Nurses need to develop a range of competencies, including skills in practical nursing, communication and management. Practical nursing skills are the hands-on skills that nurses use in their care of people; some of these skills are performed by other professionals in caring roles too. Healthcare support workers, assistant practitioners and nursing associates carry out many of these skills, and hence, this book is relevant for them too. The NMCâs standards for registered nurses and nursing associates include detailed annexes of practical nursing skills (referred to as nursing procedures) (NMC 2018a, 2018b).
Practical nursing skills are used during assessment and interventions to promote comfort and maintain health for people who, due to acute or long-term physical or mental health conditions, cannot care for themselves independently or need help to maintain their health.
ACTIVITY
Box 1.1 Activity: healthy activities
Reflect on all the activities you carry out to keep yourself comfortable and healthy each day. What would happen if you could not carry out these activities?
You might have reflected that you carry out these activities, often referred to as âactivities of daily livingâ (Roper et al. 2000) with little thought much of the time: sleeping, eating and drinking, going to the toilet, moving about, and carrying out personal hygiene. You might take medication for one or more health conditions or if you have pain, take painkilling medicines or manage your pain another way. However, any mental or physical health condition can affect these self-care activities; without help, people would quickly become debilitated and uncomfortable, with their health and well-being at risk. There are around 6.5 million unpaid carers in the United Kingdom (UK) who help family, friends or neighbours with care due to health issues (Carers UK 2019). Many nurses are involved in supporting people and their carers at home, for example, teaching them to keep their skin healthy when they lack mobility; to manage medication; to cope with mental health issues; to deal with altered elimination, such as a urinary catheter; or to deliver care at end of life. When people are admitted to hospital, nursing teams must support the individual with activities that they cannot manage themselves as part of their holistic care.
Practical nursing skills are also carried out when assessing a personâs condition and delivering interventions to improve or maintain their health; these skills are carried out in acute situations, for people with long-term conditions and people with multiple health needs, in a range of settings. When we feel unwell, we self-assess; for example, we might measure our body temperature. Some people are unable to self-assess or communicate that they feel unwell, for example, a person with advanced dementia or a person with a severe learning disability. Nurses need to be highly skilled in using a range of assessment skills for people with different health needs, and they must be able to interpret and act on the results appropriately and often speedily. People who are acutely ill or who have long-term health conditions that fluctuate in severity, need careful and skilful monitoring. Nurses must also be able to use a wide range of practical skills to promote comfort, safety and well-being, including administration of medication.
ACTIVITY
Box 1.2 Activity: immunisations
Almost everyone has had an injection at some stage, and you may have had recent immunisations before starting your studies. You probably took it for granted that the skill would be performed competently. What are the different elements of carrying out this skill? List all you can think of.
You probably considered technical aspects such as preparing the correct medicine accurately and safely. You might have identified that the nurse required underlying knowledge of the drugâs actions and potential side effects and that the nurse should use a calm and friendly approach to relax you and relieve anxiety. This example illustrates that effective practical nursing skills require a skilled motor performance (the doing element) and a sound knowledge based on best evidence (the cognitive aspect), with both accompanied by an appropriate attitude (the affective aspect).
Oermann (1990) suggested that the motor (doing) element of a practical (psychomotor) skill is often emphasised to the exclusion of the cognitive and affective components. She highlighted the importance of the cognitive base (the scientific principles underlying the performance of the skill) and the affective domain, which reflects the nurseâs values and concern for the person while performing the skill. These three aspects are now explored further.
The affective domain
The affective domain is underpinned by values, which can be defined as âcore beliefs that guide and motivate attitudes and actionsâ (see https://www.ethics.org/resources/free-toolkit/definition-values/). Nurses bring their own personal values into nursing; these values are influenced by a range of factors (e.g. family, education) and hopefully include integrity, compassion, dignity and kindness. Nurses must also embrace professional values, directed by the National Health Service (NHS) and the NMC. Values are important as they influence attitudes and behaviour. For example, NĂ„den and Eriksson (2004) found that nurses who promoted dignity had a strong moral attitude, underpinned by values such as respect, honesty and responsibility; such nurses had a âgenuine interest and desire to help patientsâ (p. 90).
The cognitive domain
The cognitive domain reflects the thinking element behind the skill, including the application of best evidence in practice and problem-solving. Being able to adapt a skill in practice requires a sound underlying knowledge of why it is being performed and the rationale for each stage. For example, understanding the principles behind oxygen therapy enables nurses to choose an administration method that is safe and acceptable for people in specific healthcare situations. Practical skills should be based on best available evidence, which may be derived from research, but could be based on experience, and from reflection on practice (see the âLearning from experience and reflectionâ section).
Nurses are accountable for their actions, so they must be able to explain the knowledge base underpinning their practice. Benner (1984) explored how expert nurses develop knowledge from their practice, learning to recognise, for example, subtle changes in peopleâs conditions. Not all nursing skills have a firm evidence base on which to implement practice, but in many areas research-based knowledge is available. Within this book, the authors have searched for up-to-date evidence to underpin practical skills, and they refer to evidence-based guidelines where available. These guidelines include the National Institute for Health and Care Excellence (NICE) evidence-based guidelines and quality standards (see www.nice.org.uk) and the Cochrane Library systematic reviews of research. Be aware: these guidelines are regularly reviewed, so check the websites for updates. Often, NHS Trusts and other healthcare organisations have their own clinical guidelines, based on best evidence, to assist nurses and other healthcare professionals to implement evidence-based practice in the local context. You should always work with your employerâs guidelines, if available.
The motor domain
Learning the motor dimension of a skill is important for an effective outcome as lack of a skilled motor performance jeopardises both safety and comfort. Knowing how to conduct a practical skill can be termed know-how type of knowledge â practical expertise and skill that is really acquired through practice and experience (Manley 1997). Nursing skills are performed in a changing clinical environment and varied settings, with people who respond and react in different ways. Therefore, nurses need to adapt skills accordingly, so practical nursing skills can never be wholly automatic in nature.
The importance of practical nursing skills for quality care
The importance of high-quality nursing care cannot be overstated, and the application of practical nursing skills is central to peopleâs experiences. The National Nursing Research...