NORMAS DEL CFR (E.U.A) PARA EL ABANDONO PERMANENTE DE POZOS

There is little doubt that the presence or lack of clinical skills has been the major area of concern and debate by both the public and the profession since the wholesale move of nursing and midwifery into higher education. Over ten years ago MacLeod-Clark et al (1996) noted that whilst managers and other stakeholders might wish for the newly qualified Project 2000 nurses to ‘hit the ground running’, such an expectation may be unrealistic and that the nurses themselves felt that they soon made up any deficits in practice (MacLeod-Clark et al 1996). Shortly afterwards, of 72 nurse managers interviewed in a DH-funded evaluation of the UK Project 2000 diplomates’ fitness for purpose, some claimed that many still required to be taught ‘basic nursing skills which we would have thought they would have been trained in’ (Carlisle et al 1999). There was also evidence in the UKCC (1999) Fitness for Practice report, that even though there had been a significant improvement in the overall pre-registration education of nurses and midwives that there were still concerns regarding the development of practical skills.

In an English context, Gerrish (2000) replicated a qualitative study she had undertaken in 1985 with ‘traditionally trained’ RGN students by interviewing a fresh cohort of newly qualified Project 2000 nurses. In the 1980s she had found informants felt that they had acquired the essential clinical skills to enable them to function as qualified nurses, though not being ‘proficient in all aspects of technical care’ (p476). By contrast, she argues, in 1998 newly qualified nurses varied in the extent to which they felt they possessed appropriate clinical skills. For example, some felt that they had deficits in administering medicines, giving injections and caring for patients requiring intravenous fluids. In the present study some students felt similarly, but took some responsibility for this:

I don’t feel like I’ve pushed myself enough. I think you have to push yourself to do, to keep yourself updated with, you know, doing medications or injections and things like that. I’ve not done enough injections; I’ve hardly ever catheterized anybody. (Student nurse Case study H)

At Case study E, charge nurses in a focus group confirmed that this did happen:

(In) our experience some semester 6 students (Year 3) are deficient in basic skills like catheterisation and wound care.

Sometimes, however, rules got in the way of students learning what practitioners believe are important skills. A community mentor makes the point:

I think it just depends, like in district they’re not allowed to give any vaccinations so, and I kind of disputed that, because if you’re with a student and it’s flu vac time, that’s great experience of them giving the injection. You’re still there, with their adrenalin, you’re with them, they are just physically doing the technique. But they are not allowed that. (Community mentor Case study G)

In common with MacLeod-Clark et al (1996), and Gerrish (2000) participants interviewed felt that these deficits were soon made up in practice, a view firmly expressed by students in Gray and Smith’s longitudinal study of student nurse socialisation in Scotland (Gray & Smith 1999). In the words of one of her students:

Well it annoys me intensely when I hear it being said…Practical skills you can pick up. It’s not that we don’t know how to do things. We are maybe a bit slower. I think it’s a handy little peg to hang their hang-ups about the course on…I have great hopes that once you’re in a job, in an area for more than four weeks that your motor skills and things like that will speed up and you will pick up the skills pertinent to that area. (Karen, in Gray and Smith 1999, p 644).

As seen in chapter 7, there is confidence from the service managers that both nursing and midwifery students have the required skills at the point of registration, but they are possibly not the same skills as were required in practice ten or more years ago. What is essential to take into consideration is that the practice of nursing and midwifery has significantly changed in terms of the kind of clinical skill that the students can be exposed to and in which they subsequently learn to become proficient.

When asked to identify what skills they might need to become fit for practice, midwifery students not only identified basic observation skills, but also those involving a more holistic approach to caring for a woman:

You need the same basic observation skills, temperature, pulse, blood pressure, abdominal palpations. competent with the general examinations, but you also have to know what care is needed and how to look after a woman who is low risk , and how to look after a woman who is high risk, how to interpret CTGs, how to perform amniotomies, how to get the doctor involved if you think the CTG is not giving a good trace, if there’s deceleration, you have to get the doctor in and how to assist the doctors as well in terms of epidurals, blood sampling, blood gas analysis. (Student midwife Case study B)

5.2.2 ‘Other Clinical Skills’

It is easy to assume that ‘clinical skills’ are those such as injections, routine observations and drug administration because a good deal of emphasis on these appears in the literature. Respondents were keen to point out, however, that a modern view of clinical or core skills should be much broader than this:

In general, I think communication, I feel that that is a huge one because a lot of midwifery care is the ‘with women’ stuff and at the negative end a lot of the complaints that we have, or where we don’t do things well, its about lack of communication or unclear communication or somebody just not realising the ‘why’ for something. So I think a large part of being fit for practice is to be able to appreciate that other people need explanation of what your doing and for you to be able to read the person and actually say, ‘excuse me one minute we’re going to be interrupted’. (Midwifery manager Case study A)

As might be imagined, in mental health care communication was felt to be a vital skill, but that practitioners might in future need to be prepared at a more advanced level than now:

(They will have to have) a range of transferable skills; those core skills, communication, the ability to work effectively and to forward think and to adapt to changing environments. I think these are all crucial skills that we would hope all of our students would have at a certain level as well as that it goes back to what we were saying earlier, there is a definite range … of what we would call psychotherapeutic skills that we would say are absolutely essential for mental health nurses who hope to operate within the next five to ten years. (Senior manager Case study F)

I think what’s really important is their communication skills, so, I think they should be calm, confident communicators and I think a lot of the other things then can fall in within that. (Director of Nursing Case study B)

When students were asked to give an example that illustrated their fitness to practice, they offered a variety of examples:

I had a patient who was passing away and relative came in and we got to discussing the fact that the patient was very religious, so we managed to include the pastor, the minister for the hospital, the family said the patient would really like that. I like being able to empathise. (Student nurse Case study F)

Just when you go on placement, that you’re doing it as well as the trained nurses and you can see how you’re getting more confident and then when you see what you’re doing is affecting work then it gives you more confidence ……( asked to give an example )…..Well in an acute admission ward, my last placement, there was a lady and she was very anxious and just being able to go in and talk with her and listen to what she was saying and help her like deal with her anxiety … (Student nurse Case study F)

It is suggested that more practitioners will need to consider working in the community on qualification. A recent study in England shows a consistent increase since 1995 in the proportion of registered nurses (RNs) working in the community (as compared with health visitors and district nurses) (Drennan et al 2007). This study shows that whilst numbers of the latter have remained consistent at approximately 10,000, the number of RNs has risen in a decade from approximately 12,000 to over 22,000. In Scotland the development and support for newly qualified nurse in the community is a priority with over 60 posts recently being created and Flying Start NHS being utilised as an integral part of their career development. The proposed integration of community nursing roles in Scotland will no doubt maximise a role for relatively newly qualified RNs in the future (SEHD 2006b).

In particular, nursing homes will feature more prominently in the work plans of the newly qualified. Mindful of this, a Scottish study (Runciman et al 2002) examined the views of nurse managers in nursing home settings with regards to newly qualified Project 2000 nurses. They noted that new staff proved to be quick learners with ‘fresh ideas’ and a ‘questioning, enthusiastic and sometimes challenging approach’. On the other hand, they felt that newly qualified staff lacked ‘organisational’ and ‘business’ skills, deficits not yet

systematically remedied by the present programme, but that might usefully be developed in the Flying Start NHS or similar post-registration programmes. Whilst Fitness For Practice programmes supersede Project 2000, it is clear that many of the strengths and some of the limitations of nurses prepared for this role in higher education remain extant (Runciman et al 2002).