Nursr Educalton T&y ( 19%) 14,287-292 0 Longman CroupUK Ltti 1992
WORK Teaching the skills of assessment through the use of an experiential workshop Nick Allcock
Assessment is a key element of the nursing process, yet the skills required to perform a nursing assessment are poorly defined in the literature. Related to this, nurse education does not adequately address how it might be possible to develop in students the skills required to plan individualised care. As a contribution to this important area of nurse education, this paper describes the first term of an assessment course, an important component of which is an experiential workshop. This workshop introduces students to the skills of observation, measurement and testing as used when assessing physiological indicators of health status. The workshop was designed to facilitate an understanding of the connection between the students’ knowledge of biological sciences and nursing practice.
INTRODUCTION The nursing process as an approach to individualised nursing care has been with us since the late 1970s and has been incorporated into preregistration courses since the General Nursing Council formally adopted it as a framework for nursing care in 1977 (Faulkner 1985). The way in which the nursing process has been incorporated into nurse education is seen by some authors as inadequate (Marks-Maran et al 1988). This is despite the emphasis placed by the United Kingdom Central Council (UKCC) on the nurse’s ability to perform the skills associated
Nick Allcock Bsc(Hons) Dip Nurse Ed RGN RNT, Lecturer in Nursing, Department of Nursing Studies, University of Nottingham, Medical School, Queens Medical Centre, Nottingham NG7 2UH. UK (Requests for offprints to NA) Manuscript accepted 18 March 1992
with individualised patient care (UKCC 1983. 1989). Marks-Maran et al suggest that, ‘Taking a nursing history or writing a care-plan is a taskbut to do it well, and in a way which allows a patient to grow and progress towards maximum health independence, requires certain skills. It is the systematic development of these skills which appears to be missing from nursing education’ (Marks-Maran et al 1988, ~5). The lack of a clear exposition of’ the skills required to perform a nursing assessment makes it difficult to teach these skills (Faulkner 1984, Marks-Maran et al 1988). This produces a mismatch between theory and practice: although the term ‘assessment’ is commonly used in nursing, the skills needed to carry out such an important task have not been well defined. This makes it difficult for teachers to develop the necessary skills in their nursing students. Faulkner (1984) has identified some of the skills involved in assessment but has tended to concentrate on those relating to communication, 287
288
NURSE EDUCATION
although tion
important
are
other skills, such as observa-
equally
assessment. Assessment
TODAY
as essential
can be defined
the nursing
process
(Kratz
and Reeves
(1990)
suggest
two
phases,
synthesis. tematic
data
They
and orderly
collection
(Stanton
biological,
spiritual
spheres
sidered. include
to
and analysis
of making the
the
of an individual
data,
a
The current
is ascertained
a need
that any therefore
the
assessment. patients,
history
nurse
health
health status
through
As nurses
effective
we know how to assess
what is not clear is how we break
skill down into its component
to complete
an assessment
this
parts in order
to
teach it. In order to clarify our ideas we began by
the
students
of
useful exercise to
clarify
their
on health and to begin to explore of assessment. some
Although
interesting
for example
themsleves of
the
the
exercise
insights
for
the
the fact that there
to discuss with their friends,
specific
mechanism
results of the exercise teaching
to
the
to nurs-
were
some aspects of health that they could not bring
evaluate
to make
an
helped
produced
and
and practical skills necesperform
which
inter-
for educationalists
to
and its relevance
the health status of a friend or relative.
students,
and subjec-
examination
session took the
and reviewed
At the end of this session students
were encouraged
nature
draw on their own clinical experience explicit the theoretical
ing practice.
con-
data about the current
lecture
process of assessment
are
health
to Assessment
of a modified
thoughts
suggest
viewing the client and through observation. There is then
form
and
should
to assessment
The Introduction
social
individual
et al (1990)
status of an individual.
Introduction
We feel that this is a potentially
must ensure
family and social history
for
of
A DESCRIPTION OF THE ASSESSMENT SKILLS COURSE
et al 1990, p 15).
assessment
tive and objective
sary
or
as ‘the sys-
assessment
biographical
including
has
analysis
psychological, of
Stanton
guide-lines
and
for the purpose
diagnosis’
the
Paul
that assessment
assessment
Any comprehensive that
as the first step in
to and about the health status of
the client/patient nursing
effective
19’79). Stanton,
collection
define
data pertaining
to an
for
feeding
the lack back
the
meant that we could not
its effectiveness
as an
approach
to
this subject.
Visit to outpatients The second session involved a visit to outpatient clinics and waiting areas where viewed patients/relatives session
was arranged
department proached
inter-
about their health. The through
manager, for their
students
and
the outpatients Sisters
permission.
were
Students
apwere
considering
what is involved in the first stage of
given outlines and aims for the session which, as
assessment,
such as the collection
this session was arrranged
went
on
to identify
interviewing,
the
observing
testing. The workshop
learning three
measuring
The following
skills
such
measuring
was designed
begin
observing,
core and
use of experiental to develop
of data, and
through
as and the
to enable students
Students
were
accompanied
by a member
introduced
to
and testing.
describes
students to Assess-
‘Visit to Outpatients’
and ‘Experiential
three form part of the 4-year
the
staff
were organised
turns to be an interviewer observer
observed
an observation communication
to experience
and communicating
outpatients
sessions of
These
being in their uniforms patients.
early on in the course,
the students
to
the three
Workshop’.
enabling
of these core skills, i.e.
the first term, which are ‘Introduction ment’,
included
of staff in
the
with to the
and
were
clinics.
The
in pairs and took it in and an observer.
the patient and recorded
The on
sheet the verbal and non-verbal of the interviewer.
programme designed to develop care planning skills to a high level. Although all three elements
A feedback session explore communication
are important, greater emphasis is placed on the experiential workshop since this is innovative
their experiences of interviewing friends and patients and to explore their feelings towards
and to our knowledge
interviewing
is unique
to our course.
allowed students to difficulties, compare
patients. Students
identified
factors
NURSE EDUCATION
that helped the communication and factors that hindered the communication. They identified a number of factors that enhanced communication relating to their own communication skills (appropriate questions, posture and positioning) characteristics of the patients (openness and friendliness) and the personal characteristics of the students (sense of humour, confidence and being ‘chatty’). All the students identified being in uniform as a factor that helped communication either by enhancing their own confidence, by feeling useful when being asked directions, or by encouraging the patient’s communication. The students also identified the exercise involving an assessment of a friend as useful as it ‘gave them ideas’. Factors that were seen as hindering communication were environmental factors such as to much or too little noise (too little noise led to fears of conversations being overheard), patients’anxiety while waiting for appointments, patients being called for appointments, patients’ unwillingness to participate (although all patients were asked their permission before they were interviewed). Many students identified the need for some sort of framework and for more experience of interviewing. These points were discussed in the feedback sessions, their relevance to assessment was pointed out and courses that would help the students to develop their skills were identified.
Assessment workshop The third element was a workshop which introduced some common measurements and tests nurses may perform or observe that can be used to assess an individual’s health status. There is evidence that observation and examination of patients is not always performed effectively. Assessment is an on-going process and thus observation and examination of patients must be accurate and reliable to ensure the continuing appropriateness and effectivenss of nursing care. Herbert (1987, p97) suggests that although observations are important, ‘often observations seem to be routine or ritual in nursing rather than a considered aspect of patient care. As a result they are not always made accurately or on NFT
C
the
most
TODAY
289
290
NURSE EDUCATION TODAY
Table Workstdons Work station
Test/Measurement
Hearing and Balance
Weber’s test Schwabach test Rotation test Blood pressure Pulse Respiratory rate Peak flow Reflolux meter Knee-jerk Finger pointing Romberg’s test Height and weight Body mass index Skin-fold thickness Handgrip strength Taste Smell Touch (two point discrimination) Pupil reaction visual acuity Urine test
Cardiovascular
system
Respiratory system Blood glucose Nervous system Height and weight Body fat Muscle strength The senses
Sight Urine testing
The workshop was planned to be experiential in nature. The use of an experiential approach to the teaching of care planning skills is supported by Marks-Maran et al (1989) who suggest that this is the most appropriate approach. The term experiential is used commonly to reflect learning through experience. As almost all learning can be said to result from experience this definition is not very helpful. Quinn (1988) suggests that the key characteristics of experiential learning are active involvement of the student, a degree of student centeredness, a degree of interaction, some measure of autonomy and flexibility and a high degree of relevance. An important element of the experiential nature of the session is that it provided the students with an opportunity to experience some of the feelings associated with undergoing or performing some tests and measurements before they were socialised into nursing, thus allowing them to develop an insight into the possible feelings and experiences of patients. The workshop was organised in a laboratory setting within the Faculty of Medicine. The laboratory provided a safe environment both psychologically and physically in which students
can practise techniques. Four tutors supervised the students to ensure the students’ safety, to help the students explore theoretical aspects of the tests and to encourage good practice, for example appropriate hand washing and appropriate explanation to subjects. A range of different measurements and tests were placed around the laboratory organised as a number of work stations. The tests and measurements used are outlined in the Table. The rationale for the selection of each of the tests varied. Many were chosen on the basis of being tests performed or observed by nurses in a variety of settings (e.g. urine testing). Others were chosen to illustrate certain physiological principles (e.g. hearing tests). Some tests were included on the basis that they are enjoyable to perform, for example the rotation test, although this test also gave the students an opportunity to observe and describe nystagmus thereby encouraging skills of observation and description. The tests were arranged to ensure the work stations occupied students for approximately the same period of time. Each work station consisted of the equipment necessary to perform the test or measurement and a worksheet. The worksheet described the test, its significance in nursing practice and possible findings. A number of questions were included which encouraged the students to consider potential sources of error in the tests (for example, ‘what factors that might affect the pulse rate should be considered when performing this measurement?‘) as well as the physiological principles involved (for example, when performing the rinue test, how is sound transmitted when the fork is placed on the bone?‘). References were also indicated to encourage further reading about the tests and their significance, and the worksheets at some of the stations instructed the students to record their observations on charts that are currently used in clinical settings. (An example of a worksheet is included in the Appendix.) Students were given a record sheet to record their own results to form a personal record. Students worked in pairs to enable them to act as subject and observer. 16 students took part in
NURSE EDUCATION
workshop which allowed constant supervision by the staff involved. The students were briefed about the aims of the session and the structure of the session was explained. Students were encouraged to make a note of how they felt when performing, or being a subject of, the tests. Students were also encouraged to answer the questions on the worksheets and to ask the supervisors if they were unsure of the answers. Each member of staff supervised three stations of a maximum of six students at a time (not all of the 12 stations were in use at the same time). This allowed time for staff to help students to link their observations with the student’s knowledge of the biological sciences, as well as time to observe and encourage good practice. Possible sources of error or bad practice were identified and pointed out to the students. This provided tutors with an opportunity to assess individual student’s performances and to rectify any deficiencies. After 10 minutes at each station, the students were instructed to move on to the next station. At the end of the workshop a tutorial was conducted. The students gave the answers to the questions on the worksheets and were encouraged to report their observations. Common errors in practice were discussed and good practice reinforced. Students were encouraged to use their knowledge of the biological sciences to explain their observations.
EVALUATION The workshop is not evaluated independently, the whole term being evaluated at the end of each term using a nominal group technique. The results from this workshop showed that students identified the workshop as one of the strengths of the course. Students thought that the session was a valuable and worthwhile experience. The main criticism of the workshop was one of a lack of background information in relation to the physiological basis of the tests. This probably resulted from the lack of time students had during the session to read and complete the questions on the worksheets which would have
TODAY
29 1
encouraged more thought and discussion on such issues. This resulted from a lack of time at each station, the students not surprisingly wishing to spend more time on performing the tests than on answering the questions. The worksheets for future groups will be included in a course laboratory manual to enable the students to keep the sheets and the tutorial will be arranged to allow students time to answer the questions. From the tutors observations of the workshop the students appeared to enjoy the session. All the students were engaged in what they were doing and there was much laughing and animated discussion. Tutors were able to reinforce good practice and point out sources of possible error, such as failing to support the arm when measuring the blood pressure. Students also discussed how it felt to undergo some of the tests and it was noticeable that several students felt uncomfortable when testing their own urine. The workshop will be repeated this year when all the worksheets, personal record sheets and references will be included in a laboratory manual which the students can keep. Slight amendments to some of the work stations will also be required to ensure better timing. In order to allow an assessment of the learning that occurred, students will be asked to complete a report outlining three of the tests that are commonly performed, detailing the rationale, possible sources of error and its significance to nursing practice. The workshop described provides an interesting method of introducing students to some of the skills required for the assessing health in terms of measurement and observation. This forms part of the development of assessment skills over the e-year foundation course. The workshop described is important because it heightens awareness, develops insights and develops skills which will be developed through the practice placements during year two. At present it is too early to say precisely the value of this as students are not yet writing care plans and have limited practice experience, however this assessment workshop has attempted to overcome the particular problem of making these vital skills more accessible to students.
2%
NURSE EDUCATION
TODAY
References Almond J 1986 Measuring blood glucose levels. Nursing Times 82 (41): 51-54 Brown S 1990 Temperature taking - getting it right. Nursing Standard 5 ( 12): 4-5 Faulkner A 1984 Teaching non-specialist nurses assessment skills in the iftercare of mastectomy patients. Unpublished Phd Thesis, University of Manchester. Faulkner A 1985 Nursing a creative approach. Bailliere Tindall, Avon Herbert R 1989 Clinical observation. In: Clark JM, Hockey L (eds) Further research for nursing. Scutari Press, London, pp 97-l 04 Hilton B A 1982 Nurses’ nerformance and interpretation of urine iesting and capillary blood glucose monitoring measures. Journal of Advanced Nursing 7: 509-52 1
Kratz C 1979 The nursing process. Bailliere Tindall, London Marks-Maran D, Docking S P, Maunder T, Scott J 1988 Skills for care planning. Scutari Press, London Stanton M, Paul C, Reeves J S 1990 An overview of the nursing process. In: George J B (ed) Nursing theories. The base for professional nursing practice, 3rd ed. Prentice-Hall, London, pp 18-29 Quinn F M 1988 The principles and practice of nurse education, 2nd ed. P Helm, London United Kingdom Central Council for Nursing, Midwiferv and Health Visitine 1983 Nurses. midwives and health visitors rules. HMSb, London United Kingdom Central Council for Nursing, Midwifery and Health Visiting 1989 Nurses, midwives and health visitors (training) amendment rules. HMSO, London
Appendix Blood glucose Introduction Glucose is the major nutrient used as a source of energy for body function. All cells use glucose although some can use other sources and under normal circumstances certain tissues (e.g. the brain) can only use glucose. It is important therefore that homeostatic mechanisms maintain blood glucose within normal levels of approximately 3.3-5.5mmolslL (fasting) and 7-Smmols/L (after a meal). These mechanisms involve complicated interactions between the storage and utilization of glucose and are controlled mainly by hormonal activity (you will look at this in detail in the meta course in term two). Measurement of blood glucose can be achieved relatively simply using visually read strips or portable meters such as the Reflolux II. Instructions Measure your partners blood glucose level following the instructions below. 1. 2. 3. 4. 5. 6. 7. 8. 9.
Explain to your partner what you intend to do and ensure you have all the necessary equipment. Wash your hands and ask your subject to do likewise. Remove a test stick from the container, check its condition and place to one side on a clean dry surface. Switch on meter and observe the code displayed. This should correspond with the code on the container. Prick the side of the finger with a lancet. Squeeze the finger to obtain a large enough drop of blood to cover the whole of the test strip. Drop the blood onto the test strip. Do not smear the blood or allow the skin to touch the pad. Immediately, press the time switch on the meter. The meter buzzes at each second from 57-60 seconds. At 60 seconds wipe the blood from the strip with clean cotton wool. 10. Allow a few seconds for the strip to dry then insert the stick, the test pads facing the on/off button. 11. Record the result which is displayed after the time reaches 120 seconds. 12. Wash your hands and clear away the equipment. DO NOT FORGET TO DISCARD SHARPS INTO THE BIN PROVIDED. Questions 1. Compare your result to the normal range. Can you explain the result taking into account your food intake? 2. Why is it so important to maintain a constant glucose level in the blood? 3. When in relation to meal times would you normally assess an individual’s blood glucose level to assess fasting levels? 4. When may this test be used to assess an individual’s health? Further reading Hinchliff S, Montague S 1988 Physiology for nursing practice. Bailliere Tindall, London, pp 168-176 Almond J 1986 Measuring blood glucose levels. Nursing Times, 82 (41): 51-54
WORK Teaching the skills of assessment through the use of an experiential workshop Nick Allcock
Assessment is a key element of the nursing process, yet the skills required to perform a nursing assessment are poorly defined in the literature. Related to this, nurse education does not adequately address how it might be possible to develop in students the skills required to plan individualised care. As a contribution to this important area of nurse education, this paper describes the first term of an assessment course, an important component of which is an experiential workshop. This workshop introduces students to the skills of observation, measurement and testing as used when assessing physiological indicators of health status. The workshop was designed to facilitate an understanding of the connection between the students’ knowledge of biological sciences and nursing practice.
INTRODUCTION The nursing process as an approach to individualised nursing care has been with us since the late 1970s and has been incorporated into preregistration courses since the General Nursing Council formally adopted it as a framework for nursing care in 1977 (Faulkner 1985). The way in which the nursing process has been incorporated into nurse education is seen by some authors as inadequate (Marks-Maran et al 1988). This is despite the emphasis placed by the United Kingdom Central Council (UKCC) on the nurse’s ability to perform the skills associated
Nick Allcock Bsc(Hons) Dip Nurse Ed RGN RNT, Lecturer in Nursing, Department of Nursing Studies, University of Nottingham, Medical School, Queens Medical Centre, Nottingham NG7 2UH. UK (Requests for offprints to NA) Manuscript accepted 18 March 1992
with individualised patient care (UKCC 1983. 1989). Marks-Maran et al suggest that, ‘Taking a nursing history or writing a care-plan is a taskbut to do it well, and in a way which allows a patient to grow and progress towards maximum health independence, requires certain skills. It is the systematic development of these skills which appears to be missing from nursing education’ (Marks-Maran et al 1988, ~5). The lack of a clear exposition of’ the skills required to perform a nursing assessment makes it difficult to teach these skills (Faulkner 1984, Marks-Maran et al 1988). This produces a mismatch between theory and practice: although the term ‘assessment’ is commonly used in nursing, the skills needed to carry out such an important task have not been well defined. This makes it difficult for teachers to develop the necessary skills in their nursing students. Faulkner (1984) has identified some of the skills involved in assessment but has tended to concentrate on those relating to communication, 287
288
NURSE EDUCATION
although tion
important
are
other skills, such as observa-
equally
assessment. Assessment
TODAY
as essential
can be defined
the nursing
process
(Kratz
and Reeves
(1990)
suggest
two
phases,
synthesis. tematic
data
They
and orderly
collection
(Stanton
biological,
spiritual
spheres
sidered. include
to
and analysis
of making the
the
of an individual
data,
a
The current
is ascertained
a need
that any therefore
the
assessment. patients,
history
nurse
health
health status
through
As nurses
effective
we know how to assess
what is not clear is how we break
skill down into its component
to complete
an assessment
this
parts in order
to
teach it. In order to clarify our ideas we began by
the
students
of
useful exercise to
clarify
their
on health and to begin to explore of assessment. some
Although
interesting
for example
themsleves of
the
the
exercise
insights
for
the
the fact that there
to discuss with their friends,
specific
mechanism
results of the exercise teaching
to
the
to nurs-
were
some aspects of health that they could not bring
evaluate
to make
an
helped
produced
and
and practical skills necesperform
which
inter-
for educationalists
to
and its relevance
the health status of a friend or relative.
students,
and subjec-
examination
session took the
and reviewed
At the end of this session students
were encouraged
nature
draw on their own clinical experience explicit the theoretical
ing practice.
con-
data about the current
lecture
process of assessment
are
health
to Assessment
of a modified
thoughts
suggest
viewing the client and through observation. There is then
form
and
should
to assessment
The Introduction
social
individual
et al (1990)
status of an individual.
Introduction
We feel that this is a potentially
must ensure
family and social history
for
of
A DESCRIPTION OF THE ASSESSMENT SKILLS COURSE
et al 1990, p 15).
assessment
tive and objective
sary
or
as ‘the sys-
assessment
biographical
including
has
analysis
psychological, of
Stanton
guide-lines
and
for the purpose
diagnosis’
the
Paul
that assessment
assessment
Any comprehensive that
as the first step in
to and about the health status of
the client/patient nursing
effective
19’79). Stanton,
collection
define
data pertaining
to an
for
feeding
the lack back
the
meant that we could not
its effectiveness
as an
approach
to
this subject.
Visit to outpatients The second session involved a visit to outpatient clinics and waiting areas where viewed patients/relatives session
was arranged
department proached
inter-
about their health. The through
manager, for their
students
and
the outpatients Sisters
permission.
were
Students
apwere
considering
what is involved in the first stage of
given outlines and aims for the session which, as
assessment,
such as the collection
this session was arrranged
went
on
to identify
interviewing,
the
observing
testing. The workshop
learning three
measuring
The following
skills
such
measuring
was designed
begin
observing,
core and
use of experiental to develop
of data, and
through
as and the
to enable students
Students
were
accompanied
by a member
introduced
to
and testing.
describes
students to Assess-
‘Visit to Outpatients’
and ‘Experiential
three form part of the 4-year
the
staff
were organised
turns to be an interviewer observer
observed
an observation communication
to experience
and communicating
outpatients
sessions of
These
being in their uniforms patients.
early on in the course,
the students
to
the three
Workshop’.
enabling
of these core skills, i.e.
the first term, which are ‘Introduction ment’,
included
of staff in
the
with to the
and
were
clinics.
The
in pairs and took it in and an observer.
the patient and recorded
The on
sheet the verbal and non-verbal of the interviewer.
programme designed to develop care planning skills to a high level. Although all three elements
A feedback session explore communication
are important, greater emphasis is placed on the experiential workshop since this is innovative
their experiences of interviewing friends and patients and to explore their feelings towards
and to our knowledge
interviewing
is unique
to our course.
allowed students to difficulties, compare
patients. Students
identified
factors
NURSE EDUCATION
that helped the communication and factors that hindered the communication. They identified a number of factors that enhanced communication relating to their own communication skills (appropriate questions, posture and positioning) characteristics of the patients (openness and friendliness) and the personal characteristics of the students (sense of humour, confidence and being ‘chatty’). All the students identified being in uniform as a factor that helped communication either by enhancing their own confidence, by feeling useful when being asked directions, or by encouraging the patient’s communication. The students also identified the exercise involving an assessment of a friend as useful as it ‘gave them ideas’. Factors that were seen as hindering communication were environmental factors such as to much or too little noise (too little noise led to fears of conversations being overheard), patients’anxiety while waiting for appointments, patients being called for appointments, patients’ unwillingness to participate (although all patients were asked their permission before they were interviewed). Many students identified the need for some sort of framework and for more experience of interviewing. These points were discussed in the feedback sessions, their relevance to assessment was pointed out and courses that would help the students to develop their skills were identified.
Assessment workshop The third element was a workshop which introduced some common measurements and tests nurses may perform or observe that can be used to assess an individual’s health status. There is evidence that observation and examination of patients is not always performed effectively. Assessment is an on-going process and thus observation and examination of patients must be accurate and reliable to ensure the continuing appropriateness and effectivenss of nursing care. Herbert (1987, p97) suggests that although observations are important, ‘often observations seem to be routine or ritual in nursing rather than a considered aspect of patient care. As a result they are not always made accurately or on NFT
C
the
most
TODAY
289
290
NURSE EDUCATION TODAY
Table Workstdons Work station
Test/Measurement
Hearing and Balance
Weber’s test Schwabach test Rotation test Blood pressure Pulse Respiratory rate Peak flow Reflolux meter Knee-jerk Finger pointing Romberg’s test Height and weight Body mass index Skin-fold thickness Handgrip strength Taste Smell Touch (two point discrimination) Pupil reaction visual acuity Urine test
Cardiovascular
system
Respiratory system Blood glucose Nervous system Height and weight Body fat Muscle strength The senses
Sight Urine testing
The workshop was planned to be experiential in nature. The use of an experiential approach to the teaching of care planning skills is supported by Marks-Maran et al (1989) who suggest that this is the most appropriate approach. The term experiential is used commonly to reflect learning through experience. As almost all learning can be said to result from experience this definition is not very helpful. Quinn (1988) suggests that the key characteristics of experiential learning are active involvement of the student, a degree of student centeredness, a degree of interaction, some measure of autonomy and flexibility and a high degree of relevance. An important element of the experiential nature of the session is that it provided the students with an opportunity to experience some of the feelings associated with undergoing or performing some tests and measurements before they were socialised into nursing, thus allowing them to develop an insight into the possible feelings and experiences of patients. The workshop was organised in a laboratory setting within the Faculty of Medicine. The laboratory provided a safe environment both psychologically and physically in which students
can practise techniques. Four tutors supervised the students to ensure the students’ safety, to help the students explore theoretical aspects of the tests and to encourage good practice, for example appropriate hand washing and appropriate explanation to subjects. A range of different measurements and tests were placed around the laboratory organised as a number of work stations. The tests and measurements used are outlined in the Table. The rationale for the selection of each of the tests varied. Many were chosen on the basis of being tests performed or observed by nurses in a variety of settings (e.g. urine testing). Others were chosen to illustrate certain physiological principles (e.g. hearing tests). Some tests were included on the basis that they are enjoyable to perform, for example the rotation test, although this test also gave the students an opportunity to observe and describe nystagmus thereby encouraging skills of observation and description. The tests were arranged to ensure the work stations occupied students for approximately the same period of time. Each work station consisted of the equipment necessary to perform the test or measurement and a worksheet. The worksheet described the test, its significance in nursing practice and possible findings. A number of questions were included which encouraged the students to consider potential sources of error in the tests (for example, ‘what factors that might affect the pulse rate should be considered when performing this measurement?‘) as well as the physiological principles involved (for example, when performing the rinue test, how is sound transmitted when the fork is placed on the bone?‘). References were also indicated to encourage further reading about the tests and their significance, and the worksheets at some of the stations instructed the students to record their observations on charts that are currently used in clinical settings. (An example of a worksheet is included in the Appendix.) Students were given a record sheet to record their own results to form a personal record. Students worked in pairs to enable them to act as subject and observer. 16 students took part in
NURSE EDUCATION
workshop which allowed constant supervision by the staff involved. The students were briefed about the aims of the session and the structure of the session was explained. Students were encouraged to make a note of how they felt when performing, or being a subject of, the tests. Students were also encouraged to answer the questions on the worksheets and to ask the supervisors if they were unsure of the answers. Each member of staff supervised three stations of a maximum of six students at a time (not all of the 12 stations were in use at the same time). This allowed time for staff to help students to link their observations with the student’s knowledge of the biological sciences, as well as time to observe and encourage good practice. Possible sources of error or bad practice were identified and pointed out to the students. This provided tutors with an opportunity to assess individual student’s performances and to rectify any deficiencies. After 10 minutes at each station, the students were instructed to move on to the next station. At the end of the workshop a tutorial was conducted. The students gave the answers to the questions on the worksheets and were encouraged to report their observations. Common errors in practice were discussed and good practice reinforced. Students were encouraged to use their knowledge of the biological sciences to explain their observations.
EVALUATION The workshop is not evaluated independently, the whole term being evaluated at the end of each term using a nominal group technique. The results from this workshop showed that students identified the workshop as one of the strengths of the course. Students thought that the session was a valuable and worthwhile experience. The main criticism of the workshop was one of a lack of background information in relation to the physiological basis of the tests. This probably resulted from the lack of time students had during the session to read and complete the questions on the worksheets which would have
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encouraged more thought and discussion on such issues. This resulted from a lack of time at each station, the students not surprisingly wishing to spend more time on performing the tests than on answering the questions. The worksheets for future groups will be included in a course laboratory manual to enable the students to keep the sheets and the tutorial will be arranged to allow students time to answer the questions. From the tutors observations of the workshop the students appeared to enjoy the session. All the students were engaged in what they were doing and there was much laughing and animated discussion. Tutors were able to reinforce good practice and point out sources of possible error, such as failing to support the arm when measuring the blood pressure. Students also discussed how it felt to undergo some of the tests and it was noticeable that several students felt uncomfortable when testing their own urine. The workshop will be repeated this year when all the worksheets, personal record sheets and references will be included in a laboratory manual which the students can keep. Slight amendments to some of the work stations will also be required to ensure better timing. In order to allow an assessment of the learning that occurred, students will be asked to complete a report outlining three of the tests that are commonly performed, detailing the rationale, possible sources of error and its significance to nursing practice. The workshop described provides an interesting method of introducing students to some of the skills required for the assessing health in terms of measurement and observation. This forms part of the development of assessment skills over the e-year foundation course. The workshop described is important because it heightens awareness, develops insights and develops skills which will be developed through the practice placements during year two. At present it is too early to say precisely the value of this as students are not yet writing care plans and have limited practice experience, however this assessment workshop has attempted to overcome the particular problem of making these vital skills more accessible to students.
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References Almond J 1986 Measuring blood glucose levels. Nursing Times 82 (41): 51-54 Brown S 1990 Temperature taking - getting it right. Nursing Standard 5 ( 12): 4-5 Faulkner A 1984 Teaching non-specialist nurses assessment skills in the iftercare of mastectomy patients. Unpublished Phd Thesis, University of Manchester. Faulkner A 1985 Nursing a creative approach. Bailliere Tindall, Avon Herbert R 1989 Clinical observation. In: Clark JM, Hockey L (eds) Further research for nursing. Scutari Press, London, pp 97-l 04 Hilton B A 1982 Nurses’ nerformance and interpretation of urine iesting and capillary blood glucose monitoring measures. Journal of Advanced Nursing 7: 509-52 1
Kratz C 1979 The nursing process. Bailliere Tindall, London Marks-Maran D, Docking S P, Maunder T, Scott J 1988 Skills for care planning. Scutari Press, London Stanton M, Paul C, Reeves J S 1990 An overview of the nursing process. In: George J B (ed) Nursing theories. The base for professional nursing practice, 3rd ed. Prentice-Hall, London, pp 18-29 Quinn F M 1988 The principles and practice of nurse education, 2nd ed. P Helm, London United Kingdom Central Council for Nursing, Midwiferv and Health Visitine 1983 Nurses. midwives and health visitors rules. HMSb, London United Kingdom Central Council for Nursing, Midwifery and Health Visiting 1989 Nurses, midwives and health visitors (training) amendment rules. HMSO, London
Appendix Blood glucose Introduction Glucose is the major nutrient used as a source of energy for body function. All cells use glucose although some can use other sources and under normal circumstances certain tissues (e.g. the brain) can only use glucose. It is important therefore that homeostatic mechanisms maintain blood glucose within normal levels of approximately 3.3-5.5mmolslL (fasting) and 7-Smmols/L (after a meal). These mechanisms involve complicated interactions between the storage and utilization of glucose and are controlled mainly by hormonal activity (you will look at this in detail in the meta course in term two). Measurement of blood glucose can be achieved relatively simply using visually read strips or portable meters such as the Reflolux II. Instructions Measure your partners blood glucose level following the instructions below. 1. 2. 3. 4. 5. 6. 7. 8. 9.
Explain to your partner what you intend to do and ensure you have all the necessary equipment. Wash your hands and ask your subject to do likewise. Remove a test stick from the container, check its condition and place to one side on a clean dry surface. Switch on meter and observe the code displayed. This should correspond with the code on the container. Prick the side of the finger with a lancet. Squeeze the finger to obtain a large enough drop of blood to cover the whole of the test strip. Drop the blood onto the test strip. Do not smear the blood or allow the skin to touch the pad. Immediately, press the time switch on the meter. The meter buzzes at each second from 57-60 seconds. At 60 seconds wipe the blood from the strip with clean cotton wool. 10. Allow a few seconds for the strip to dry then insert the stick, the test pads facing the on/off button. 11. Record the result which is displayed after the time reaches 120 seconds. 12. Wash your hands and clear away the equipment. DO NOT FORGET TO DISCARD SHARPS INTO THE BIN PROVIDED. Questions 1. Compare your result to the normal range. Can you explain the result taking into account your food intake? 2. Why is it so important to maintain a constant glucose level in the blood? 3. When in relation to meal times would you normally assess an individual’s blood glucose level to assess fasting levels? 4. When may this test be used to assess an individual’s health? Further reading Hinchliff S, Montague S 1988 Physiology for nursing practice. Bailliere Tindall, London, pp 168-176 Almond J 1986 Measuring blood glucose levels. Nursing Times, 82 (41): 51-54
