OPINION

'Many students don't see fundamental care as learning'

11 July, 2010

Student nurse Ebony Kunze on the importance of student nurses providing fundamental care for patients.

I am a second year student and throughout my training I have never had a problem with providing fundamental care to the patients that I am looking after. I feel that if without providing fundamental care then I would not be providing a duty of care that the patient deserves.

The term “extra pair of hands” I have heard my fellow students use many of times, and I have experienced it myself when completing my first placement at the beginning of my training. The ward was short staffed but I did not complain when I was asked to help a patient with their personal hygiene needs, I just carried on with what I had to do ensuring that the patient received all the care and help that they needed. Once the fundamental care had been given to the patients, I would then look out for learning opportunities and took them on. I feel that many students do not see fundamental care as learning, which is why many people, can see them as “too posh to wash”. But without learning the fundamental care first then what kind of nurse would you be without it.

When I worked as a HCA I also worked with student nurses who were on placement. On one shift I was providing fundamental care to a patient and asked the student if they would help, the response I got was “Is ok I will just watch”. At the time I was a little shocked and the thought ran through my mind of why that person was training to be a nurse if they did not want to get stuck in with providing fundamental nursing care.

Along with feeling like an extra pair of hands is the supernumerary status that students have when they are on placement. When I am on placement I have never thought of myself as supernumerary purely because I forget that I have that status, but too many students use it to their advantage stating that they cannot do something as they are supernumerary or that they are only there to observe what is being done, in my experience how can you learn something if you do not do it yourself? The RCN defined supernumerary status as “students being additional to the workforce and establishment figures”. O’Dowd (2005) says that students are supernumerary during their course, and the experience that they gain on placement should be determined by educational need. He goes on to say that students are not observers because they have to take part in clinical activities under direct or indirect supervision to develop the skills required to become a nurse. From this it is clear that without doing the tasks you are not going to learn the nursing skill.

In my opinion there is nothing better than helping patients with fundamental care, it gives nurses opportunities to spend time talking to patients, allowing patients to express and concerns, worries, anxieties that they have in which the nurse can address and reassure the patient. As well as allowing assessments to be made of skin integrity, observing for pressure sores, helping to rehabilitate the patient, and give the patient confidence to have a go at washing themselves. This can help the well being of the patient and make them feel like they are able to do tasks.

As students we have nursing proficiencies to complete which are split up into four domains of professional and ethical practice, care delivery, care management and personal and professional development. How do students expect to meet any of the proficiencies and domains if they will not provide fundamental care, they would not be delivering or managing care, and they would not be developing personally and professionally. How can they create a care plan for a patient if they do not assess the patients’ needs to begin with? Arguably not all proficiencies fall under fundamental care but it would be a good starting point. From experience when I was to begin my first placement I was very interested in doing the “drug round” but after doing one I felt that I would rather be assisting a patient with their breakfast, or helping them have a wash. I have learnt that I do need to do drug rounds to build up my skills in that area, but if I do the breakfast drugs I will then not do the lunchtime drugs so that I can hand out the patient’s meals and provide assistance to the patients that need it.

About the author

Ebony Kunze, second year student Nurse from Bournemouth University

Readers' comments (18)

mike | 11-Jul-2010 10:24 am
I think that the entire suggestion that students do not do fundamental care or they (or degree Nurses for that matter) are too posh too wash is insulting!

Yes it is part of any role to provide basic care, and we do. However there is a fine line between 'mucking in' when needed, and being used to shore up poor staffing levels. Unfortunately all too often it becomes the latter for students.

In your first year, yes there is a lot students can learn from HCA's and by performing basic care tasks. However in second and especially third years, this MUST take second place to opportunities to learn and practice higher clinical tasks from medication rounds to wound care, as these are the roles we are expected to perform upon graduation.

There is no point in putting someone through 3 years of training if all you have at the end of it is a really good HCA.

However this does NOT mean that students and Nurses will not perform basic care on top of this!
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Marjorie Lloyd | 11-Jul-2010 9:54 pm
This paper raises some good points but it should be about learning too - going home at the end of the day and asking yourself what have I learnt today can help put things into perspective.
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Graham Dalton | 12-Jul-2010 7:41 am
Come on now! This is not about student nurses, but people in general. Many nurses are too lazy to be involved in personal care also.

Most placement settings will simply not allow students to stand around and watch. Maybe watch the first time, but then get involed helping, then taking an active role.

Most people will not stand around whilst a person is in need, but there will always be those that do.

Any extended period of study/learning always changes a person. There will be a point where the student transitions in to a nurse, even before registration. Maybe we need to revisit Benner. Let's give some space for learning and development.
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Anonymous | 12-Jul-2010 7:52 am
I agree with mike. It is an important to ensure that we are doing all aspects of care and not just a small section of care. As a student I have all to often been used as a HCA due to staff shortages, however when there are other learning opportunities to be taken then the supernumercey status gives us that opportunity to go and carry this out, I feel that after 3 years in my training it has gone so fast and that every opportunity must be taken in the 3 years as very soon we will be counted in the numbers and will need to ensure that all aspects of the patients care is carried out effectively even if this does mean delegating to others as when we are qualified if we do not do the drug rounds because you would prefere to give the patients thier meals then who is giving them the important medications which they need?
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Anonymous | 12-Jul-2010 1:32 pm
I completely agree that student nurses have a duty to provide the basic care that patients need. However, in my experience as a student nurse I am often asked to provide this care to patients when other members of staff cannot be bothered to provide it themselves.
I feel I have a moral obligation to the patients in my care and wouldn't let them suffer by refusing to give them the care they need. I know that assisting patients with their basic hygiene needs is a fundamental part of nursing and provides opportunities for assessment and evaluation but student nurses also need to be afforded opportunities to get to grips with other aspects of care in order to become effective practitioners. Student nurses KNOW that basic care is important but we are often missunderstood. Our hesitation to go and take another patient to the toilet while four HCAs stand around chatting is often us trying to say "hang on a minute, I only have 3 years to learn how to be a nurse, I know how to assist patients with their hygiene needs, what's next?". I am often hesitant to speak out as I want to pass my placements and don't want to make waves and jeopardise my career. On the other hand, I want to ensure that I am a safe practitioner and don't have significant gaps in my learning. We are student nurses NOT student HCAs!
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Lesley Rankin | 12-Jul-2010 7:10 pm
I would agree to some extent with Ebony's comments and the responses to it. I would like to add though that the very few student nurses I have met who have refused to partake in essential care because they feel 'its not their role' and not because they are moving into their second and third year and want to learn more about the role they will be taking on when qualified, have usually been challenged by fellow students, tutors, and placement staff. It is not an acceptable attitude to have either during training or once qualified and must be challenged in order to uphold the nursing profession and install confidence in the training we are currently receiving, which is often misunderstood and results in media frenzied headlines of graduate nurses being "too posh to wash". It is the minority that seem to be tarnishing the brush for the majority.
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Steve Williams | 12-Jul-2010 8:22 pm
Oh dear... this is an unfortunate situation where, alas, I am going to sound like a real wuss - wimping out by saying I can see and agree with some of the truth on both sides of this debate.

Both mike and Graham have made some very valid points with which I wholeheartedly concur.

First of though, muchos Kudos goes to Ebony for presenting a very thought-provoking, well-presented and succinct article about this very delicate subject.

So in no particular order of “rightness”... and please let me make all my points before making your minds up on my degree of “wussiness”...

Yes, I fully agree with mike that Registered Nurse training should eventually be more than just “hands-on” care (although I think that IS always a rather good place to start an education in the caring profession.)

I also agree with mike that students should not be used as an extra pair of hands to cover up the NHS’s inability to provide adequate staffing levels on the wards and cover-up the numerous decades of abuse perpetuated upon front-line nurses by successive governments (both Socialist and Conservative.)

As numerous recent NT news articles have highlighted, the nursing profession is riddled with an endemic culture of bullying, sexism and “class and caste” discrimination from the NMC, the NHS, the RCN and even UNISON. This gets reflected down the strata to ward level where the “unclean” frontline castes such as RNs, students and HCAs stoically battle it out as to what the definition of “Nurse” really means.

On top of this self-inflicted, hormone-evoked, fracturing debate there’s a liberal amount of honey-coated icing deliberately layered on by older nurses (yes I’m one - but I'm not one who pines for the Fjords) who probably can’t remember last Thursday... let alone 1963!

I do, however, agree with Graham and Ebony that there are some slightly “less than enthusiastic” student nurses who will milk the term “supernumerary” to cover for the fact they want an easier ride during their training.

Alas, in the long run, this attitude does these particular students no personal favours because when they qualify they find that life in the NHS is definitely NOT an easy ride. In fact the culture-shock for this minority is usually so great that they either quit, become nurse tutors or brown-nose their way into “NHS management” as soon as they get the opportunity.

For example, when I used to work at The Hillingdon Hospital (way back in the 90s - wow last Century stuff eh?) I was very amused by the shocked reactions of some of the “Project 2000“ students when they discovered that as RN’s (if they qualified) they would be expected to work weekends or even nights!

These days I am still involved in nurse training (albeit it in Canada) and I try my best to treat/teach each student according to the level of their individual needs as I have assessed them (and I don’t pretend that I always get it right - I’m only human too!)

So if the student is fairly new (or at least new to the concept of caring) then I tend to take them around with me and involve them in the “practical/bedside” aspects of the job (and YES as an RN in Canada we DO get our fair share of hands-on stuff.) I certainly do not allow them to merely ‘observe’ me I ask them to actively participate in HELPING me... not using them as an extra pair of hands that I can delegate tasks to (although I have seen other RNs and even HCAs doing this - and it is plain wrong IMHO.)

If the student is more experienced (either because they are further along the training or they are already fairly fluent in the concept of caring - due to previous career or personal life experience) then I take them with me when I’m involved with more of the “unit management” or “logistics” aspects of being an RN.

Once again I do not allow student nurses to merely observe me, nor do I delegate tasks, we deal with administrative tasks together. This way I find it’s a two-way learning process because I am nearly always learning new problem-solving ideas from the students I come in contact with.

Finally, for the really experienced students I try to show them - by example only - qualities that cannot be “taught” such as prioritisation, clarity of purpose, calmness, leadership, decision-making, tolerance, explanation, good humour, understanding, humility, the ability to admit mistakes and offer apologies, the ability to try to pass on good-practice and knowledge to the next generation of nurses without appearing condescending (oooh difficult!)

Before I bid them goodbye I offer them one final piece of advice... “Try not to end up an old cynical bar-steward like I am now!”

I hope they try to internalise it! :-)
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Ebony Kunze | 12-Jul-2010 9:23 pm
I think that in my blog I have protrayed that all students feel that they should not partake in fundamental care, this was not what I was meaning. I meant it as in a minority not a majority.
I feel I have disturbed a wasps nest so to speak.
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Steve Williams | 13-Jul-2010 7:16 am
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I think that in my blog I have portrayed that all students feel that they should not partake in fundamental care, this was not what I was meaning. I meant it as in a minority not a majority. I feel I have disturbed a wasps nest so to speak.

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Don't unduly worry about it Ebony... most of us “real” nurses (male or female - who have the titanium testicular fortitude to post under a regular name/handle) will cut you some slack.

Your original missive raised some salient points that need obviously need discussion.... In a civilised and august profession such as ours (yes, I mean Nursing) these issues need to be regularly raised and thrashed out in a public forum such as this... even though this medium is somewhat elitist and female chauvinistic.

Like I implied before... there are good students and then some bad ones... Alas, the same glib epithet GLOBALLY applies to all RNs, HCAs, PSWs, Nursing Auxiliaries et al.

Don't beat yourself up about it... the fact that you even recognise this incongruity is something that I hope us “registered” nurses will all subsequently “reflect” upon …. whatever the F*ck that actually means in layman's English!

I reflect upon myself every morning in the shaving mirror....

“Anonymous” Just a word of advice... don't even bother to reply to this message – I never ever read your so-called “serious” replies anyways!
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mike | 13-Jul-2010 12:13 pm
Ebony you didn't at all really, don't worry about it.

It is just like any other debate that is worth having on this site, it will bring out strong opinions on both sides (and a few people with nothing much to say apart from insults). In this particular case it has been debated many times before and usually brings out the 'everyone who wasn't trained in my day is too posh to wash' brigade, and people will rightly respond to that as it is wrong. Like I said strong opinions on both sides. Neither side is taking it out on you personally though, myself I actually like the fact that you brought it up as a topic to discuss.
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Anonymous | 14-Jul-2010 10:42 am
Everybody should be willing to wash if needed. Its not about us all the time, its our job to help the patients, thats what we signed up for, we know its tough.... After gaining experience caring, washing, doing ob's, writing notes and knowing about the stress, i am about to embark on nurse trainig. I have done the worst and I am prepared to carry out again what I have already learnt, its not an issue for me so long as I have a mentor willing to teach me the skills i need to learn to become a nurse. Steve Williams has hit the nail on the head, I truely hope my mentor shares his attitude. Will see?
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meba | 15-Jul-2010 12:42 pm
As a student nurse I can wholely relate to being used as an extra HCA when on placement. This I find insulting as there are many learning opportunities that I have asked to be involved in and been denied as I may take too long. I have been left to do basic care and toileting rounds and meals, all of which I know is important but these are areas that I don't need to learn skills in. I was a HCA for many years before deciding to train as a nurse therefore I know all about patient care in these areas. I feel that sometimes students are pushed aside on placements and this very much depends on your mentor. Ihave a brillant mentor at the moment who spends every shift ensuring I am doing something that I need to learn and highlights areas that need developing. But without her I am used as another pair of hands on the ward that is just there to preform HCA duties.
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Anonymous | 18-Jul-2010 8:02 pm
I feel like HCAs seem to be a form of lower life form and how dare anybody ask a student to perform the same tasks as they do. I am an HCA who performs phlebotomy ECGs and many other additional tasks which i am quite happy to learn students.however in many situations the student has told me they know how to do an ECG but when i have invited them to carry it out they havent got a clue. I feel sometimes students feel they are too good to be doing any task an HCA does there is a wealth of learning there to be had I have NVQ 3 and a foundation degree in health and social care but i am looked at as if i am stupid if i try to help or told they already know how to do the task even though they quite clearly dont
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mike | 18-Jul-2010 11:34 pm
Anonymous | 18-Jul-2010 8:02 pm, I think you need to come down off that very high horse a little bit.

First of all, I have to remind you that noone is having a dig at HCA's here, you tend to infer that yourselves.

Second of all your NVQ 3 and your foundation degree do qualify you to perform basic tasks yes, but you are still not accountable, (and to be honest until you are I would question any HCA's advanced role), or trained to the same level as a staff Nurse, and you cannot, and are not expected to, perform these tasks at the same level a staff Nurse does. These are just basic facts. Therefore noone is questioning you have a role to play in teaching a student, but I am sorry that role cannot replace the teaching of a fully qualified and experienced Staff Nurse.

At the end of the day, Student Nurses are training to be Nurses, not HCA's. So when those students look to a staff Nurse for training, you cannot get huffy or dismiss them, it is often because they know that in a very short period of time they will be performing AS a staff Nurse, not a HCA (which many do during training, myself included).

And yes I am sure you can quote examples of students who didn't have a clue and a few whose knowledge didn't quite match yours, but that happens across every rank. I myself can quote examples of HCAs with their much touted NVQs who I would not let near a hamster, let alone a patient. I have also met poor Nurses and poor Doctors. Thankfully I have also met a lot of good examples across every rank too, and yes that does include students.
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Louise | 22-Jul-2010 3:07 pm
I agree with Ebony as well as Mike. You both raise valid and worthy points. I personally find fundamental care very rewarding (though there are many times that I've had to delegate it due to numerous other pressures such as coordinating a shift/running ward rounds/dealing with a crisis etc.) I believe qualified nurses should set an example to student nurses by demonstrating such tasks/doing it together (at least once fgs), after all how can you assess your student if you havent' seen them perform these duties? And if you've got time to watch you've got time to do!
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Louise | 22-Jul-2010 3:08 pm
That should be haven't. My apostrophe went astray!
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Louise | 22-Jul-2010 5:03 pm
That should be haven't. My apostrophe went astray!
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Neesy | 23-Mar-2011 11:55 pm
I have to agree with Ebony and Mike.

I am a 40yr old mature nursing student with husband and 3 kids and about to qualify, also I have been a senior care assistant for 9 years in a care home and love the personal care aspect of my job.

I have seen fellow students crack under the pressure of trying to do the job of a student nurse AND an HCA. I too have had a difficult time on placements trying to split myself in half. The problem is that for me, i want to pass placements without causing problems, so when i am on shift i do every task that needs done to the point where i am exhausted and sore when i get home.

All day the HCA's and the staff nurses call my name every 5 seconds to delegate my next task before i have even finished the one i am doing. By the time i actually get to do drug rounds or doing a clinical/nursing task i am exhausted and have lost the will to live! ....and we wonder why so many students drop out :(

In first year of training i agree that personal care should be a focus for student nurses but i think 2nd and especially 3rd year there should be a little bit of slack cut so that the other fundamental aspects of nurse training can be achieved. When students go to qualify they need to be skilled to the competencies of a staff nurse so that they can do the job.

Ok...rant over :P

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