I remember being worried about my total patient care exam because I was working in paediatrics (St.Julian's ward) for three months and there weren’t many suitable children to provide total care for. The exam required us to demonstrate skill in supporting nutrition and toileting needs and performing general hygiene and mouth care. However, the children were often in for relatively minor surgery (such as circumcision or inguinal hernia repair). They would be self-caring on admission, briefly incapacitated by an anaesthetic then quickly up and running about again before heading straight out through the exit at full speed. Children in for other reasons such as orthopaedic correction would often be fixed to some kind of metal frame for weeks on end but were still perfectly able to eat, clean their teeth and make mischief. In the end the ward sister took pity on me and said she would do my assessment with a little boy who was recovering from a pyrexia of unknown origin (PUO). He was fully independent, if a little weak, and about to go home. With his mother’s consent, I went through the motions of helping him into the big ward bath, preparing his lunch, encouraging him to clean his teeth and standing outside the toilet door asking him if he needed any help. Everything was very straight forward and the Sister duly marked me as passed but it hardly stretched my skills in the way someone who was assessed whilst working in elderly care would have been. This was the chief limitation of having to do the assessment at a certain point in time, it meant it could be more tick box than meaningful.
As well the 'total patient care' assessment, there was drugs, aseptic technique and ward manangement (always the grand finale). All I remember about the drugs one was that we had to undertake a drug round with our assessor, perform various calculations and memorise two drugs in detail to be tested on orally (tested not taken I hasten to add), My chosen drugs were paracetamol and digoxin. Educationalists, including myself, question the benefit of these very superficial approaches to learning (memorise - recall - recite) but to do this day I remember more about those two drugs than any other.The aseptic technique assessment was a joy to behold and a horror to complete. At the time we used disposable dressing packs with forceps, gloves, solutions tray, apron and gauze. We used a non-touch technique, had 'clean' and 'dirty' hands and worked in a positive air flow treatment room wherever possible. The assessment started with trolley preparation which we had to clean from top to bottom making sure the wheels were last. For my assessment I chose to do a partial removal of a corrugated drain from a surgical wound. This procedure involved the removal of a safety pin from the drain (this secured the drain in position, presumably this would now be stiched into place), the adjustment of the drain position and the re-insertion and closure of the safety pin. The wound area would also be cleaned and a sterile pad applied. All of this would be done with a pair of forceps and no-direct hand contact (not even with gloves on). Truly a challenge. I passed first time so perhaps an early indication of my eventual career path.
My ward management assessment took place on an acute medical/cardiac ward. It was a ward that I spent most of my time being in a state of stressful high alert because I had managed to go through my three years with very little experience of cardiac arrest; I was convinced that this placement would render me a 'rabbit in the headlights' in the event of a patient collapsing pulseless. I do remember the lovely staff nurse who helped prepare me for the assessment (no qualified mentors then, just willing qaulified staff). I was working with her one morning and it was very busy indeed. I noticed she had a long written list of things to do such as booking appointments, arranging discharges and talking to relatives and I asked if this was ok to do for the assessment. Absolutely she said, how else would you remember it all? I had honestly thought it would necessary to have it all memorised much as we had to do for the drugs assessment, Having said that we were expected to know our patients extremely well and whilst notes about patients were permitted, we would be expected to give a no-reference-to- notes verbal report about them to the ward sister, night sister or clinical tutor on demand (standing up straight, no cardigan and no coffee cup in sight).
Today, the problem of assessing the right skills, in the right place and at the right time remains a thorny one for nurse education. There is a real challenge in finding enough clinical placements to ensure all students have the same kind of exposure to the same kind of experiences as well as the same opportunities to develop a common set of core skills. One advantage of nurse training in the 1980’s was the commonality of experience with every student having a placement in theatres, midwifery, intensive care, general surgery and medicine, elderly care, Accident & Emergency (A&E), paediatrics, gynaecology, orthopaedics and the community. The clinical teachers came out to the wards regularly to work with the students. They were highly visible and clinically credible, something which is difficult to achieve now with nurse educationalists being located in University buildings, the majority of which are far removed from the clinical placements they serve. Whilst there are echoes of the past in today’s link tutor roles, the context is quite different not least because the partnership between clinical placement and higher education is now based on a contractual obligation rather than the ‘in-house’ partnership of old. All in all a very different environment for today's student to work in, not necessarily better or worse but different.Next week: Elderly care, my first ward at last.
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