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Ready for work?: The changes I’d make to nurse education

August 26, 2014

A guest blog by Florian Nightingale
So, as a newly-qualified nurse with a special interest in pre-hospital emergency care, there are things about my undergraduate programme that I would change. There are things I would remove from my degree and others I would add – inter-disciplinary training with other healthcare professionals for one thing.

 
My experiences in pre-hospital care brought me into contact with paramedics and doctors, but what struck me most about the registered nurses I worked with was their autonomy – more precisely, their abilities to physically assess people beyond taking basic observations. These are skills that, as I have often found, are perceived as advanced and beyond the scope or remit of a staff nurse. I’m talking more than simply checking a blood pressure, feeling a pulse, counting respirations and recording pulse oximetry and temperature. I feel that my undergraduate training gave me very little preparation for physically assessing a person. Assessment should go beyond just taking a basic set of observations and bleeping the house officer. So what would I add?  Time for some bullet points. I like bullet points.

 

  • Respiratory assessment skills: auscultation, percussion, checking chest expansion, ABG interpretation or at least a working knowledge thereof.
  • Cardiovascular assessment: similar to above, with the addition of auscultation of heart sounds, looking at a JVP, ECG interpretation (both rhythm strip and twelve lead)
  • Neurological assessment: more than just checking pupil reflexes and limb strength maybe? A good knowledge of FAST examination.

 

These are things I’d like to see because we really should be able to do them. Our initial survey of a patient, when done well, can make a huge impact on that patient’s care. We can also provide another opinion for when the patient is re-examined. It enables us to track a patient’s progress with a greater level of knowledge gained from our physical assessment. For example, what I want to know that when I meet someone with a chest drain is, is the affected lung up? Are there breath sounds and is the air entry good? I’d achieve that through percussion and auscultation, plus observation of chest expansion. Equally, if I have a patient with a tracheostomy, I want to auscultate to confirm air entry and ensure secretions are not going to risk setting off a chest infection. If I have someone with congestive cardiac failure who has recently been given a diuretic as treatment for pulmonary oedema, I want to be able to assess its effects more accurately.

 
I’ve chosen to talk about respiratory assessments because this is something I’m interested in – though there is an element of cardiac assessment in there too. Imagine you have a patient who is known to have atrial fibrillation and you check their pulse using a pulse oximeter and you’re not comfortable with the reading you get. Auscultating an apex beat would be the logical next step, but I’ve seldom seen nurses do it. I feel that as a student I wasn’t taught anywhere near enough on physical assessment. I’ve learned what I know from other sources: paramedics, willing doctors and nurses in pre-hospital care.

 
It’s the same with cannulation and phlebotomy. These are essential skills – wherever you work, people will need blood taking and intravenous medications given. But being reliant upon a phlebotomist or an on-call junior doctor to perform them isn’t what I’d call a satisfactory situation. If I’m honest, I wish they were taught at undergraduate level, then confirmed as competent when employment commences. Making processes slicker – preventing medication delays – is vital. Septic patient? Activate the Sepsis Six within the hour! Relying on someone else to insert IV access (that may or may not last) so you can give the essential fluids and antibiotics just isn’t acceptable. I certainly don’t like the look of that situation.

 
Anatomy and physiology is something else I found lacking after my first year. Pathophysiology too. Understanding normal anatomy and physiology is key to understanding disease processes and how nursing care can affect our patients. But instead of modules on this, I had ‘decision making theory’ and ‘how to work as part of the MDT’. What we got out of them was an lively debating session (read argument) with other healthcare students – fascinating but of little tangible benefit. To me, understanding the process of decision making isn’t as much use as more time devoted to understanding my patient’s current physical condition through a thorough knowledge of specific pathophysiologies.

 
Simulation is something I’d make compulsory. Frankly, it’s more than essential – it’s a massive chance to improve the quality of nurses we produce in the UK, starting at undergraduate level. The voluntary organisation I work with outside the day job has convinced me of its value. They’ve trained to me to insert supraglottic airway devices (Igels to you and me) as well as Geudels. Within nurse education, simulation would provide a good way of not just teaching but also assessing us: can I explain what ABCDE stands for? Have I done my life support training? Do I vaguely know, by the third year. what a Geudel looks like and possibly how to insert the damn thing?

 
We need more training in situations involving a deteriorating patient because once qualified, opportunities appear to be scarce. Military medicine/combat casualty care has led the way in showing how the best team work is based on drills and training together. The slicker the drill, the more difference it can make. These lessons are now being transferred to civilian medicine. Ultimately, simulation can boost the confidence of people like me who, although I now work in emergency care settings, never had the chance of a placement in such an area. It is also a safe environment for learning and a training environment where you can guarantee an acutely unwell person who will need constant assessment and management. The hit-and-miss nature of placement means that this is something you might not otherwise see.

 

News that the government is planning to increase the number of training places for ‘physician’s assistants’ (although at 225, numbers are still tiny) might cause some people to question whether nurses of the future will really need ‘advanced’ skills. But my feeling is that introducing yet another professional group is not helpful. We already have nurse and paramedic practitioners. So where will we draw the boundaries between physician’s assistant and these already-existing roles? Why not expand what we already have to cover the remit of what a physician’s assistant would be? Create a nurse/paramedic practitioner beefed-up, if you will, with a greater level of training in areas outside their speciality to give a good generalist background and skills base. See the lack of definition for specialist/practitioner roles for nurses and other non medical health care professionals as a helpful opportunity for innovation?

 
Universities love to bang on about good practice, evidence based practice and the ideals of nursing; there is however something of a disparity between this and the reality of a ward. My experience is that my lecturers were out of practise too long to be really in touch with what it is like to be a nurse in the modern NHS. Granted they have some excellent knowledge and can teach well for the most part but being out of touch just makes all the ideals hard to swallow after being disenchanted on a very first placement. I feel that we need to be better prepared for the real world of work once we have finished our degrees. To me, more ready to work equates to better care. Ultimately isn’t that what we all want? To do the best job possible? If it isn’t then it’s time to collect your P45 and head to the job centre.

 
For the BBC News story on Physicans’ Assistants, see: http://www.bbc.co.uk/news/health-28896625

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11 Comments
  1. Barbara Bradbury, Halland Solutions permalink

    I completely agree with you. It is time to take stock of the skills needed by today’s healthcare professionals and ensure that people are educated fully to be able to practice those skills. If you started with a blank sheet, you might change the nursing curriculum considerably, rather than keep tweaking it and providing a course that does not equip nurses for their role once qualified. The courses that inform the knowledge and skills development of Advanced Nurse Practitioners could be the content of the nursing undergraduate course if that is what is going to serve the population and delivery of health care to its best. Do we need Advanced nurses or just nurses?

    I think it is widely accepted that basic nursing care as taught pre-1990 (or thereabouts) is no longer what nurses do. This has gradually become the remit of Health Care Assistants. Some commentators get rather upset at the use of the word ‘basic’ when immediately followed by ‘nursing care’. There are still enough nurses around – I am one of them – who completely understand that phrase and what constitutes a level of excellence in its delivery. However, although now the province of the HCA, the term is still used. I think this contributes to the sense I have that nursing has lost its way.

    Some nurses can prescribe; some can undertake a physical assessment; some can insert lines; take blood…. the list goes on. It is surely time that we redefined nursing, based on what we need from the modern nurse. We should also be clear about what isn’t nursing, which seems to include making beds, pressure area care, washing patients, feeding them and giving them bedpans. Without doubt, ensuring that hospitalised patients have tissues and a sputum pot within their reach is definitely basic nursing care of the past! We can then stop defending ourselves when the HCAs complain that they do the ‘real work’ and ensure that the undergraduate programme prepares nurses to practice competently from the day they graduate.

    • junegirvin permalink

      Dear Barbara,

      Undergraduate programmes do prepare nurses to practice as novice nurses. I’m not clear from your post whether you think that undergraduate nursing programmes are teaching pre 1990s curricula – I interpreted it that way and on that basis I can say that nursing programmes are continuously updated in partnership with practice. Practice areas (NHS and PVI sector) after all, provide 50% of the degree and all of the development of skills apart from initial dexterity. University programmes are not constructed in a vacuum – they are as relevant as they can be to today’s novice practice given there is a three year lead time. If programmes are seriously not relevant then this is down to individual universities, and this inconsistency should be addressed. It is not a universal issue.

      All best
      June

  2. junegirvin permalink

    Dear Florian,

    Have you given this feedback to your university? I’m sure they would like to hear it, and I’m also sure they would love to talk to you about some of the things you mention. Some of the skills may be possible in an undergraduate programme but some may not be and it would be useful for that dIscussion to happen.

    You say yourself that watching experienced nurses operate is impressive and a lot of what you see is exactly that – experience. Observing and ‘computing’ all the times that they have seen and observed certain things and making a judgement about what it means. That doesn’t come from skill acquisition – although skill acquisition is the first step – it comes from practice (in every sense of the word), familiarity, constantly learning and taking post qualifying education opportunities.

    I’m disappointed to hear that your course didn’t give you a good grounding in anatomy and physiology – you should especially feed that back to your Uni.

    Good luck and nice writing!

    J

  3. Florian Nightingale permalink

    Dear June,

    I’ve provided feedback via national student survey but should my university be in contact to ask for feedback I’ll happily provide it. If they don’t ask I’ll happily provide it any way. I can understand how some skills couldn’t be learned at an undergraduate level given how it couldn’t be assessed in placements by mentors with varying skill levels. The one thing I’d really love to see added in at a minimum is a good degree of simulation, especially if there is a medical school as well because this would be an invaluable chance for soon to be doctors and nurses to learn together and begin to understand what each different person can provide for patient care.
    I do fully realise that I am very much at the bottom of the pile and despite three years of university, I have a lot of experience to gather. That said, perhaps placements could be better thought through. My university seemed at best haphazard in placement allocation with no real structure to it. That helps a lot. I’d like to be able to put that to them. A time will come.

    Thank you for reading and I’m glad you found my semi diatribe/critique eloquent and pleasing to read.

    All the best,

    Florian.

    Dear Barbara,

    As regards do we need more advanced nurses or just nurses, the only thing that I can really say is that we need to close the gap between the two more. Skills hierarchy and preconceptions of what nurses should and should not do is something that is detrimental for the most part. It holds us back and means we can’t quite do as much for the patients as we potentially could.

    Prior to starting my degree course I was a care assistant for just under a year near my home town. This was a stop gap between one degree and starting the nursing. It was very helpful as it showed me I could do it. I agree that I did more of what is considered essential/basic nursing care as a care assistant than I now do as a registered nurse. I do worry about what the care support workers I work with do owing to variable experience, levels of training and such like. Don’t get me wrong, I won’t shy away from it but the role of the nurse has definitely changed since the inception of Project 2000 and we have to move with the times. If I could wipe the slate clean and start it afresh I would definitely be interested in it. However, root and branch reforms will never be popular or really accepted I believe. Nurse education being a constant political hot potato will not help. Each successive government getting stuck in meddling. Perhaps letting us look at it from within and redefining it would help rather than it being used to serve a political end?

    All the best,

    Florian.

  4. PoppyP permalink

    Really interesting blog-assessment is so important. June is right it would be good to feed this back to uni.
    I think the concept of “advanced” is often equated with “jobs doctors do” when in fact its a fair way from that. “Advanced” practice is really about mastery and application of expertise.Assessment skills or prescribing are not advanced practice they are just different tools in the toolbox. Tools don’t make master craftsmen/women-expertise and experience do.

  5. Florian Nightingale permalink

    Ultimately Poppy that’s it really. Different things from an arsenal of skills. At the end of the day this is a team game where each individual can bring something different and potentially vital to the course of a patient’s journey through healthcare. We are expected to act as advocates, being better able to assess someone is advocating for them. We can provide something else through our assessment that can inform the bigger picture. We all bring something different to the game that we play which is ultimately a team game.

    Florian

  6. Thanks for commenting. I think this harks back to the old old question that is still at the heart of nursing: should nursing’s future development be about taking on more and more ‘technical’ tasks, or should the emphasis be on relationships, long-term support, and specialist nursing areas such as continence, skin care and nutrition?
    I think the answer to this is to some extent dependent on the area of nursing in which one works – the community and emergency care cater for very different patient groups with differing needs and priorities. But even saying this still leaves open the question of whether we can articulate a set of ‘core’ nursing values to which all nurses should subscribe. Linking this to your point – is ‘advanced’ assessment really a nursing skill if it is not carried out in the context of these nursing values?
    From a political point of view I think it’s clear that the ‘technicians’ are starting to gain ground; we are moving to a place where acute hospital trusts are questioning the value of nursing degrees that don’t equip graduates to ‘hit the ground running’ with the skills that a modern acute health care setting requires; venepuncture and cannulation are the most obvious examples. From this perspective, nursing is seen as so anxious to emulate other professions by restricting entry to those with a traditional liberal degree, that it has lost sight of the kind of practical, pragmatic health care professionals that hospitals really need. A few Trusts are already looking at setting up their own ‘apprenticeship’ style nurse preparation, and I think this is a reflection of the views held by many employers.
    I completely agree that teaching vital skills like venepuncture and cannulation at undergrad level would expedite care and improve nurses’ confidence because they wouldn’t always be waiting for others to come and carry out these jobs on their behalf. But I also believe in a broader education; while not immediately apparent, the ideas it imparts often come to fruition further down the line, and in unexpected and creative ways. Sad to say, I think this will increasingly come to be viewed as an unaffordable luxury. Trusts don’t want to have to pay to teach skills to nurses post-registration; if they had their way, I think we would already be seeing much more skills-focused degrees.

  7. Dear Florian,

    A well articulated piece, but I sense a fixation with technical elements of care that cross the boundaries between nursing and medicine. It is all very well being taught many of the skills mentioned, but they would have to be meaningfully contextualised, sufficiently practiced and practice maintained. This would requires appropriate and timely clinical practice placements, otherwise proficiency (the requisite level for safe care delivery) will never be reached and skills / care provided will always be sub-optimal and present a significant patient safety issue.

    The simulation comments are most welcome, but the overwhelming educational evidence indicates that simulation education has to be appropriately constructed, targeted and carefully prepared (environmental, technically and psychologically authentic) for it to be optimally efficacious. Simulation has seen by many as a salvation of all other educational short-comings. One of the major successes in medical simulation is its use in the development of critical care clinical decision making / prioritisation skills, including crisis resource management / team leadership through the explicit recognition of the nature and source of human error and highly skilled, participant centred debriefing.

    FYI – the nursing faculty at the University where I work conducts a diverse range of simulation education, provided by appropriately training staff that starts with very basic things and gradually builds to complex care. Senior nursing students are encouraged to participate in the critical care scenarios that we run (in Post Graduate Medicine) for FY1 / FY2 doctors and core medical trainees.

    What you appear to be suggesting is specialisation during basic training?

    With kindest regards

    Ken

  8. Dear Florain and other commentators,

    I do agree with the concept that nursing as a profession is slightly under skilled. I’m a student nurse who moved to nursing from the Ambulance Service and was shocked to find band 5’s waiting for hours for a junior doctor to cannulate a patient after coming from part of the NHS where if you can’t cannulate you can’t be a band 5. In a time where as Grumblingappendix has already mentioned providers don’t want to lose time and money training staff on basic skills (I deliberately used the word basic, as to our medical, military and pre-hospital colleagues cannulation is a basic skill).

    I do think the universities are in a difficult position as they are having to prepare student nurses to work in a hundred specialties, not all of which are acute focused. For nursing to evolve and compete to get training places commissioned we need to be clear about what we offer, I personally feel we have the values and academic side of nursing education right but clinical skills and the underpinning assessment abilities are the missing side of the triangle. If we can learn basic observation, skin assessment and communication skills in the under-graduate phase why not bolt on auscultation and percussion for example which is useful in hospital and the community. Other health professional groups learn this on a 2 year foundation degree, just because nursing might move to having more ‘technical tools’ it in no way subtracts from our core values or devalues ‘basic nursing care’ which is a point I have had raised when discussing this topic with others.

    We have a Critical Care Programme (Disclaimer, voluntary run and not part of the university programme) in Southampton, Consultants and Advanced Practitioners (Nurse, Doctor and Paramedic) come and give monthly teaching to medical and nursing students who have in interest in that area, both professions groups learn together exactly the same, if your interested feel free to visit.

    I look forward to working with Physicians Assistants and seeing what they bring to the MDT party, if they can improve a patients experience great. Any loss of training places or funding to nursing because of their role is because we weren’t pro-active and failed to fill that gap in the market. As nurses we need to ask ourselves what are we offering commissioners and how can we make them understand our massive value to modern healthcare including our values.

    Thank you for your blog and generating healthy debate.

    Kind Regards,

    Alex

  9. Florian Nightingale permalink

    Dear Ken,

    I love the fact that your uni has put a premium on simulation as a means of teaching and gaining a wide variety of skills that will serve well. Further to that, the skills are transferable. I can see some of your comments about timely placements, however, what has been put to me more is that mentors aren’t adequately trained to assess it or even do more advanced assessments eg chest auscultation. We do have to have that first. A process that will be worthwhile as it will better equip nurses and students for generations to come. We have to break the barrier of the current generation not be able to assess. We can help them learn and give something back. I also mean to point out that my university distinctly lacked in practical education. More of a premium was put on theory which couldn’t translate into practice owing to a lack of practical training therefore we couldn’t really translate the theory sadly. What irks me is people really see some skills as being fenced off from nurses as we are nurses.

    All the best,

    Florian

    Dear Alex,

    I am driving at the fact that we aren’t quite ready to work. This creates more trouble for both us and service providers as it makes an impact on patient care. For example, I have to ask someone else to do my bloods, cannulas and IV medications. To me this is detrimental to patient care. Delays in treatment and delays in investigations for my own patients aren’t great. Drawing either my coordinator or one of my other colleagues away from their patients is not a great thing either.

    The programme you advertise is something that I will be looking into as it is something that really fascinates me.

    It’s interesting you cite your experiences in the ambulance service and the roles of military health care personnel as well. Military medicine has really helped to shape civilian medicine and often drives developments. It’s a shame that perhaps the skills aspect of this hasn’t been translated across the gaps.

    All the best,

    Florian.

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