them, because behaviour has both a direct and indirect impact on personal health. For the safety of both clients or patients, and themselves, the healthcare/nursing assistant must be able to recognise actual and potentially unsafe behaviours in a timely manner and be able to act accordingly.
Science underpins the role of the healthcare/nursing assistant. While demonstrating compassion and empathy for clients and patients, their support and interventions must be rationally driven. This requires an evidence-led approach, for which the principles of currency (up-datedness and completeness), relevance (significance), authority (dependability), and accuracy, are key. However brief, research should underpin each of preparation and planning, support and interventions, reflection, and reporting. It is the basis of critical thinking.
A healthcare need is associated with a potential or actual decline in a person’s ability and/or motivation to care for themselves and their surroundings. Hygiene and good nutrition may be at risk, often exacerbated by reduced mobility. The healthcare/nursing assistant must understand the importance of good nutrition and hygiene to wellbeing and recovery, and actively ensure the continuation of both through advice and coaching, performing housekeeping duties, advising on positive lifestyle changes, monitoring, and referral to other support services for dietary support and practical aids.
Basic nursing care comprises support with a client’s/patient’s health-related needs, including help with medication, nutrition, and supervision to ensure their safety. It also includes support for personal daily activities such as washing, dressing, eating, moving, and hygiene. It is associated with regularly recurring care services that are distinct from treatment care. Basic nursing care has a role at each stage of ill-health and infirmity: preventative, remedial, palliative, and restorative. It is unique in each case, with the client or patient ideally being a partner in their own recovery or maintenance. The healthcare/nursing assistant may be just one of the wider care networks, including friends and family. While referred to as “basic,” this branch of care is complex in its contextual diversity, including its physical setting, wider environment, support network, and the personal capacity, resources, and response of the client or patient. It may become very close to social care. The knowledge to guide actions from an early stage in healthcare/nursing assistants’ development will comprise guiding principles, planning models and methods, professional planning (time, resources, processes), rights and obligations, reflection, and reporting.
The healthcare/nursing assistant may need to participate in medical-diagnostic and therapeutic tasks, including in emergencies which, in healthcare, may and will happen, in such situations they need to know how to respond, quickly, and in what order. They must know where and how material, fluids, medication, and tests are stored for use in emergencies, and which tests to administer to ascertain the patient’s condition and assist in procedures. They must know which tests to administer to ascertain the person’s condition, and which immediate treatments are called for as a result. They should know how to treat and/or stabilise the person and their immediate situation, while detecting and reporting on observable effects or reactions. Under instruction they may need to collect additional medical data. They may need to perform simple first aid or wound care, to provide support aids, and therapeutically to reposition the person. Throughout this process the healthcare/nursing assistant may be both taking and giving instructions and guidance, from a superior professional on the one hand, and to family and friends on the other. This requires the confident application of a range of knowledge types
From principles to planning, actions, and reporting, health and safety is likely to be the first and most continuous topic in the healthcare/nursing assistant’s formal preparation and learned daily awareness. A healthcare need makes a person vulnerable to a multitude of risks and harm in addition to those directly relating to their disability or illness. If in the home, a previously safe space may become hazardous. If in hospital, risk is still present, from cross-infection to malfunctioning equipment. The client’s or patient’s dependency on others creates further risks, from the actions of friends, family, and strangers, to substandard care from healthcare/nursing professions. The healthcare/nursing assistant has safeguarding and other health and safety duties throughout the healthcare cycle, including the requirement to draft, conform to, and/or update risk assessments, depending on the care setting. When incidents and emergencies arise, they are also often the first responder, with the requirement for expert urgent action.
Information and data are key to safe and effective care. The healthcare/nursing assistant must work with standardised care assessment instruments and risk scales. They must be data-rational, knowing how to check and calibrate instruments, read, and interpret findings, and report them in an accurate and timely way. They should be confident users of the organisation’s information systems, purposes, and formats. Within the rules for data protection, they should collect and record relevant information regarding activities, habits, sensory perceptions, participation, and circumstances, likewise their response to medication. They should participate in continuous observation, monitoring, and updating.
Geriatric care is a large and growing part of the healthcare/nursing assistant’s role. The manifestations of a healthcare need may include fractures, delirium, dementia, incontinence, poor mobility, and frailty. Whether in hospital, residential care, or the client’s home, the healthcare/nursing assistant will form part of a multidisciplinary team, having a sufficient understanding of acute illnesses, chronic diseases, disabilities, and frailty, and the relevant medication and treatments, to fulfil their role. Where this is to assist rehabilitation, they may need to know what adaptations and aids are available, and how to arrange and support transfer between care settings. A knowledge of palliative and end of life care, and the associated legal and ethical issues relating to extreme dependency, is relevant.
Palliative care is given to improve the quality of life of patients with a serious or life-threatening disease, such as cancer. It addresses the whole person, not just their disease. It aims to prevent or treat, as early as possible, the symptoms and side effects of the disease and to address any related psychological, social, and spiritual problems. In a range of settings, the healthcare/nursing assistant must have sufficient knowledge of cancer or other diseases to follow instructions while fulfilling the spirit of palliative care, practically, and with other care givers such as family members.
In addition to cancer, other chronic diseases include diabetes, heart disease, obesity, stroke, and arthritis. They are conditions that normally last for at least one year, and require ongoing medical attention, or limit daily life, or both. Diabetes, cancer, and heart disease are leading causes of death in developed countries. Chronic diseases feature most in the health care of older adults. They are strongly associated with lifestyle habits such as lack of exercise, smoking, and excessive consumption of unhealthy food. On this account, the healthcare/nursing assistant’s caseload will be heavily associated with these chronic diseases: their prevention and mitigation. As with the immediately preceding topics, beyond the extent of disciplinary knowledge that characterises the occupation, deeper knowledge will go in tandem with caseloads and specialisation, for which the healthcare/nursing assistant requires self-learning skills and agency,
Administrative and legal frameworks differ across countries, settings, and organisations. For international comparative assessment is therefore on what matters irrespective of the administrative and legal arrangements in place. This comprises procedural and conditional knowledge: the healthcare/nursing assistant’s knowledge and understanding of their relationship with rules, procedures, and guidance, and their ability to respond appropriately. However, advanced a healthcare system may be, healthcare/nursing assistants are commonly expected to undertake tasks that are not within their role or that they have not been trained for. They must therefore know how to respond constructively to undue pressures exerted on them, for whatever cause or reason.
Four factors set the boundaries for a healthcare/nursing assistant’s role: the legal framework, professional requirements, organisational requirements, and their own role description and capacities. They must therefore know and understand the legal conditions under which they act, and the consequences of violations. They must also know and internalise the relevant codes of principles and ethics; recognise ethical dilemmas and conflicts and know when and how to refer these for advice and guidance. They must understand, support, and encourage self-determination, and respect the client or patient’s right to refuse care and treatment, and withhold consent. They should understand and respect the expectations of clients, patients, friends, and family. They should appreciate that within the law different organisations have different boundaries and procedures, not all of which may be compatible with processional standards. In such instances they need to check their understanding and seek advice.
This annex adds brief mention of the operational factors for on-site assessment of live demonstrations, referred to in this chapter as “performance assessment.” Though differing from OECD’s online infrastructure and superstructure for PISA, there exists a large-scale tested infrastructure for global performance assessment that might be adapted, applied, and connected at various points to PISA’s current arrangements.
These scenarios taken from the LSA-VET study (Baethge and Arends, 2009[5]) have the potential for a range of assessment types. Their correspondence to the chapter’s five processes is shown in brackets beside the titles.
Although the focus is on processes 3 and 4, below, each touch on other processes, knowledge, and contexts.
← 1. In the Standard Occupational Classification (SOC), which is mostly used in the United States, the medium-level healthcare occupations are “Home Help Aides” (31-1121), “Nursing Assistants” (31-1131), and “Personal Care Aides” (31-1141).