Mecanismos de Desvíos

All the participants stated that they were very uncomfortable that nursing auxiliaries reviewed the patient’s skin most of the time, while the responsibility for maintaining the patient’s skin integrity lay with the qualified nurse. The non-clinical nurses argued that further clarification about the roles of nurses and nursing auxiliaries in skin care was needed from regulatory authorities was required to ensure that patients received the best care. The non-clinical nurses also maintained that the only sensible solution to this disconnect between care delivery and responsibility was to have a nurse whose only job was to deliver hands-on nursing care like pressure ulcer prevention:

Darlene (Senior Nurse Manager): “We need to be clear about what we expect from

nursing auxiliaries because they are the ones delivering the pressure area care. So if the nursing auxiliaries see signs of a pressure ulcer developing like redness of the skin, what do they do about it? There ought to be clear guidelines about the nursing auxiliaries’ role in pressure area care that are implemented uniformly throughout the Trust. If the nursing auxiliaries have concerns about a patient’s skin, it needs to be clear where they can take those concerns to.”

Millie (Principal Lecturer): “I am concerned by the amount of care that is not given

by qualified nurses and we are now at that point where the boundaries between unqualified and qualified nurses are being blurred. If care is given by a whole team of nurses, then healthcare assistants are just as important a part of the team as qualified nurses. But this has led to the debate about whether we are creating a two nursing tier system again, like the old SRN (State Registered Nurse) and enrolled nurse that used to exist (until 1986).”

The non-clinical participants in this study felt that further clarification of the role of nursing auxiliaries with regards to pressure ulcer prevention was needed from regulatory authorities. This seems a bit strange because the professional guidelines for nursing state that nurses are responsible for all aspects of patient care, but they are allowed to delegate some aspects of patient care provided that the person delivering the care is competent and is adequately supervised (NMC 2008a; 2008b). This means that nurses are obliged to oversee all the nursing care that patients receive to ensure that they receive the highest standard of care possible (NMC 2008a). Therefore, it is clear that if the nursing auxiliaries have any concerns about a patient’s skin then they should highlight their concerns to the nurse who is looking after that patient.

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senior nurse managers are aware that the majority of skin care in clinical practice is delivered by nursing auxiliaries and students. This partially verifies the accounts of the clinical nurses in this study who state that they do not take part in the skin care of their patients because they are under pressure to prioritise other aspects of nursing. This does not recuse the ward based participants of responsibility for the decisions that they make about the skin care of their patients, as all nurses are accountable for all aspects of the nursing care of their patients (NMC 2008b). It must also be noted that clinical nurses in this study like any other employees are also accountable to their senior colleagues such as line managers. This means that it is possible that their decision making is influenced by the decisions made by their senior colleagues, but ultimately each nurse is accountable for any decision that they make with regards to the care of their patients.

The views expressed by the non-clinical nurses in this section appear to contradict some of the statements that they made about the impact of clinical priorities on the skin care delivered by nurses. Some of the non-clinical participants stated that clinical priorities like the drug round should not prevent nurses from taking part in the skin care of their patients, but in this section they concede nurses do not deliver the majority of skin care to their patients. Perhaps, the non-clinical nurses felt that their ward based colleagues were coming up with excuses for not playing a greater role in care to maintain their patients’ skin integrity. It is also possible that the non-clinical participants felt that the nurses could prioritise their work load in a different way in order to enable them to play a greater role in the prevention of pressure ulcers. In the absence of any other evidence, the clinical participants’ view that they are under pressure to prioritise other things above participating in care to maintain skin integrity appears to be a viable explanation. This does not discount the possibility that there may be another reason why skin care is prioritised in the manner that it is by the nurses in clinical practice that was not identified in this study. Whatever the case may be, the participants’ accounts of the prioritisation of care to prevent pressure ulcers merit further examination in subsequent research to ascertain if similar views are held by clinical and non-clinical nurses working in other settings.

The other salient point that emerges from the data in this section is that the non-clinical nurses feel that nursing auxiliaries should not be delivering the majority of skin care and perhaps should be replaced with State Registered Nurses. The non-clinical participants’

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statements intimate that they feel that nursing auxiliaries are not appropriately qualified to be undertaking the lead role in delivery of care to prevent pressure ulcers. This contradicts the view of the clinical nurses who feel that nursing auxiliaries are appropriately trained to deliver interventions to maintain their patients’ skin integrity. Therefore, further scientific enquiry is needed to establish if the disconnect between the views of clinical and non- clinical nurses in this study about the competence of nursing auxiliaries applies to other settings. This is particularly important because this disparity in the views of the role that nursing auxiliaries should play in pressure ulcer prevention has not been previously highlighted in any other study.

All the participants in this study concurred that the majority of skin care in clinical practice is not given by nurses. They pointed out that that nurses are permitted to delegate some aspects of patient care like pressure ulcer prevention care to nursing auxiliaries, but they needed to be more aware of their legal responsibility to the patient in terms of the pressure ulcer prevention care that is given:

Cerys (Deputy Ward Manager): “All registered nurses should be aware of the legal

consequences of pressure sores because the patient’s got the right to have first-class treatment. If you don’t put the right dressing on or give the wrong treatment that patient could lose their limb. When some nurses are dressing a wound they just pick any dressing because they think that as long as the wound is dressed then its job done! Because when you ask them their rationale for using wrong dressings they say cause so and so had also put it on there. But what did the care plan say? These nurses don’t understand the damage that they can do to the patient by using the wrong dressings. They need to focus on the patient as a person with regards to wound healing, rather than just focusing on putting on a dressing and moving onto the next patient!”

Millie (Principal Lecturer): “We can only advise qualified nurses about what the law

says, but whether they uphold the right of the patient or not in clinical areas is down to them and their personal professional standards. Qualified nurses are there to delegate care appropriately and to lead the nursing team. But as a qualified nurse, you should want to see the patient’s skin to check if it is changing, ensure that patient is eating and is hydrated appropriately and to make sure that the manual handling techniques are adhered to when those patients are repositioned. I have no objection to unqualified nurses doing things; but there are things that I would expect a qualified nurse to do, like seeing the patient’s skin, particularly in areas that are at risk of pressure ulcer like bony prominences and buttocks.”

The participants’ statements about the responsibility of a nurse with regards to the skin care of their patients are line with the latest guidance from the NMC. Nurses are allowed to

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delegate some aspects of patient care provided to the nursing auxiliaries and students as long as they are qualified to deliver care and are supervised, but nurses retain responsibility for all aspects of patient care (NMC 2008a; 2008b).

The participants’ accounts also suggest that nurses could be made more aware of their responsibilities with regards to pressure ulcer prevention, but the onus to obey the professional guidance on patient care lies with each individual nurse. These assertions are supported by simple logic. This is because logic dictates that a programme of education makes people more aware about a given topic. There is however, a vast difference between knowing what the right thing to do is, and actually doing it.