1980's elderly care: Australian lift and the coming of Roper

During my three years I was fortunate to see a wide variety of specialties and experience a wide range of nursing challenges. My first placement was in an elderly care ward where I worked for 12 weeks. The ward was in a one storey building, a modern addition to the old Mid Herts. site on Church Crescent close to our accommodation (St.Albans City Hospital if you haven't been on this journey before!). The ward was set out in a traditional nightingale style, with beds lining the walls either side of the ward and ancillary rooms such as the kitchen, bathroom, treatment and sluice rooms situated at either end. All of the patients were female and over the age of 65 with a high prevalence of conditions such as stroke and cancer and chronic disorders such as Parkinson’s disease, diabetes, chronic obstructive airways disease, emphysema, rheumatoid and osteoarthritis and heart disease. Patients with multiple pathologies were as common then as now in elderly care wards often requiring complex treatment programmes from a range of professionals such as nurses, dieticians, physiotherapists, pharmacists, speech and language and occupational therapists and of course the physicians.

Work in elderly care was physically demanding and then, as now, space in each bed area tended to be limited making it hard to work efficiently; equipment aids were also in relatively poor supply when compared with today’s NHS hospitals. We had a bathroom hoist with a couple of slings to accommodate different sized patients (one often in the wash or on loan to our counterparts in the male elderly care ward), monkey poles above the beds and pump up variable height beds. Some patients were issued with turning or sliding boards to aid transfer but for most patients manual handling was the norm with lifting techniques such as the Australian lift in common use. This lift entailed two people standing one either side of the upright, bed-bound patient. Each person would then put their shoulder beneath the axilla of the patient, link their hands beneath the patient’s upper thighs and together lift the patient up the bed. This lift required co-ordination, strength and a fair amount of trust on the part of the patient. Unfortunately for the nurse it was highly likely to put a strain on the neck or spine and thankfully, in the UK at least, it is now recognised as an unsafe lift for both nurse and patient (shoulder injuries, skin damage through shearing) and should therefore never be used. Back then though, most of our patients were highly dependent and there were many occasions when nurses were at risk of back injury because of poor equipment, training, staffing and/or awareness.

The Australian Lift - not as funny as they seem to think!

Working in an elderly care ward was hard but it gave us an opportunity to develop core nursing skills which stood us in good stead throughout our nursing careers. The ‘back-round’ system of care ensured that every patient was visited on a regular basis, re-positioned if necessary, toileted and given a drink or fed. Mouth, hair and skin care were routinely carried out along with general hygiene care and mobility support  (today's use of Intentional Rounding is not as innovative as some would make out).

However, the regulated, task-oriented approach which had been in use for so many years fell out of favour as the profession moved in the 1980’s to adopt a more individualized approach to care. The work of nurse theorists such as Nancy Roper, the UK born nurse who defined nursing in the context of a model of daily living, provided a framework for care which allowed the nurse to adopt an individualised, holistic approach to care which encompassed all the patient’s needs from eating and drinking to sleeping, working and playing, breathing, maintaining a safe environment through to expressing sexuality, controlling temperature, elimination, mobilization, communication and dying. When used effectively the model, which is in widespread use around the world today, ensures important elements of care are not overlooked. The work of others such as Dorothea Orem and Virginia Henderson was equally influential, although it was usually the case that there were many years between the development of the theory and the implementation in practice.

However, delivering individualised care in the way Roper and others envisaged it is difficult in a modern healthcare environment. The pressures of time, staffing, targets and the complexity of patient’s needs often reduce nursing to a list of key priorities, the things that must be done rather than the things that should be done. The modern dilemma (in the UK anyway) is how to keep to an indivudalised approach to nursing and still ensure essential care for all is carried. 

Next week: Fleas and more in A+E

Being assessed in practice - 1983!

In 1983, assessment of clinical practice took the form of four practical examinations spread over the three year training period (I know it sounds antiquated but remember this is pre-project 2000 and the concept of continuous assessment hadn't quite crept in yet!). The practical exams were nerve wracking because they took place in the clinical area in front of everyone and also because, like the written exams, they had to be passed to progress to the next stage of training (so maybe not so antiquated after all).

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.

It all sounds very labour intensive now but the assessments for total patient care and aseptic technique did thoroughly test the ability to apply a procedure correctly and taught us a lot about doing things the right way. I think that learning the right way to do something in totality and then assessing it formally, with a bit of pressure in the mix,  fixes it in your mind for a long time. Habits when formed are hard to break (bad driving habits spring to  mind), so getting the right habit formed in the first place is very important, it then becomes routine, ordinary, the norm. It is from this secure position that nurses can make informed decisions about modifying practice where necessary e.g. the patient who is in their own home with an infected wound and not a dressing trolley in sight.

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.