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Practice comment

Student nurses should not underestimate the value of delivering hands-on, personal care


Even though HCAs now deliver most bedside care, student nurses must realise the value of developing skills in essential care, says Ben Bowers

Recently a very experienced community colleague retold a student nurse’s disappointment that she had spent a six-month placement working in a residential home. This experience was particularly unsatisfactory for the student because she felt she had not learnt anything from washing people which will aid her practice when she qualifies.

Being a holistic practitioner, my colleague challenged this view. However, as we come to increasingly rely on healthcare assistants to deliver personal care, are tomorrow’s nurses perceiving washing patients as a role separate from being a qualified nurse?

The harsh reality of modern healthcare is that there are relatively few qualified nurses while there are increasingly more patients. As practitioners we often manage this by overseeing HCAs who deliver the bulk of hands-on, personal care.

But like any delegated task, we need to know what care we are asking others to deliver and the outcomes of such interventions. For qualified practitioners, this means being willing to help patients with their personal hygiene and advocating the high standards of respect and dignity we expect of the whole team. For example, my colleagues and I are busy community nurses but when the opportunity arises we welcome the chance to help a patient wash.

Helping patients with personal hygiene gives nurses the opportunity to use all their assessment, observational and communication skills. You discover how well they can coordinate their actions, mentally process what is being said and express themselves. It is a great opportunity to learn how to assess patients’ skin integrity, bodily functions and their variations in physical stamina. Most importantly, it is the best way to learn the telltale signs of clinical problems and when someone is not coping physically.

‘Helping patients with personal hygiene is one of the most fundamental and crucial relationship-building skills available to nurses, regardless of their seniority and clinical experience’

Nurses often have to assess patient needs quickly and efficiently. Other members of the team may deliver much of the personal care for patients but nurses need the knowledge and skills to oversee that the care meets each patient’s needs. This is particularly important for patients at a higher risk of conditions such as pressure ulcers, skin infections or fluid retention.

Without the hands-on experience of delivering personal care and seeing how situations present, nurses are ill equipped to prevent potential problems. Developing such nursing skills can be compared to learning to read. Before we learn to read, all the pages in a book appear just as important. Once you have experience of reading you develop the knowledge to cut straight to the main text, avoiding the publisher’s information and uninteresting forewords.

Student nurses often hear all these reasonings in college lectures and from their clinical mentors. I remember sitting through just such a lecture thinking, “Well, this may be true but the qualified nurses I see in practice hardly wash patients.”

In reality, no matter how busy things get, most nurses will make time to help patients wash when they believe they have complex needs, or if they need extra support or end-of-life care. The reason for this is simple: helping people to wash shows them you have time for them. It helps build up trust and aids the nurse-patient therapeutic relationship far more than countless drug rounds or other clinical interventions.

Helping patients with personal hygiene is one of the most fundamental and crucial relationship-building skills available to nurses, regardless of their seniority and clinical experience. My advice to student nurses is to embrace these opportunities while you do not have other time pressures and reflect on your experiences. These skills will prove invaluable in delivering, overseeing and evaluating meaningful, holistic care.

BEN BOWERS is community charge nurse, Cambridge Community Services and Queen’s Nurse, Cambridge

  • To read a Research report on how students’ supernumerary status affects their views of nursing, click here.

Readers' comments (17)

  • I do not agree with this as most of the first year as a student nurse is about proving hands-on, bedside care and they are replied upon to do this in the final years. Many wards understaff themselves on days when they have extra students as they have enough hands on board and I have never seen a student argue about this. Students are very undermimed and should be recognised more that to be treated like another outsider.

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  • I would agree with this student that 6 months is a long time to spend in this placement however for different reasons than those portrayed in this article. As students we do understand the importance of basic care however this is learnt early on and there is so much else to learn in a short amount of time. My personal opinion is that a greater number of shorter placements is preferable to maximise experiences.

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  • I agree with the article with regards to providing personal care - it is an essential part of holistic nursing. I am, however, a bit tired of hearing students complain about being 'used' as HCAs. If you are not happy about being used to 'make up the numbers' it is up to you to say something. I remember being on a placement and someone asking if I would go to another ward as one of their HCAs was off sick. I politely refused, explained my reasons and no more was said. Students need to be more assertive whilst on placement - it is up to them to seek out learning opportunities - they can't expect everything to be handed to them on a plate, and if its time for washing and beds, they should embrace the opportunity to get to know their patients whilst working on their communication skills. I have just qualified as a staff nurse having had mostly positive placement experiences and being pro-active in gaining as much from each placement as possible.

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  • Yes but the focus of a residential home is outside the day to day function of a nurse after all. If it really was a placement in a residential and not a nursing home then it lacks any absolute context relevant to nursing as a whole subject. Compare their experience to someone who had an acute surgical or medical ward in your third year and it is obvious which would have been more credible and incredible. That is not to with nursing or residential homes per se but it does affect the marketability of that nurse if their career ideals involved something more acute. The rigidity of nursing courses actively discouraged placement changes unless they are requested before but of course you hope your placements are relevant anyway.
    And if your not the kind of person to complain well there you go. residential home six months.

    yes we can claim the relevance of direct nursing care, skincare, nutrition, foot care, physical mobility, handling etc. But six months? That is going to be long and quite dull. The essence is not a return to health. It is not about a curative environment in the medium that their peers will be facing and the element is not of acute care which is still the biggest area of clinical practice.
    Two to four weeks of intense work and study and even responsibility in these environments is enough and i personally would ask for it to be changed as would almost everybody i knew on my course.

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  • I agree we need hands on experiance but I also dont want to be expected to know something as a NQ nurse and no know it because I spent 3 years washing people. I love being with patients and I was an NA prior to coming to uni but I came to uni so that I could help more within the team Re: meds, dressing and so on.... I will however NOT gain much knowledge on these things if I spend an entire placement working as if I'm a HCA..

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  • The article is of course wrong for the majority of us won'tbe working in a community hospital with not much else to do but basic nursing.

    Students really shouldn't underestimate just how much stuff is not even going to be mentionned on the course let alone not taught.

    Also they will have to cope with ward staff blithely clattering on about basic care.
    Yet, let's face the music. If students had a majority of good examples to follow from these nurses who never practice what they preach then the issue of basic care would not exist.

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  • I hope that you really honestly do not feel that "basic nursing" is not important in anywhere bigger than "a community hospital". I have worked in some of the biggest most acute trusts in the country and good care revolves around providing meaningful hands on care regardless of your status. Speaking for many of my trained colleugues, we lead by example. Of course like any career, our profession is made of all sorts of charictors and some shy away from doing some tasks. However, without getting the basics right regardless of our setting we can not truely meet our patients needs

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  • Yes, learning essential caring tasks is well… essential, but please teach us how to carry out high standards of personal care. From day one on my first placement I have regularly had to beg nurses to teach me. Most of my personal care skills have been developed through trial and error, and self-directed study.

    Nursing is failing student and newly qualified nurses. There are mentors who do not want to be mentors, mentors who do not teach evidence-based practice, and mentors who will sign students off as competent when they have not observed the student carrying out the skill.

    I am now a third year student and I am expected to focus on developing management skills. This means I need to practice managing a team, administering medications, prioritising care delivery, giving bad news, dealing with social issues, discharge planning, participating in ward rounds and multidisciplinary meetings. Sometimes this feels like I am being asked to run before I can walk. Fortunately my current placement is supportive, but I know of fellow students who are not treated as supernumerary and are rarely allowed to participate in qualified nurse roles. They are still being asked to work alongside HCAs, making breakfast, doing tea rounds, toileting and washes – whilst this is acceptable in the first year, by the third year we need your support to further develop our knowledge and clinical skills. I cannot underestimate the stress this lack of support can cause students.

    It is not that we underestimate the opportunities gained from assisting patients meet their personal hygiene, elimination, and nutritional needs, we want nurses to lead by example, we need to be taught and challenged in practice. I want a nurse to ask ‘What did you pick up from that experience? Did you notice…?’ I want nurses to show me how to plan care and empower patients, explain how they assess a wound, discuss the importance of nutrition for healing. How can I learn if no one is observing me undertake essential care tasks and challenging my practice? I may be a third year, but I still want qualified nurses to give me instruction in personal hygiene, skin care, catheter care, pressure ulcer prevention, last offices, manual handling, infection control etc, to make up for a couple of dodgy placements where staff have been reluctant, downright unwilling, or too busy to teach.

    Unfortunately, as the wards are overstretched many nurses have no option but to use students as a free pair of hands. Instead of leading by example and using personal care tasks as teaching opportunities, students are sent off to work alongside HCAs who do not always have the underpinning knowledge to teach safe, evidence-based personal care. It is now possible to get to the third year without a qualified nurse observing and assessing a student in their ability to undertake the fundamental basics.

    For my cohort, the end of the course is fast approaching when we will no longer be able to hide behind our student status. This is very frightening for students who have had bad luck with their placement allocations – yes, there are bad placements with limited learning opportunities, we don’t always whinge for the sake of it. The consequences of inadequate training are apparent – I have witnessed the stress experienced by newly qualified nurses whose training has not prepared them for qualification, because they were not given the opportunity to practice their management skills as students.

    Student and newly qualified nurses are being failed by lack of support and supervision. Yes, we need to practice and value essential caring tasks, but we are supernumerary for a reason. With fifty percent of our time spent in university, we have to gain a range of experiences during our limited time on placement.

    Fortunately I have had two fantastic hospital placements, intensive care and respiratory, where a strong culture of teaching exists, but I have had other placements where I have needed to be assertive to achieve the learning outcomes specified by the NMC and university – an assertiveness I doubt I could have mustered, had I started the course ten years earlier at eighteen. Despite two good placements, I still worry about being ready for qualification next summer and hope for a first job that offers a period of preceptorship.

    It is not that students underestimate the value of giving personal care, we need to participate in a variety of learning experiences to achieve our learning outcomes, and we need your guidance and support to become safe, efficient practitioners ready for qualification. Personally I don’t want to be an underpaid doctor, I came to nursing because I want to care, but I need someone to show me how to deliver evidence-based care, not abandon me on the ward, or leave me to muddle through my training unsupervised.

    Some nurses appear to have skipped reading the bit of the code that states 'You must facilitate students and others to develop their competence'.

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  • I have been reading through all these comments and not one person has praised the hca,s They do a very good job and students can learn so much from them. Comunication privercy dignety diplomercy social skills,reporting back to senior staff,to be able to know your patient and there fore notice changes, how important are all these skills,nutrition, i could go on an on. We are the back bone of the nhs an its about time we are given the credit we deserve instead of being spoken about like we are just s**t shovelers . In my oppinion students should all have to work as a hca for at least6 months before they start there training .

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  • Hi Marie, I didn't mean to undermine the work HCA's do in my post, and I am always happy to work alongside HCAs and learn from them, as many are excellent practitioners with years and years of experience and knowledge to pass on - as with life it comes down to personalities, some nurses and HCAs relish learning, teaching and teamwork, whilst others carry on with outdated practice or can't always explain the rationale behind what they're doing. Throughout my training I have glued myself to anyone willing to pass on their knowledge!

    The nursing role has changed so HCAs are doing the majority share of essential care tasks, which is a shame for nurses who miss the communication you have when helping with washes etc. Nursing is certainly different from what I thought I was going into. There needs to be balance - as a student we have a large number of set clinical skills and outcomes we have to be assessed and signed off on, but this is impossible if we are unsupervised and not challenged in our practice. I don't have a problem working with HCA's, but I need to develop my competence in nursing skills, so I will be ready for qualification.

    I often thank HCA's for their help, because I really appreciate the work they do. I also agree with your point that students should work as an HCA for at least 6 months before starting training, it would definitely have helped me.

    A large part of the problem is the supernumerary status of students, are we part of the team or aren't we? I think it would be better if students were based in hospital, going out to university, rather than the other way round.

    I could write loads about the problems with modern student nurse training...

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