Roles, Responsibilities, Education, and Training of Healthcare Assistants In Long-Term Care: An International Evidence Review

Introduction to the evidence review

Worldwide, Healthcare Assistants (HCAs), also known by a range of alternative role titles (e.g., care worker, healthcare aide, and other terms discussed later), play a vital role in delivering direct care within long-term residential care settings. In this review, HCAs are defined as unregistered or non-regulated healthcare workers who provide direct personal, social, and supportive care to residents under the direction and supervision of registered healthcare professionals, primarily nurses [1-3]. The role typically involves supporting older adults and individuals with complex health and social care needs. Responsibilities commonly include providing fundamental care, assisting with personal care and activities of daily living (ADLs), monitoring basic health indicators, and offering emotional and social support to residents.

HCAs make a substantial contribution to the delivery of person-centred care and the effective functioning of multidisciplinary teams [2]. As frontline care providers, HCAs play a critical role in maintaining the safety, wellbeing, dignity, and quality of life of residents living in long-term care facilities [1]. However, the scope of HCA roles, role expectations, and the nature and extent of formal education and training vary considerably across countries and, in some cases, between regions within the same country [3]. Such variation has been associated with differences in workforce competence, the consistency and quality of care delivered, staff retention, and the sustainability of long-term care services [4]. Variations in standards and training also have important implications for resident outcomes, organisational efficiency, and the long-term sustainability of healthcare systems [1].

Global demographic change and population ageing have further intensified reliance on HCAs, particularly within long-term residential care, where demand for direct care continues to outpace workforce capacity [5,6]. The increasing prevalence of frailty, dementia, stroke, multimorbidity, and other chronic conditions has heightened the need for a skilled and sustainable HCA workforce capable of meeting increasingly complex care needs. Despite growing reliance on HCAs internationally, there remains limited comparative evidence examining approaches to HCA roles, responsibilities, education, training, and workforce development [4]. Much of the existing literature focuses on specific aspects of workforce training, role delineation, or regulation, providing fragmented insights rather than a comprehensive synthesis of international evidence to inform future policy and practice.

In Ireland, the HCA role has expanded significantly in response to demographic changes, policy reforms, and persistent healthcare workforce shortages. Despite this expansion, ongoing challenges remain in relation to role clarity, regulation, professional status, and recognition of the significant contribution HCAs make to long-term care [7,8]. Variability in education and training provision, together with limited opportunities for career progression, further compounds these challenges and may adversely affect workforce recruitment, retention, and the consistency of care delivery [9].

This paper highlights the importance of recognising HCAs not only as providers of direct care but also as integral contributors to care quality, resident safety, and the sustainability of health and social care systems. Investment in a well-educated, appropriately supported, and professionally recognised HCA workforce is essential to strengthening long-term care services and achieving positive outcomes for residents, families, healthcare systems, and wider society.

Aim

The aim of this literature review was to synthesise international evidence on Healthcare Assistant (HCA) roles, responsibilities, education, and training within long-term care settings, and to identify transferable insights to inform sustainable workforce development and support the delivery of safe, high-quality, person-centred care.

Objectives of the review:

1. To examine how Healthcare Assistants roles and responsibilities are defined across different international long-term care settings.
2. To explore the nature and scope of education and training programmes for Healthcare Assistants internationally.
3. To identify key themes, challenges, and best practices related to Healthcare Assistants workforce development.
4. To highlight transferable insights that may inform policy, workforce planning, and training frameworks within long-term residential care.

Methodology

Scope of the review

This literature review was undertaken as part of a wider study examining the roles, responsibilities, education, and training of Healthcare Assistants in Ireland. The scope of the review was guided by the overall aim and key concepts underpinning the study: the Healthcare Assistants role, long-term care, education, and training. The review sought to identify international approaches and evidence that could inform workforce development within the Irish long-term care context with transferable insights for other nations.

Literature review method

An integrative literature review methodology was employed to enable the inclusion and synthesis of diverse forms of published evidence, including empirical studies examining HCA role delineation, educational preparation, and workforce development strategies as well as previous reviews and commentaries. This approach facilitates a comprehensive understanding of complex healthcare workforce issues by integrating evidence from varied methodological and publication sources [10].

The analysis of policy and guidance documents was informed by structured approaches to document analysis commonly applied in health policy research, enabling systematic examination of policy intent, scope, implementation, and implications for practice [11]. Grey literature was included to provide a broader understanding of workforce policy, professional frameworks, and practice contexts, particularly in relation to the Irish healthcare system, and to reduce potential publication bias in evidence synthesis [12].

Databases and search strategy

Electronic searches were conducted in January 2026 using the EBSCOhost platform across key health and social care databases, including the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, and Health Source: Nursing/Academic Edition. The search period was limited to publications from 2016-2026 to capture contemporary evidence and emerging developments in HCA workforce roles, education, and training. Additional historical sources were included where relevant to provide contextual understanding.

The search strategy combined controlled vocabulary, keywords, synonyms, and Boolean operators to maximise retrieval of relevant literature. Key concepts included healthcare assistants, long-term care settings, roles and responsibilities, skills, competencies, education, and training. Subject headings, equivalent terms, and database-specific expanders were applied where available. Examples of the search strategy are presented in Table 1.

Search Set	Search Terms / Strategy	Search Mode
S1	Health care assistants AND (qualifications OR requirements OR training OR education) AND (responsibilities AND roles)	Proximity
S2	(health care assistants OR health care assistants OR HCAs OR nursing assistants OR support workers) AND older person care) AND (nursing homes OR care homes OR long term care OR long-term OR residential care OR aged care facility)	Proximity
S4	healthcare assistants AND nursing homes long term care AND (skills AND competencies)	SmartText Searching
S5	healthcare assistants AND (skills AND competencies)	Proximity

Table 1: Search terms.

Additional focused searches were undertaken on related areas, including healthcare regulation, scope of practice, competency frameworks, and continuing professional development, to capture evidence relevant to workforce governance and education.

Eligibility criteria

Literature was considered eligible for inclusion where it met the following criteria:

Inclusion criteria:

• ·English-language publications published between 2016 and 2026 (with additional historical references included where required for contextual insights);
• ·Peer-reviewed studies and relevant grey literature;
• ·Literature examining HCAs or equivalent roles within long-term residential care settings;
• ·Evidence addressing HCA roles, responsibilities, education, training, competencies, regulation, or workforce development;
• ·International evidence with potential relevance and transferability to the Irish long-term care context.

Exclusion criteria:

• ·Publications unrelated to HCAs or equivalent care roles;
• ·Studies examining HCAs working exclusively outside long-term residential care settings (e.g., acute hospitals or primary care);
• ·Publications that did not address HCA roles, responsibilities, education, training, competencies, or workforce development.

Consistent with integrative review methodology, interpretation of the evidence focused on identifying areas of variation, uncertainty, and inconsistency, as well as implications for workforce development, policy, and practice [13].

Analysis

In keeping with integrative review methodology, included literature was analysed using a structured thematic approach. An initial coding framework was developed inductively from key concepts, recurring topics, and patterns identified across the literature in relation to the objectives of the review. Articles and documents were reviewed systematically and relevant findings were extracted and coded according to the emerging framework. Codes were subsequently compared across sources to identify similarities, differences, and recurring themes within the evidence base. This process enabled synthesis of the key findings and identification of overarching themes relating to HCA roles, responsibilities, education, and training. Findings from the review are presented across four parts, consistent with the conceptual structure developed from the evidence synthesis [10].

Results

Overview of the included literature

The searches identified over 150 sources of information. The evidence originated primarily from Europe, the United Kingdom, North America, Australia, and New Zealand, reflecting diverse approaches to HCA roles, education, regulation, and workforce development in long-term care. The literature comprised qualitative, quantitative, mixed-methods, and evidence synthesis studies, together with policy and professional reports detailed in the full report [14],

The findings of the review are presented in four parts, to directly address the four objectives of the review:

• ·Part 1. Terminology and variation in Healthcare Assistant role definitions
• ·Part 2. International approaches to education and training programmes for Healthcare Assistants
• ·Part 3. Workforce development: challenges, opportunities, and best practices
• ·Part 4. System-level pressures and future directions

Part 1: Terminology and variation in healthcare assistant role definitions

Part 1 examines international variation in HCA terminology, role definitions, responsibilities, and scope of practice within long-term care settings. It highlights the challenges arising from inconsistent role boundaries and explores the evolving contribution of Healthcare Assistants to direct care, person-centred practice, and the delivery of safe, high-quality care.

1.1 Role definitions

Across the international literature, HCAs are generally characterised as unregistered or non-regulated healthcare workers who provide direct care to individuals in long-term residential care settings under the supervision and direction of registered healthcare professionals, primarily nurses [4,6,15,16]. Within this review, the HCA role is defined as encompassing workers who provide personal, social, and supportive care to residents requiring ongoing assistance with activities of daily living (ADLs), personal care, and health-related support over an extended period. Long-term residential care (LTRC) includes settings such as nursing homes, care homes, long-term care facilities, residential care facilities, and aged care facilities.

The literature identified education and training as distinct but complementary components of HCA preparation. Training was primarily described as the development of practical skills required to undertake specific care activities safely and consistently within healthcare settings. For HCAs, this commonly includes competencies such as infection prevention and control, moving and handling, basic life support, and recording physiological observations. Training is typically task-focused, competency-based, and aligned with organisational standards and requirements [15].

Education was described as a broader process involving the development of knowledge, understanding, critical thinking, and professional awareness. It supports HCAs to understand the principles underpinning their practice, including person-centred care, safeguarding, communication, ethical responsibilities, and reflective practice. The literature suggests that integrating both education and training supports safe practice, enhances care quality, promotes workforce development, and contributes to improved resident outcomes [16].

1.2 Variation in terminology and role titles

A wide range of titles are used internationally to describe roles comparable to HCAs in long-term care settings. Terminology varies according to healthcare systems, regulatory structures, professional hierarchies, and national education frameworks.

In Ireland and the UK, commonly used titles include Healthcare Assistant (HCA), Care Assistant, Care Worker, Support Worker, Nursing Auxiliary, and Healthcare Support Worker. In North America, particularly the United States and Canada, comparable roles include Certified Nursing Assistant (CNA), Patient Care Technician, Personal Support Worker, Continuing Care Assistant, Nurse Aide, and Personal Care Assistant [17,18].

In Australia and New Zealand, roles are commonly described as Aged Care Worker, Assistant in Nursing, or Personal Care Worker, with variation in employment arrangements and responsibilities [19]. Across Europe, equivalent roles are shaped by national languages, healthcare structures, and training systems. Examples include Pflegehelfer/in in Germany, Aide-soignant(e) in France, Verzorgende in the Netherlands, and Auxiliar de enfermería in Spain. Although these roles broadly align with HCA functions, the level of education, regulation, and scope of practice differs between countries (World Health Organization, 2019) [20].

The variation in terminology reflects wider differences in how care roles are regulated, formalised, and integrated within healthcare systems. Other internationally used terms include Direct Care Worker, Clinical Support Worker, Allied Health Assistant (AHA), Residential Care Worker, Home Care Assistant, and Unregulated Care Provider. Despite differences in terminology, these roles share a common purpose: providing essential, person-centred care and support, generally under the supervision of registered healthcare professionals.

Within Ireland, Healthcare Assistant is the most commonly used term. HCAs are recognised as frontline care providers who support the delivery of care under the direction and supervision of registered nurses or facility managers. HCAs responsibilities include assisting with direct care activities and contributing to the work of multidisciplinary teams across hospital, residential care, and community settings.

1.3 The supportive care dimension of the HCA role

Although much of the foundational literature examining HCA roles predates the timeframe of this review, more recent evidence continues to highlight the central contribution HCAs make to resident care and healthcare workforce sustainability. Working under the supervision of registered nurses and other qualified professionals, HCAs undertake a combination of direct care, observation, monitoring, and supportive activities. This close and sustained contact with resident’s places HCAs in a key position to recognise changes in physical, psychological, and social wellbeing and report concerns to nursing and clinical staff [16].

The literature emphasises the relational and communicative aspects of HCA practice. HCAs contribute to therapeutic relationships with residents and families, supporting person-centred approaches and influencing residents’ dignity, autonomy, and quality of life within residential care environments [21]. HCA responsibilities also extend to supporting routine clinical activities, maintaining documentation, and contributing to care planning processes under nursing supervision [15,22,23].

Contemporary evidence increasingly conceptualises HCAs as integral members of long-term care teams rather than solely task-based care providers. The contribution of HCAs extends beyond physical assistance to include emotional support, advocacy, companionship, and preservation of dignity for vulnerable older populations [16]. The increasing demand for these supportive roles reflects wider demographic trends associated with population ageing and increased care dependency, as highlighted by the Social Protection Committee and the European Commission [24].

Despite international recognition of the importance of HCAs, substantial variation remains in role expectations, education, and training. These differences contribute to variation in workforce competence, quality of care, and staff retention [25]. For example, evidence from Poland highlights the importance of effective collaboration between HCAs and nurses, with 77% of HCAs reporting good cooperation with nurses. However, participants identified the need for nurses to have greater awareness of HCA competencies to maintain effective teamwork. Clear regulations, role definitions, and validated education and training pathways were identified as essential for public safety [26].

1.4 Role ambiguity and boundary issues

A recurring theme across the literature was the lack of clarity regarding HCA roles, responsibilities, and professional boundaries. Historically, the HCA role developed to support registered nurses by undertaking activities considered to fall outside the professional nursing role, under the direction and supervision of qualified nurses [27]. HCAs have also been defined as workers who provide assistance and support to healthcare professionals across health and social care settings, with direct or indirect professional supervision [28].

The expansion of HCA roles has frequently occurred without corresponding development of regulation, clearly defined scopes of practice, or systematic education and training frameworks [28,29]. The literature identifies concerns that unclear role boundaries may contribute to inappropriate delegation, inconsistent expectations, and risks to patient and resident safety [27].

In Ireland, concerns regarding role definition and standardisation have also been identified. The independent think tank for Action on Social Change (TASC) reported that the HCA role remains insufficiently defined despite its growing importance within the healthcare system [9].

This review highlighted the absence of a nationally consistent role description and standardised task framework, resulting in uncertainty regarding responsibilities and potential overlap with nursing duties. Furthermore, variation in regulation, qualifications, pay, and employment conditions contributes to inconsistency across the sector [9].

1.5 Responsibilities of the Healthcare Assistant role

The literature identifies HCAs as undertaking a broad range of essential responsibilities across long-term residential and community care settings. Core responsibilities include supporting activities of daily living (ADLs), such as personal hygiene, dressing, mobility, feeding, and continence care, alongside supporting oral care, hydration, nutrition, comfort, and emotional and social wellbeing. HCAs also contribute to monitoring residents’ conditions, recognising changes in physical or psychological status, and reporting concerns to registered nurses and other healthcare professionals [2,30].

Although HCA work is frequently described in task-based terms, the literature increasingly challenges definitions of the role that focus solely on completion of specific tasks. Such approaches risk reducing care delivery to a checklist of activities and fail to capture the complexity of HCA practice. In everyday care environments, HCAs are required to interpret residents’ needs, prioritise care, recognise subtle changes in health and wellbeing, and adapt their approach according to individual circumstances. These activities require judgement, communication, and relational skills that extend beyond discrete care tasks.

A broader conceptualisation of the HCA role therefore recognises their contribution to continuity of care, resident wellbeing, and multidisciplinary team functioning [1, 2, 9]. The evidence indicates that the HCA role encompasses not only the provision of direct physical care but also ongoing observation, advocacy, reassurance, and support that contribute to safe and effective long-term care delivery.

1.6 Person-Centred Care and relational care

Person-centred care (PCC) is consistently identified within the international literature as a fundamental component of high-quality care, particularly for older adults and individuals with complex health and social care needs. PCC emphasises recognition of the individuality, preferences, values, adherence to human rights, relationships, and lived experiences of each person, with the aim of promoting dignity, autonomy, and meaningful participation in everyday life [14,31,32].

Within long-term residential care settings, PCC is associated with improved resident wellbeing, enhanced satisfaction with care, and stronger relational continuity between residents and care providers [33].

Given the significant proportion of direct care provided by HCAs, the literature highlights the importance of ensuring that education and training adequately prepare HCAs to deliver person-centred care. Effective preparation requires more than procedural competence and should include the development of empathy, compassion, communication skills, and reflective practice. These relational competencies enable HCAs to translate PCC principles into everyday care interactions and support meaningful relationships with residents [33].

Evidence from Australia demonstrates the potential value of experiential learning approaches in developing these competencies. Bennett et al. [34] examined an aged simulation training intervention involving 732 eligible staff members across eight group residential care sites. The three-hour simulation activity, which incorporated an aged simulation suit, resulted in improvements in aspects of compassion and person-centred approaches among aged-care staff [34]. This evidence highlights the importance of educational approaches that enable HCAs to understand residents’ experiences and develop compassionate, person-centred care practices.

1.7 Creating a healthy and homely living environment

The literature identifies HCAs as important contributors to creating safe, supportive, and meaningful living environments within long-term care settings. Achieving a healthy and homely environment requires collaboration between employers, managers, nursing staff, and HCAs, with each contributing to resident safety, wellbeing, and quality of life [35].

Research examining the experiences of nurse assistants in promoting meaningful daily life for older residents identified two key themes: the importance of building reciprocal relationships that strengthened residents’ self-esteem and supported co-created, equitable care; and the creation of meaningful interactions that fostered closeness and enabled residents to express appreciation. By applying PCC principles, nurse assistants enhanced both residents’ quality of life and their own professional satisfaction [34, 36].

The literature also highlights the importance of maintaining safe physical and psychosocial environments in long-term care. Legislative and organisational frameworks require employers and staff to address areas including fire safety, occupational health and safety, stress management, and workforce wellbeing [37]. Ensuring a safe and supportive environment requires effective risk management while simultaneously protecting resident dignity, autonomy, and quality of life [38].

1.8 Core care domains and scope of practice

The literature identifies several core care domains that underpin the HCA scope of practice. These include:

• Fundamental or essential care, including support with hygiene, hydration, nutrition, feeding, mobility, comfort, and movement.
• Observation and monitoring, including recognising changes in residents’ physical, psychological, or cognitive condition and reporting concerns appropriately.
• Delegated care, involving the performance of specific care activities delegated by qualified healthcare professionals, particularly registered nurses, within defined boundaries and under appropriate supervision [29].

In many healthcare systems, HCAs undertake delegated clinical activities following appropriate education, training, competency assessment, and professional oversight. In addition to direct care responsibilities, HCAs frequently contribute to documentation, communication, and the organisation of care processes within multidisciplinary teams.

However, the literature also identifies concerns regarding role expansion and role drift, particularly in contexts affected by workforce shortages and increasing care demands[39]. In some settings, HCAs may undertake activities beyond their formal education, training, or established scope of practice. This creates uncertainty regarding accountability, delegation, and professional boundaries, with potential implications for resident safety and quality of care.

The evidence therefore emphasises the importance of clearly defined roles, competency frameworks, appropriate education and training [40], and effective supervision. Clear guidance is required to ensure HCAs understand delegation boundaries, recognise changes in residents’ physical and mental health, and follow appropriate procedures for escalating concerns to registered healthcare professionals.

1.9 Specific responsibilities of HCAs caring for older adults

The literature identifies HCAs as providing compassionate, respectful, and holistic care to older adults in long-term care settings, supporting wellbeing, maintaining dignity, and promoting safe care practices [29]. HCA responsibilities extend across physical, psychological, social, and supportive domains and commonly include personal and intimate care, assistance with activities of daily living (ADLs), mobility support and prevention of frailty [41], nutrition and hydration, monitoring vital signs, infection prevention, communication, and end-of-life care. HCAs also contribute to the coordination and implementation of individualised care plans under the supervision of registered healthcare professionals [1, 42-44].

Although medication management does not come under the remit of Healthcare Assistants in Ireland legal and ethical principles and patient centred care are mentioned in the British Journal of Healthcare Assistants and safe medication management is presented by the WHO [45-48].

Activities of Daily Living

Supporting ADL represents a core component of HCA practice and include supporting hygiene, oral care, nutrition, hydration, mobility, continence, pressure ulcer prevention, wound care, and palliative and end-of-life care. Effective delivery of these responsibilities requires HCAs to understand the complex interaction between physiological, psychological, sociocultural, environmental, and socioeconomic factors influencing health and wellbeing [49,50].

Oral care

Oral health is an important component of quality care for older adults, with poor oral health commonly reported among residents in long-term care and associated with negative impacts on health, nutrition, and quality of life [51]. The National Institute for Health and Care Excellence (NICE) guideline NG48, Improving Oral Health in Care Homes, provides recommendations to support improved oral care practices. However, evidence regarding implementation and effectiveness remains limited. Tsakos et al. [52] evaluated an oral health intervention based on NICE recommendations across 22 care homes in London and Northern Ireland involving 119 residents. The intervention, which included staff education and use of the Oral Health Assessment Tool (OHAT), demonstrated feasibility, with high completion rates for oral care plans (90%). Further evidence indicates that caregiver education and ongoing support can improve oral health outcomes among dependent older adults [53,54]. However, oral care remains an area requiring greater prioritisation, staff knowledge, organisational support and oral health education [55,56].

Nutrition and hydration

Nutrition and hydration support are central responsibilities within HCA practice and contribute significantly to maintaining health and wellbeing of older adults [57]. While HCAs frequently provide direct feeding support, the wider care team shares responsibility for ensuring dignity, privacy, and a positive mealtime experience. Blomberg et al. [58] explored staff perspectives on mealtimes in nursing homes through seven focus groups involving 52 participants, including HCAs. Findings highlighted that those mealtimes represent more than nutritional support; they provide opportunities for social interaction, relationship-building, and recognition of individual preferences. The study emphasised the importance of collaborative approaches to prevent nutritional care becoming fragmented.

Pressure ulcer prevention and wound care

Pressure ulcer prevention was identified as an important area of HCA responsibility, requiring appropriate knowledge, skills, and ongoing education. Liu et al. [59] explored the experiences of 10 healthcare support workers involved in pressure ulcer prevention. Participants demonstrated strong commitment to preventing harm; however, barriers included limited knowledge and skills, staff shortages, workload pressures, and variation in practice. The findings highlight the need for structured training, teamwork, and organisational support.

In some long-term care settings, HCAs are increasingly involved in supporting wound management, particularly for residents with chronic or complex wounds [60]. Given the potential risks associated with inappropriate wound care, competency-based education is required to support safe practice. Structured programmes such as the Wound Resource and Education Network (WREN) provide targeted education in areas including wound assessment, dressing selection, infection prevention, and monitoring healing progress. Such initiatives have been associated with improved confidence, competence, and care outcomes among HCAs. The need for improved wound care education is further emphasised by the significant healthcare burden associated with wound management, estimated at £5.3 billion annually in the UK, with limited access to specialist expertise and workforce knowledge gaps identified as contributing factors [61].

Palliative and end-of-life care

HCAs play an important role in supporting older adults receiving palliative and end-of-life care. Palliative care focuses on improving quality of life and relieving symptoms for people living with serious or life-limiting illness, whereas end-of-life care represents a specific phase of palliative care focused on comfort, dignity, and support for individuals and families during the final stages of life [30,62].

Keywords: The literature highlights both the emotional importance and challenges associated with HCA involvement in end-of-life care. Saunders [42] found that HCAs often felt marginalised and undervalued and identified the need for greater education, organisational support, and recognition of their contribution. Molloy and Phelan [63] explored palliative care experiences among 16 nurses and 18 HCAs working in long-term care facilities. Three themes emerged: living, reflecting the importance of maintaining quality of life; loving, describing the emotional relationships developed between staff, residents, and families; and letting go, capturing experiences of death, loss, and bereavement. The study highlighted the importance of recognising staff emotional experiences and providing support to enhance resilience.

The need for structured palliative care education and competency development for HCAs is consistently identified within the literature. The Royal College of Nursing [64] recommended that HCAs providing palliative care should receive appropriate skills development under the supervision of qualified professionals. White et al. [62] examined palliative care competencies, including knowledge, behaviours, attitudes, and education needs among nurses and HCAs providing supportive (Level 2) palliative care. Communication and education were identified as key competency domains with important implications for workforce preparation [65].

Overall, the evidence demonstrates that HCA responsibilities extend beyond task completion to encompass holistic, relational, and supportive care. The breadth and complexity of these responsibilities highlight the importance of appropriate education, standardised induction, competency development, supervision, and recognition of the HCA contribution within long-term care systems [66].

Part 2: International approaches to education and training programmes for Healthcare Assistants

Part 2 examines international approaches to HCA education and training and identifies key themes relating to entry and pre-employment preparation, workplace learning and induction, continuing professional development (CPD) and competency development, career progression pathways, and educational approaches and learning environments.

2.1 Entry and pre-employment preparation

The literature highlights the importance of appropriate entry requirements, pre-employment preparation, and structured training pathways in developing a skilled and sustainable HCA workforce. The OECD [4,40] emphasises that improving working conditions, including remuneration, career development opportunities, staffing levels, and access to education and training, is essential to making care work attractive and sustainable while supporting a resilient workforce capable of delivering high-quality, person-centred care.

For HCAs, effective preparation includes clear role definitions, standardised induction, appropriate delegation processes, access to professional development opportunities, and recognition of their contribution to long-term care delivery. Evidence suggests that more structured preparation pathways support clearer role expectations, greater accountability, stronger integration within multidisciplinary teams, and improved professional recognition [67,68].

International variation exists in the organisation and standardisation of HCA education pathways. In the UK, HCAs have access to structured vocational qualifications, workplace induction programmes, and continuing professional development opportunities aligned with Skills for Care competency standards [15]. These frameworks support HCAs to develop competencies required for person-centred care and increasingly complex care situations.

In contrast, many European countries have less standardised approaches to HCA education and workforce preparation, with variation in entry requirements, regulation, and training pathways. In Ireland, evidence indicates that HCA education and training remain variable across public and private long-term care settings, with inconsistencies in induction practices and limited access to structured CPD opportunities [7,8,69]. Similarly, in parts of North America, HCA equivalents, such as Certified Nursing Assistants, typically undertake mandatory pre-employment education, certification requirements, and supervised clinical practice; however, ongoing professional development requirements are less consistently embedded [23].

Overall, evidence from jurisdictions with more structured entry, induction, and education systems indicates positive workforce outcomes, including improved competence, reduced turnover, and enhanced quality of care [16].

2.2 Workplace learning and induction

Structured workplace induction was identified as an important component of HCA preparation, supporting staff to understand their scope of practice, delegated responsibilities, organisational expectations, and professional boundaries [37]. Internationally, effective induction programmes commonly combine classroom-based education, e-learning, workplace orientation, observation of experienced staff, and supervised practice.

The literature suggests that combining theoretical learning with supported workplace experience enables HCAs to apply knowledge in practice, develop confidence, reduce errors, and comply with organisational and legal requirements [37]. Informal workplace learning also contributes significantly to HCA development. Through daily interactions with residents, observation of experienced colleagues, reflective practice, and participation in routine care activities, HCAs develop practical skills, clinical awareness, and professional confidence [70].

Workplace learning environments that support reflection, supervision, and continuous improvement enable HCAs to adapt to changing responsibilities and increasingly complex resident needs [71,72]. These findings highlight the importance of viewing induction and workplace learning as ongoing processes rather than one-time events.

2.3 Continuing Professional Development and competency training

Continuing professional development (CPD) was consistently identified as an important mechanism for maintaining and enhancing HCA competence, supporting quality improvement, and improving workforce retention and job satisfaction. However, the literature indicates that access to CPD opportunities remains inconsistent within long-term care settings internationally.

Evidence highlights the importance of organisational support, effective leadership, and positive workplace cultures in facilitating staff engagement with CPD and enabling the translation of new knowledge and skills into practice [73]. CPD is particularly important as long-term care populations increasingly include older adults living with frailty, dementia, multimorbidity, and complex health and social care needs [74,75].

A systematic review by Aleo et al. [76] found that linking CPD opportunities with career progression pathways and managerial support may increase the attractiveness of employment in long-term care while improving resident outcomes and staff satisfaction. Similarly, a scoping review by Fitzpatrick et al. [77] examined professional development and career planning for nurses working with older adults in care homes between 2010 and 2021. Key factors associated with effective professional development included access to structured learning opportunities, education tailored to older adult care, adequate staffing levels, protected study time, flexible working arrangements, and supportive workplace environments.

King et al. [78] identified factors influencing the impact of CPD across individual, team, organisational, and system levels. These included staff motivation, relevance of learning to everyday practice, preference for workplace-based learning, supportive leadership, and a positive organisational culture. Collectively, these factors were associated with improvements in person-centred care and service outcomes.

The literature indicates that combining formal education, competency assessment, and workplace-based learning supports HCAs to develop and maintain the skills required to meet evolving workforce demands while maintaining resident safety and care quality [61,37,76] [79]Hsu et al., 2022). However, Samuel et al. [80] highlighted the need for further research examining the financial and workforce resources required to implement sustainable CPD programmes within long-term care settings.

2.4 Career progression and development opportunities

Career development was identified as an important component of HCA workforce sustainability, providing opportunities for progression, skill enhancement, increased responsibility, and professional recognition. The literature highlights a range of structured development opportunities available to HCAs, including additional certifications, competency-based programmes, and specialist training in areas such as dementia care, palliative care, and wound management [37,61].

Beyond technical competencies, evidence highlights the importance of developing HCAs’ confidence in recognising and responding to residents’ changing needs, escalating concerns appropriately, and understanding the impact of small, everyday interactions on residents’ experiences of care [81]. These aspects reflect the relational and person-centred dimensions of HCA practice that extend beyond task-based responsibilities.

However, access to career development opportunities remains inconsistent internationally. The literature identifies organisational, financial, and policy-related barriers that can limit participation in education and progression pathways, particularly where roles lack formal recognition, standardised competency frameworks, or established routes for advancement [25, 50, 82]. Limited opportunities for progression may contribute to reduced workforce motivation, challenges with retention, and difficulties in attracting staff to long-term care roles.

2.5 Educational approaches, assessment, and learning environments

The literature identifies the importance of appropriate educational approaches, assessment strategies, and supportive learning environments in preparing HCAs for increasingly complex care roles. Hayes, Garfield, and Beardmore (2015) examined pedagogical approaches underpinning HCA education and healthcare workforce development in the United Kingdom, highlighting the value of experiential learning, evidence-informed education, reflective practice, and collaborative partnerships between higher education institutions and healthcare providers.

As HCA roles continue to develop and become increasingly formalised in some healthcare systems, the need for robust learning environments has become more prominent. For example, the introduction of the Care Certificate in England sought to establish a consistent foundation of knowledge, skills, and behaviours for healthcare support workers. Effective learning environments, both clinical and academic, are considered important in supporting educational quality, workforce preparedness, and the development of professional identity (Health Education England et al., 2015).

Peate [71] similarly emphasises the importance of accessible, structured, and clinically relevant learning opportunities to support the development of a competent, confident, and professional HCA workforce. However, the literature identifies limited evidence regarding HCA learning preferences, preferred educational modalities, and the most effective approaches for supporting learning across diverse HCA populations.

The evidence also highlights that HCA competence extends beyond the demonstration of technical skills. HCAs are required to integrate knowledge, values, communication skills, and compassionate behaviours into everyday interactions with residents. Education and assessment approaches therefore need to recognise both task-based competence and the relational skills required to deliver person-centred care [83].

Part 3: Workforce Development: Challenges, opportunities, and best practices

Part 3 synthesises key themes identified within the literature relating to workforce development challenges, opportunities, and best practices in long-term care. Findings are organised into four interconnected thematic areas: regulation and workforce governance, workforce sustainability, education and development, and system-level innovation.

3.1 Regulation and workforce governance

Regulation debates

The literature highlights that HCAs remain largely unregulated in many countries, despite their substantial contribution to direct care delivery. Netherwood [84] argues that if education, training, and regulatory oversight are considered essential for ensuring the quality and safety of care provided by registered nurses, similar principles should apply to HCAs who also undertake significant responsibilities in patient and resident care.

Regulation has the potential to support consistent standards of practice, promote accountability, and strengthen access to education and professional development opportunities. These measures are considered important in sustaining the principles of safe, compassionate, and person-centred care within healthcare systems [75].Foundas [38] further highlights the concept of the “dignity of risk” within residential aged care, emphasising the importance of staff understanding and appropriately managing risk while respecting resident autonomy.

However, the literature also identifies challenges associated with regulation, professional recognition of HCAs, and the contribution of internationally educated nurses (IENs) working in HCA roles. Allan and Westwood (2016) explored experiences of internationally educated nurse and identified barriers to obtaining UK nurse registration, particularly related to English language testing requirements and perceived inconsistencies in registration processes as the barriers to working as HCAs.The challenges of language assessment for IENs have been documented in many other countries [85]. Consequently, some IENs remained employed as HCAs for many years despite holding nursing qualifications in their countries of origin. The evidence suggest that employer-supported language development and clearer progression pathways could assist these workers in achieving professional registration.

Duignan et al. [86] examined the application of risk-based regulation (RBR) within nursing and midwifery regulation in Ireland, with particular consideration of implications for HCAs. Risk-based regulation focuses regulatory attention on areas where potential harm is greatest rather than relying solely on rigid compliance requirements. Drawing on responsive regulation theory and right-touch assurance approaches, the authors argue that proportionate regulatory mechanisms should consider both intrinsic and extrinsic risks.

Given that HCAs provide substantial elements of direct care while frequently remaining outside formal regulatory systems, approaches such as organisational regulation, clearly defined delegation frameworks, competency standards, and appropriate supervision may enhance patient safety without creating unnecessary regulatory requirements at the individual level. Although challenges remain, including differing perceptions of risk and political influences on regulatory approaches, risk-based regulation may provide a flexible framework for supporting workforce development while maintaining quality and safety standards [86].

Professionalisation of Healthcare Assistant roles

The professionalisation of HCA roles remains an ongoing international debate. Kessler et al. [87] distinguish between specialist expertise, where professions seek to relinquish routine tasks, and holistic expertise, where professions retain broader responsibility for a range of care activities. Their analysis of nurse–HCA relationships identified a fragmented pattern of nursing work consistent with a specialist-discard model, where aspects of care are increasingly transferred to support workers. In Ireland, Grainger [88] highlights ongoing discussion regarding professionalisation and the appropriate level of oversight required for HCAs, particularly in response to the expanding scope of their responsibilities and increasing involvement in direct resident care.

Safe staffing and skill mix

The literature identifies HCAs as an important component of discussions regarding workforce shortages, skill mix, and safe staffing. However, approaches to defining and regulating staffing requirements vary considerably internationally.

A study in Italy examined staffing standards across residential care facilities through analysis of 45 regional regulatory documents. Findings demonstrated considerable variation in staffing requirements, with nursing care allocation in intensive residential care settings ranging from 90 to 148 minutes per resident per day. While staffing standards commonly specify requirements for nurses, equivalent standards for other workforce groups, including HCAs, physiotherapists, and social workers, are less consistently defined [89].

The potential contribution of HCAs to addressing workforce shortages has also been examined internationally. Fitzgerald et al. (2020) explored whether HCAs could contribute to addressing nursing workforce deficits in Kenya, drawing on examples from Europe. The authors highlight considerable variation in support roles internationally and describe how financial pressures and workforce shortages have contributed to task-shifting from nurses to HCAs in many European Union countries.

However, task-shifting raises important considerations regarding appropriate skill mix, education and training requirements, accountability, and regulatory oversight. While HCAs may contribute to addressing workforce gaps, evidence suggests that introducing or expanding these roles requires careful planning to ensure safety, effectiveness, and sustainability (Fitzgerald et al. 2020).

Healthcare Assistant role expansion and professional supervision models

The literature indicates that successful integration of HCAs into healthcare teams requires clear role definitions, appropriate delegation processes, structured education, and professional recognition [90]. Without these foundations, role expansion may contribute to uncertainty regarding accountability, boundaries, and expectations.

Historical examples from nursing workforce development demonstrate the importance of clearly defined roles and governance structures. For example, the Enrolled Nurse (EN) role in the UK, introduced in 1961 as a second-level nursing registration, was phased out by the mid-1980s, with training discontinued by 1992. More recently, the Nursing Associate (NA) role, introduced in England in 2017, was developed to bridge the gap between HCAs and registered nurses. However, Shiel et al. [91] highlight that these expanded roles provide important lessons regarding the need to recognise the distinct knowledge, skills, and contributions of staff groups providing ongoing direct care to residents.

Research indicates that HCAs can support healthcare delivery by undertaking fundamental and delegated care activities, enabling registered nurses to focus on more complex clinical responsibilities [92]. Effective integration of HCAs within multidisciplinary teams and interdisciplinary approaches, supported by appropriate supervision and role clarity, has been associated with improved continuity of care, higher resident satisfaction, and enhanced quality outcomes [93,94].

3.2 Workforce sustainability and wellbeing

Retention

Retention challenges among HCAs are evident across multiple health systems, including Ireland, the UK, Canada, and Australia. However, the literature indicates that several factors influencing retention are amenable to policy and organisational intervention. In particular, workplace conditions, access to job resources, supportive leadership, and opportunities for development influence staff experience, engagement, and the ability to provide high-quality, person-centred care.

Maintaining quality care within long-term care settings requires attention to the wellbeing of the workforce delivering that care. Midje et al. [95] highlight the importance of the relationship between job demands and job resources in shaping work engagement and supporting person-centred practice. Their findings suggest that workforce wellbeing is closely linked to care processes and the capacity of staff to provide relational, consistent, and individualised care.

Job satisfaction and wellbeing

Keywords: Despite the important contribution of HCAs to long-term care delivery, challenges relating to workload, burnout, limited role recognition, and low morale remain prevalent, particularly in settings already experiencing staffing pressures [66,96]. These workforce challenges can contribute to missed care, care left undone, and variation in care quality, with potential implications for resident outcomes [97] (Jones et al., 2020; Kalisch et al., 2009;. Inadequate supervision, unclear role boundaries, and limited regulatory oversight may further increase risks where HCAs undertake responsibilities beyond their training [98].

Job satisfaction is consistently identified as an important factor influencing HCA retention and quality of care. Conyard et al. [29], in examining HCA experiences in Ireland, found that only 11% of respondents reported a high degree of overall career satisfaction, while 87% reported average levels of satisfaction. Similarly, intrinsic satisfaction, relating to enjoyment and fulfilment derived from the work itself, was reported as high by only 6% of participants, with 91% reporting average levels.

The same study assessed general wellbeing using the General Wellbeing Schedule [29]. Findings indicated that 54% of respondents experienced positive (41%) or low-positive (13%) wellbeing, while 13% reported marginal wellbeing and 31% experienced significant stress or distress. These findings demonstrate both the commitment of HCAs to their roles and the ongoing need to address workforce wellbeing and job satisfaction.

The literature identifies several factors associated with improved HCA satisfaction and retention. Formal recognition of skills and competencies may enhance intrinsic satisfaction and strengthen perceptions of professional value [99]. While Conyard et al. [29] highlight the importance of supportive working environments, effective teamwork, workload management, and strategies to address occupational stress. Peer support and mentoring approaches may also contribute to workforce development, with McIntosh et al. [100, 101] and Boyce et al. (2022) identifying the potential for experienced HCAs to support new entrants and contribute to team-based learning.

Career attractiveness and workforce development

The attractiveness of HCA roles remains a significant workforce challenge. In the study by Conyard et al. [29], many participants were uncertain about their level of occupational satisfaction, suggesting opportunities to strengthen recruitment and retention strategies. The authors argue that greater recognition, structured career pathways, and professionalisation of the role are required to enhance the attractiveness of HCA employment in Ireland while supporting patient safety, workforce wellbeing, and public health outcomes.

The literature consistently identifies competency development as closely linked with care quality, staff retention, and job satisfaction. Opportunities to acquire and demonstrate skills through recognised education and competency frameworks may strengthen workforce confidence, improve role clarity, and support retention of HCAs in healthcare roles [1, 86,102].

3.3 Education, skills, and professional development

Training and workforce development

The literature highlights the importance of sustained investment in workforce development within residential care settings and community-based care more broadly. Scoping review evidence from Fitzpatrick et al. [77] emphasises the need for structured professional development opportunities and career planning to support the long-term care workforce. Education, induction and training are identified as important mechanisms for enhancing unregulated healthcare workforce capability, improving care quality, and supporting staff retention [67, 68].

Evidence from McCabe et al. [103] demonstrates the potential impact of targeted workforce education. Their study found that a staff training intervention within residential aged care settings resulted in significant improvements in residents’ quality of life compared with standard training approaches. These findings reinforce the importance of moving beyond basic task preparation towards education that develops the knowledge, skills, and values required for person-centred care.

At a policy level, the European Commission’s Green Paper on Ageing highlights the need to strengthen workforce capacity through ongoing education, training opportunities, and intergenerational approaches to address the challenges associated with population ageing (European Commission, 2021). The evidence indicates that workforce development strategies must consider both current care demands and the increasing complexity of future long-term care needs (HealthcareJobs.ie (2026)

Competency development and interprofessional education

The inclusion of HCAs within interprofessional education (IPE) initiatives has been identified as an opportunity to strengthen workforce capability and integration within multidisciplinary teams. Participation in interprofessional learning can improve communication, collaborative working, understanding of professional roles, and recognition of the contribution of different members of the care team [101]. For HCAs, IPE may support greater clarity regarding professional boundaries, delegation processes, escalation procedures, and teamwork, while also providing opportunities for mentorship and shared learning. Improved collaboration and role understanding across healthcare teams have the potential to enhance care coordination and contribute to improved resident and patient outcomes [104,105].

Digital skills and workforce innovation

Digital technologies are increasingly recognised as offering opportunities to strengthen health and care systems and support workforce development. Socha-Dietrich [106] highlights the importance of engaging and empowering healthcare workers to participate effectively in the digital transformation of healthcare.

The OECD [69] identifies the potential for technology to improve productivity and efficiency within care systems through better use of workforce skills, improved information management, and support for preventive approaches that may reduce dependency and avoidable hospital admissions. However, the literature also emphasises the importance of appropriate safeguards, including transparency, data protection, and consideration of digital literacy among healthcare workers.

For HCAs, developing appropriate digital competencies may support improved documentation, communication, care coordination, and access to information. However, successful implementation requires education and training that considers the diverse learning needs and existing digital confidence of the HCA workforce.

Part 4: System-Level pressures and future directions

Part 4 presents key strategic insights derived from the literature, focusing on future directions for strengthening the HCA workforce in long-term care. The findings highlight the importance of addressing system-level pressures through integrated workforce planning, appropriate governance, recognition of HCA contributions, and sustainable approaches to education and role development.

4.1 Cost of care and workforce sustainability

HCAs play an important role in reducing the human and economic burden associated with nursing-sensitive adverse events, including pneumonia, delirium, urinary tract infections, and pressure injuries [5]. Through their continuous presence in long-term care environments, HCAs are well positioned to contribute to prevention, early recognition of deterioration, and ongoing monitoring of residents’ health status. Effective utilisation of HCA skills therefore has potential implications for resident outcomes, operational efficiency, and the wider sustainability of healthcare delivery.

The funding environment for residential aged care in Ireland is complex and constrained. A significant proportion of residents rely on State-funded support, while the sector is simultaneously influenced by wider economic reforms and trends towards privatisation. These factors may affect resource allocation, staffing capacity, access to education and professional development, and the overall sustainability of the workforce. The literature highlights the interconnected relationship between workforce planning, funding models, regulation, and the structured development of HCA roles and career pathways across care settings [107].

4.2 Strategic insights and future directions for HCA workforce development

The literature identifies several strategic directions required to strengthen the HCA workforce and support sustainable long-term care systems. These approaches reflect a shift towards more integrated, person-centred, and future-focused workforce models, emphasising coordinated planning, workforce recognition, role development, and appropriate governance.

Integrated workforce planning

Integrated workforce planning that aligns workforce numbers, skills, competencies, and service requirements is identified as essential for long-term care sustainability. Effective planning approaches should account for demographic change, increasing levels of dependency, and the growing complexity of residents’ health and social care needs [4,108]. Workforce strategies that incorporate HCAs as a valued component of multidisciplinary teams have the potential to improve service capacity, reduce pressure on registered professionals, and support continuity of care.

Regulation as an enabler of standards and professional recognition

The literature suggests that regulatory frameworks should be viewed as mechanisms for supporting quality, accountability, and professional development rather than solely as restrictive processes. Proportionate regulation can provide clearer role boundaries, support competency recognition, and facilitate safe role development while maintaining appropriate standards of care [109].

Clearer role distinction, formal recognition, and structured career pathways are consistently identified as important factors in improving workforce retention and job satisfaction [110,7]. These approaches should also recognise the diversity of the HCA workforce, including the contribution of migrant workers and the importance of addressing issues relating to gender, age, and workforce inclusion. Whelan et al. [39] explored the strategic optimisation of the allied health assistant workforce by recommending one step at a time, with this step being identification of workforce governance.

Digital capability and role development

The literature identifies digital skills development and strategic role expansion as increasingly important components of future HCA workforce development. As long-term care systems respond to ageing populations and increasing care complexity, HCAs require appropriate preparation to engage with digital technologies, support information management, and contribute effectively within evolving models of care [111,112].

Strategic workforce development that combines appropriate education, role clarity, and digital capability may contribute to improved quality and safety of care, reduced workforce burnout, enhanced retention, and greater resilience within long-term care systems [113, 28]. Zigante [114] explored the role of new technologies in modernising long-term care systems by monitoring the social environment.

4.3 Scope of practice, competency development, and professional identity

The literature highlights the importance of reframing regulation as a mechanism for protecting standards, supporting workforce development, and maintaining public confidence in healthcare delivery. Appropriate governance structures can support clearer career pathways, recognition of competence, and improved workforce sustainability [88].

Continuing professional development (CPD) linked to career progression structures, leadership opportunities, and professional recognition, may strengthen motivation and retention while contributing to improved care quality and resident outcomes. Downie et al. [115] define scope of practice as the boundaries of a healthcare worker’s knowledge, skills, and experience, encompassing the activities undertaken within their professional role. However, inconsistencies in how SOP is defined and applied, such as in the case of HCA roles, can create uncertainty regarding professional boundaries and may affect the delivery of safe, effective, and efficient care.

Overall, the literature emphasises the need for clearly defined roles (and SOP boundaries), standardised induction, competency-based training, and appropriate supervision. Workforce development approaches should support both technical competence and effective collaboration within multidisciplinary teams. Interprofessional learning is identified as an important strategy to enable HCAs to work effectively alongside nurses, allied health professionals, and other members of the care team to deliver coordinated, person-centred care.

Education and training programmes should include core competencies such as communication, personal care, mobility support, nutrition and hydration support, and clinical observations, alongside more specialised areas including wound care and palliative care. Clearly defined competency assessments are required to support safe practice and accountability [4,9]. Informal workplace learning also remains an essential component of HCA development, complementing structured education programmes and supporting the maintenance of high standards of care through experiential learning and daily practice [116-118,103].

4.4 Workforce sustainability

The literature identifies workforce sustainability as a critical challenge in the context of increasing demand for long-term care. Internationally, recruitment and retention difficulties are influenced by workload pressures, inadequate remuneration, limited career progression opportunities, and challenges in recognising the contribution of care workers [9,108]. These pressures have implications not only for workforce stability but also for continuity, safety, and quality of resident care.

Evidence indicates that strategies supporting HCA wellbeing, recognising experience and skills, and providing structured career development pathways are associated with improved staff retention and enhanced quality of care [7,9]. The increasing reliance on migrant HCAs in Ireland, many of whom are internationally educated nurses who have not met Irish regulatory requirements for nursing registration, further highlights the importance of equitable employment practices, appropriate recognition of skills, and targeted support to facilitate integration within the long-term care workforce [110].

The literature suggests that a sustainable HCA workforce requires coordinated action across policy, organisational, and educational systems. This includes recognition of the HCA role beyond task completion, acknowledging the supportive, relational, and advocacy functions that contribute significantly to residents’ experiences of care.

In Ireland, pathways for pre-employment preparation and workplace learning are available; however, gaps remain in relation to consistent induction practices, accessible and practice-relevant continuing professional development, and integration of digital competencies into HCA education and practice [7,8]. Furthermore, redefining HCA competence beyond technical task performance to incorporate relational care, advocacy, protection of residents’ rights, communication, and meaningful engagement is identified as essential to strengthening the professional identity of HCAs and improving long-term care outcomes [107].

Conclusion

This review synthesised international evidence on the roles, responsibilities, education, and training of HCAs within long-term residential care. The findings confirm that HCAs are fundamental to delivering safe, high-quality, person-centred care, particularly in the context of population ageing, increasing dependency, and growing complexity of care needs. Despite their essential contribution, the HCA workforce remains inconsistently defined, variably supported, and insufficiently recognised across healthcare systems.

The review highlights substantial international variation in HCA roles, scope of practice, education, and regulatory approaches, contributing to role ambiguity, inconsistent workforce expectations, and challenges for accountability and delegation. Evidence consistently indicates that clearly defined roles, competency-based education, structured induction, continuing professional development, effective supervision, and supportive governance strengthen workforce capability, retention, and quality of care. At the same time, workforce sustainability continues to be challenged by recruitment and retention difficulties, limited career progression, workload pressures, and the increasing complexity of long-term care.

International evidence offers valuable insights for strengthening the HCA workforce in Ireland. A strategic, coordinated, and evidence-informed approach is needed to support greater role clarity, investment in education and training, career development, supportive workplace environments, and appropriate governance. Recognising HCAs as skilled and valued members of multidisciplinary teams is essential to strengthening workforce sustainability and ensuring the delivery of safe, compassionate, and person-centred long-term care.

Limitations and gaps in the literature

While the literature provides robust international insights and evidence of best practice, limitations remain. Irish-specific studies are limited, particularly longitudinal research evaluating workforce interventions and studies examining the experiences of internationally educated HCAs. There is limited evidence regarding the long-term impact of regulatory reforms at national and regional levels. Addressing these gaps is critical for informing evidence-based policy, workforce planning, and professional development initiatives for HCAs.

Implications for policy and practice

The findings of this review have important implications for the future development of the HCA workforce in Ireland and other countries. A key priority is the development of a nationally consistent framework defining the HCA role, scope of practice, and core competencies. Clear role boundaries and competency standards would support safe delegation, accountability, effective multidisciplinary working, and consistent delivery of person-centred care. Such frameworks should recognise that HCA practice extends beyond task-based activities to include relational care, communication, advocacy, safeguarding, and supporting residents’ dignity and autonomy. A coordinated approach to education and workforce development is also required. Standardised induction, competency-based training, and accessible continuing professional development would support HCAs to meet the increasingly complex needs of long-term care populations, including those living with frailty, dementia, chronic illness, and palliative care needs. Education pathways should combine practical skills development with broader knowledge, reflective practice, and person-centred care approaches. Workforce sustainability requires investment in career pathways, recognition of skills, supportive working environments, and opportunities for professional development. Addressing recruitment and retention challenges in the short and long-term requires attention to workload, wellbeing, remuneration, workplace culture, and equitable support for the increasingly diverse HCA workforce, including internationally educated care workers.

Appropriate governance arrangements are needed to support role development while maintaining quality and safety. Proportionate regulation, effective supervision, and clear competency requirements can strengthen accountability and safety without limiting workforce flexibility. Overall, policy and practice should recognise HCAs as skilled and valued members of the healthcare workforce. Strategic investment in role clarity, education, career development, and supportive work environments is essential to strengthening workforce sustainability and ensuring safe, high-quality, person-centred long-term care in Ireland and elsewhere.

Declarations

The authors declare no competing interests.

Acknowledgments

The authors acknowledge the guidance, support, and insights provided by Leading Healthcare Providers (LHP) Skillnet and particularly by Ms Carmel Kelly, Managing Director, and Ms Clodagh Killeen, Learning and Development Project Manager. They played an important role in initiating, commissioning and guiding the research, as well as contributing sector knowledge and perspectives.

Ethical Approval

Ethical approval was not required for this evidence review.

Funding

Provided by Leading Healthcare Providers (LHP) Skillnet to undertake the research project, with the evidence review being one of the constituent parts.

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