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Nursing OSCEs
Nursing OSCEs A complete
guide to exam success

EDITED BY

Catherine Caballero

Fiona Creed

Clare Gochmanski

Jane Lovegrove
All at the University of Brighton
Great Clarendon Street, Oxford OX2 6DP

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Preface

This book has been designed to help you develop the skills, knowledge and confidence to
successfully complete a simulated (OSCE) examination. This book will provide you with an overview
of the OSCE process. It will take you through an introduction to the use of simulation in nursing as
a form of assessment of your clinical skills and will help you understand the OSCE process.

This book differs from other OSCE books as it specifically focuses on common skills that may be
assessed via OSCEs in your university. It will enable you to revise for these specific skills and will
help you to study appropriately for success.

Each chapter outlines the key revision required for your simulated examination, provides a step by
step guide to the procedure, explains what the examiners are expecting of you, provides examples
of OSCE criteria and common questions asked at each OSCE station and identifies top tips for
helping you to pass your examination. The textbook is supported by a number of online resources
available at the Online Resource Centre. These resources include colour step by step PowerPoint
presentations of each skill, videos for selected skills and useful website addresses to help you fully
prepare for your OSCE.

There are a number of people we would like to thank for their contributions to this book. Our thanks
go to our colleagues at the University of Brighton and our local Trust Hospitals who have helped us
with this book including Tina Attoe, Claire Cree, Paula Deamer, Kate Devis, Terry Stubbings and Sue
Sully. Special thanks to Janette Grabham and production team for their assistance with video
recording. We would also like to thank everyone at the Oxford University Press for their support and
guidance in producing this book.

Thanks go to all the reviewers, academics, practitioners and students who offered their suggestions
to improve this book. Their comments have been invaluable in this process.

We would also like to specially thank the first and second year students whose quotes are included
(anonymously) throughout Chapter 14. These students were participants in Fiona’s unpublished
MSc research study exploring students’ and lecturers’ perceptions of the use of OSCEs in nursing
education.

We sincerely hope you find this book valuable for your OSCE preparation and we wish you all
success in passing your examinations.

Catherine Caballero, Fiona Creed,

Clare Gochmanski and Jane Lovegrove
Contents

About the editors and contributors

How to use this book

Part I Process and preparation

1 An introduction to OSCE assessments Fiona Creed

2 Overview of the OSCE station Fiona Creed

3 Preparation for the OSCE assessment Fiona Creed

Part II Skills

4 Interpersonal communication Sue Sully

5 Hand hygiene and infection control Jane Lovegrove

6 Aseptic non-touch technique (ANTT) Catherine Caballero

7 Measuring, assessing and recording: pulse, body temperature, respirations and oxygen
saturation Paula Deamer and Tina Attoe

8 Measuring blood pressure Kate Devis

9 Urinalysis Jane Lovegrove

10 Assessment of medication calculation skills Terry Stubbings

11 Administration of oral medication Fiona Creed

12 Recognition of acute deterioration Fiona Creed

13 Basic life support (BLS) Clare Cree

Part III Final preparation

14 Reflecting upon your OSCE Fiona Creed

Glossary

Index


About the editors and contributors

Editors

Dr Catherine Caballero DPhil, MSc, RN, PGCHSE, BSc (Hons), Dip Nursing. Senior lecturer at the
University of Brighton. Catherine has a Doctorate of Philosophy from the University of Oxford. She
has a background in surgical nursing, specializing in day surgery and in 1995 was appointed as the
first laparoscopic nurse practitioner in the UK. Catherine’s passion is in the development of clinical
skills and her interests relate to clinical decision making, nursing knowledge, clinical skill
development and mentorship and the support of learners in the clinical environment.

Fiona Creed MSc, BSc (Hons), RN. Senior lecturer at the University of Brighton. Fiona has a
clinical background in general and neurological intensive care nursing and teaches acute clinical
skills and post registration acute care nursing. Fiona is currently a PhD student at the University of
Brighton where she is exploring clinical decision making during episodes of acute patient
deterioration.

Clare Gochmanski is a skills laboratory technician at the University of Brighton. She is responsible
for looking after five skills labs across the university sites assisting with simulation teaching,
programming simulators and assisting with student skills practice session. Clare organizes and
coordinates the OSCE examinations at the University.

Jane Lovegrove MSc, BEd, RNT, RN. Principal lecturer in clinical skills at University of Brighton.
Jane’s clinical background is in intensive care, cardiac surgery and coronary care. Her current
clinical and educational interests are in grading clinical practice and using high fidelity simulation
to assist students in clinical decision making.

Contributors

Tina Attoe RN, Dip Nursing, PGCHSE, MA. Senior Lecturer, School of Nursing and Midwifery,
University of Brighton.

Clare Cree Dip Nursing, BSc (Hons), MSc. Lecturer Practitioner, School of Nursing and Midwifery,
University of Brighton.

Paula Deamer RN, BSc (Hons), MA. Senior Lecturer, School of Nursing and Midwifery, University
of Brighton.

Kate Devis RN, BSc (Hons), PGCE, MA. Previously Lecturer Practitioner for Clinical Skills between
the University of Brighton and BSUH NHS Trust, and a Senior Lecturer at Mzuzu University,
Malawi.

Terry Stubbings BA (Hons), RN (Adult), Dip Nursing (Lond.), PGCEA. Senior Lecturer, School of
Nursing and Midwifery, University of Brighton.

Sue Sully MA BSc (Hons), PGDip, Dip Ed, RN, RNT. Senior Lecturer, School of Nursing and
Midwifery, University of Brighton.


How to use this book

Nursing OSCEs: A complete guide to exam success has been specifically designed to help you revise
and prepare for your OSCE as quickly and successfully as possible:

Key Revision

Everyone knows how busy life can be in the run up to exams, so this useful section quickly
highlights the essential facts that you need to know for your OSCE.

Putting it all together for your OSCE

Step by step instructions clearly explain how to undertake a skill at the OSCE station.
Accompanying photographs help you remember what to do.
Video

When this video camera icon appears in the text a video of the skill is available on our online
resource centre.

Examiners’ marking criteria

Prepare for your OSCE by knowing exactly what the examiner expects of you ahead of the big day;
you can use these checklists to practice with classmates and get feedback to improve your skills.

Examiners’ questions

You may be asked questions to assess your knowledge underpinning the OSCE stations. These
examples are typical questions that examiners really do ask and answers are provided at the end of
every chapter for quick revision.

Common errors in this examination

Avoid those classic mistakes by knowing what they are and consider our auther’s advice to pass the
first time

Top tips

This quick list is perfect for consulting just before your OSCE.

About the online resource centre

The key to passing your OSCE is prepare, prepare, prepare-this book has a dedicated website to
help you get started. These resources are freely available but are password protected. To access the
resources simply visit the website and enter the following username and password when instructed
to in the book:

Username: caballero

Password: signpost

• Videos of key skills

• Powerpoints including colour photographs to aid revision

• Web links to evidence based guidelines so your knowledge is up-to-date

• Lecturer resources including tips and advice for running OSCEs

You can find further advice and revision help for your OSCEs by going online now to
www.oxfordtextbooks.co.uk/orc/caballero/


PART I
Process and preparation



Chapter 1
An introduction to OSCE assessments

Fiona Creed

Chapter aims

By the end of this chapter, you will understand:

• OSCEs and other types of simulated examinations,

• The background to simulated examinations,

• Why simulated examinations have been developed,

• The difference between formative and summative simulated examinations,

• Standardization of simulated examination,

• Aspects of skills assessed using simulation,

• The validity and reliability of simulated examinations.

Introduction

It is likely that at some stage throughout your nursing programme you may be asked to attend a
simulated examination. This often causes many students to panic a little as they are often unfamiliar
with this type of examination and often unsure what this form of assessment involves and what they
should expect. Simulated assessments are occurring with increasing frequency in many health care
courses. They usually involve undertaking formal clinical examinations related to clinical skills
outside of the clinical practice area. These examinations are referred to in a number of ways
including OSCEs, university clinical assessments and clinical assessments. The key element
common to all these assessments is that they use simulation in a non-clinical environment. That is to
say the assessment occurs outside of a clinical environment—usually in a clinical skills room at your
university. The purpose of this introductory chapter is to help you to understand:

• What is a simulated examination,

• The background to simulated examinations,

• Why simulated examinations have been developed,

• The difference between formative and summative simulated examinations,

• Standardization of simulated examination,

• Aspects of skills assessed using simulation,

• The validity and reliability of simulated examinations.

What is a simulated assessment/OSCE?

Within health care, several terms are used when discussing examinations using simulation and this
may appear confusing. Therefore, to ensure consistency and to simplify discussion the term OSCE
will be used throughout the book.

A simulated examination or simulated assessment is one that is examined using a simulated patient
and/or a simulated situation. Assessors are provided with objective marking criteria and these
criteria are used to judge the student’s performance (Jones et al. 2010). Students are normally
allocated a set amount of time to complete the assessment and they are provided with feedback in
relation to their assessment. This is referred to as an OSCE (Objective Structured Clinical
Examination) in several universities, although other terms may be used.

Whilst there are considerable variations, in the use of simulated examinations in health care it is
important to acknowledge that common features exist. These common features include:

• Examinations which are held in a simulated environment usually within a university

setting/university clinical skills room/simulation area.

• Examinations which use actors or other students/lecturers in the place of real patients.

• Examinations which usually adhere to university examination regulations.

• Assessors are usually university lecturers. Occasionally expert practitioners will be

involved in the university assessments.

• Students are normally required to ‘rotate’ around a number of clinical assessment

‘stations’. This allows the assessment of several skills during one examination.

Several health care professions now use simulated examinations including:

• Nursing

• Paramedics

• Physiotherapists

This type of assessment began in medicine where simulated examinations have been a common
feature of clinical assessment throughout the UK for several years.

Historical development of examinations using simulation

OSCE examinations were first developed in 1979 by Harden and Gleeson for the assessment of
clinically focused skills in medical students. In the original development students rotated around
20–30 stations and would spend 5–10 minutes at each station either performing one skill or writing
answers to an exam.
Harden and Gleeson (1979) felt that this approach was more reliable than traditional forms of
assessment. It also places emphasis on the importance of developing effective clinical skills.

The popularity of the assessment of clinical skills using simulation rapidly spread throughout
medical schools in the UK and now the majority of medical schools test their students using these
methods. Because of the widespread adoption of this assessment method there are similarities
between what is assessed and the structure of the assessment throughout medical schools in the
UK. This has led to some standardization of what is assessed and how it is assessed.

Since this initial development in the UK the use of OSCEs to assess students has spread
internationally and to other disciplines. They have been widely adapted in medicine to assess
clinical competence and modified to suit local conditions. In the last decade the use of OSCE as an
assessment tool has become very popular in nursing and allied professions.

Why have simulated examinations been developed?

Initial simulated examinations were designed to allow the assessment of clinical skills in a safe
environment away from the clinical area where mistakes in assessment and diagnosis would not be
detrimental to patient care (Bloomfield et al. 2010). They were initially derived to be an assessment
strategy but are more importantly viewed as a learning tool whereby the student is provided with
objective, expert clinical feedback to allow the student to learn from the assessment and improve
their practice.

However, alongside the need for learning from clinical assessment, several other factors have
encouraged the development of the simulated examinations across all health care courses. These
factors include:

Professional regulation

Some regulatory bodies, most notably the Nursing and Midwifery Council (NMC), have made
explicit the need for simulated examinations during nursing pre-registration programmes. Whilst
the NMC does acknowledge the need for the majority of skills to be assessed in practice it has
begun to acknowledge the importance of assessment through simulation. The essential skill clusters
(NMC 2007) clearly identify the need for skills to be assessed using simulation prior to admission to
branch. The only area that this explicitly relates to currently is assessment of aseptic technique,
where the NMC states that this must be assessed through simulation by the end of year 1. The NMC
may make further recommendations in relation to simulated examinations in the future.

The inclusion of skills that require assessment using simulation has meant that most universities
that provide pre-registration nursing programmes are required to include these examinations as
part of the student nurse’s educational programme.

Patient safety

Health care is becoming increasingly litigious and the need to protect the patient and maintain
patient safety is clearly paramount. Some educationalists feel it is more appropriate to allow the
student time to learn practice and be assessed in a simulated environment prior to experience with
patients in a clinical area. These educationalists acknowledge that there is a need for students to be
assessed in clinical practice as well, but maintain that practice and assessment outside of the
clinical area using simulation will enhance real clinical experience.

Drive for objective assessment

Recent educational studies, most notably Duffy’s research (2004), have identified inconsistencies in
clinical assessment. These inconsistencies have affected the objectivity of clinical assessments and
it is argued that several students have passed clinical skills assessments where they perhaps should
have failed. Other factors may also make objective assessment of clinical skills difficult. These
include lack of time or resources for clinical assessment, interruption of the business of ward areas,
increasing scarcity of appropriate clinical placements and the limited opportunity to assess some
skills in some clinical areas. It is also acknowledged that care of the patient should always take
priority over assessment of the student and in some very busy areas this does reduce the time
professionals have for student assessment.

Educational establishments’ valuing of clinical skills

The use of simulated examinations in health care requires a huge investment of resources by
educational establishments. The resources required include:

• Setting up the examination,

• Running the examination,

• Providing feedback,

• Post assessment counselling/developing action plans.

Investment in these costly resources highlights the value that universities attach to the
development of clinical skills.

Formative versus summative clinical examination

Simulated examinations are usually referred to as being a summative or formative examination. This
educational terminology often confuses students and registered nurses alike so it is vital to clarify
the type of examination being assessed.

Summative examination

This is an examination that the student must pass in order to progress in their chosen career. These
summative exams are typically held in ‘key stages’ of the student’s course. For example, in nursing,
summative examinations may be held prior to admission to the branch programme at the end of the
first year or prior to admission to the professional register at the end of the final year. Students are
normally allowed up to three sometimes four attempts to pass a summative examination, although
this, of course, depends on the university’s examination regulations.

Formative examination

This is an examination designed to provide the student with constructive objective feedback about
the area being assessed. There is not normally a requirement for the student to pass a formative
examination although some universities may insist that the student retakes the examination to
demonstrate learning as a result of the initial examination. Most universities will use formative
examinations as an opportunity to develop an action plan with the student that will enable them to
build upon and enhance their skill/knowledge.

Standardization of skills assessed using simulated examinations

It was highlighted earlier that there does appear to be some standardization of simulated
examinations in medicine and medical students can expect to sit very similar types of simulated
examinations throughout the UK.

However, in other health care professions the type of examination and the subject of the
examination may vary greatly between institutes and there is currently very little standardization in
the UK. This reflects the early stage of development of simulated examinations in other health care
professions. It is expected that some guidance may be provided by regulatory bodies, e.g. the NMC,
but at the moment this has not yet happened.

Which aspects of skills are assessed?

Again there is great variation in which aspects of skills are assessed. This varies between
universities and between health care professions. In general, simulated examinations will assess the
performance of a skill and professional attributes associated with that skill and may or may not
assess the knowledge related to the skill.

Box 1.1 Remember

You are strongly advised to discuss the type and nature of simulated examination that is used in
your university with the lecturers that are involved with simulated examinations. This book will
provide a general overview and general guidance in relation to simulated examinations in health
care with a particular emphasis on pre-registration nursing. Examples of skills likely to be assessed
are included in Table 1.1.
 Table 1.1 Examples of skills in nursing that may be tested via OSCE

Performance of skill

The performance of a skill is an essential element to all simulated examinations. Some simulated
examinations will only assess the ability to correctly perform a skill. This is known as assessment of
the psychomotor elements of the skill. The university may test underpinning knowledge that relates
to the skill by using another examination format, e.g. multiple choice tests.

Professional attributes

Most simulated examinations will assess whether the skill is performed in a professional manner.
This may involve assessing whether the student is attired professionally, communicates with the
patient effectively, understands the limitations of their ability, understands the need to appropriately
approach the patient and maintains an appropriate attitude to the patient and/or situation.

Box 1.2 Remember

You are strongly advised to discuss what parts of the skill are being assessed in the simulated
examination that is used in your university with the lecturers that are involved with examinations.
The lecturers will identify which areas are being assessed in each simulated examination.

Knowledge related to the skill

Many universities fundamentally believe that skills and knowledge are so inextricably linked that
there is a need to assess these together. In these examinations it is likely you will be asked a series
of questions that will demonstrate your understanding of the theory or knowledge related to that
skill.

Validity/reliability of simulated examinations

Many students worry that their examination will be difficult and that some examiners will be
stricter than others when marking the examinations. All examinations are rigorously tested to
ensure that the examination measures what it is intended to do (validity) and that it is a fair and
equitable experience (reliability).

Validity

All universities will have invested a considerable amount of time ensuring that the examination does
test the associated skill accurately. To this end most examination marking tools are tested time and
time again and refined until the examiners are sure that the examination can assess that skill
appropriately. In addition to this, most universities insist that those assessing the skill are clinical
experts and these lecturers/clinical staff may be required in some universities to be assessed using
simulated examinations before they are permitted to be an examiner for that particular skill.
Reliability

Again universities have several systems in place to determine that simulated examinations are as
fair and objective as possible. Some universities use advanced statistical analysis of each station
and of each examiner and each examiner is given a score representing the overall fairness, parity
and objectivity. This system ensures that examiners are consistently fair and subjectivity is avoided.

You must therefore be reassured that you will be assessed fairly by nurses or lecturers who have
expertise in teaching or undertaking the clinical skills they are assessing. The use of objective
criteria will ensure you are assessed in exactly the same manner as the other students in your
cohort or group.

How can this book help you?

Having completed the action points (see Box 1.3) it is advisable to continue reading through the
following chapters, as your time allows. The next two chapters in the book will help you to
understand more details about OSCE assessments:

• Chapter 2 will provide an overview of ‘typical OSCE stations’ to enable you to

understand how your OSCE assessment may be undertaken.

• Chapter 3 will provide you with some advice on how you may begin to prepare yourself
for your OSCE assessment.

Once you understand exactly what an OSCE involves and how you can prepare, you are advised to
read the following chapter or chapters that relate to your own OSCE:

• Chapters 4–13 will provide detail related to specific OSCE assessments. These subjects
have been chosen as a representation of skills your university may assess using an OSCE
assessment. It is most unlikely that you will be assessed on all of these skills so you may
just wish to initially concentrate on the skills your own university assesses. However the
other chapters will be useful for assessment of these skills in practice.

• These chapters have been carefully planned to ensure that they each include:

Key revision for your OSCE assessment,

Step by step explanation of the skill you are being assessed on using evidence-based
explanations for each step,

An example of an OSCE criteria grid for that skill,

Common mistakes made at that OSCE station and how to overcome these,

Top tips for passing your OSCE,

Reading/reference lists that you may wish to refer to,

Links to electronic material available on the OSCE book website

see www.oxfordtextbooks.co.uk/orc/caballero/.

Throughout the skills-focused chapters there are some common themes that examiners will be
assessing you on and emphasis will be placed on these important aspects. These include:
 • Professional attitude,

• Communication with the patient and other staff,

• Ability to undertake the skill effectively,

• Knowledge related to the skill,

• Ability to maintain infection control,

• Documentation throughout the process.

These are all important features and will be common aspects of the assessment. It is important that
you pay attention to these areas when preparing for and undertaking your OSCE.

The final chapter, Chapter 14, focuses on the use of reflection in the OSCE assessment practice.
This is of particular use in formative and summative assessments as you may wish to reflect upon
the areas you have done well in and begin to explore how you may improve on aspects of the
assessment that you felt could be better.

What now?

At this stage, it will be useful to develop your own personal study plan which may include:

• Checking that you understand what an OSCE may involve. You may wish to read around
the subject of OSCE and it may be useful to review some of the references in the
reference list if you would like more detailed explanations. You may wish to utilize the
personal study plan to identify what you have learnt from this chapter and what you need
to plan to do next.

• Discussing with your own university’s clinical skills team which OSCE you will be
expected to undertake during your nursing programme.

• Reviewing the skills chapters that will be useful either in your OSCE or in clinical
practice.

Box 1.3 Personal study plan

Five important things I have learnt from reading this chapter

Plan for future reading/study/revision

Online resource centre

You can find further advice and revision help for your OSCEs by going to online now to see
www.oxfordtextbooks.co.uk/orc/caballero/.

References

Bloomfield, J., Pegram, A. and Jones, C. (2010). How to pass your OSCE: a guide to
success in nursing and midwifery. Harlow: Pearson Education.

Doran, T. and O’Neil P. (2002). Core clinical skills for OSCEs in medicine. London:
Churchill Livingstone.

Duffy, K. (2004). Failing Students. London: Nursing & Midwifery Council.

Harden, R.M. and Gleeson, F.A. (1979). Assessment of clinical competence using an OSCE.
Medical Education 13:41–54.

Jones, A., Pegram, A. and Fordham, C. (2010). Developing and examining an objective
structured clinical examination. Nurse Education Today 30:137–141.

Nursing and Midwifery Council (2007). Essential skills clusters. London: Nursing and
Midwifery Council.


Chapter 2
Overview of the OSCE station

Fiona Creed

Chapter aims

This chapter will help the reader understand:

• What to expect from an OSCE,

• How simulated exams are organized,

• The examination environment,

• The role of the patient and examiner,

• The structure of a simulated examination,

• The timing of a simulated examination,

• Examination regulations,

• Top tips for understanding the structure of your own examination.

Introduction

Student health care practitioners are often apprehensive about simulated examinations as they have
never undertaken an examination like this before and often do not know what to expect. The
purpose of the chapter is to explore the OSCE process and help you to understand and plan for your
own OSCE.
Organization of simulated examinations

OSCE examinations may be organized very differently depending upon the subject of the
examination and your own university’s preference. Most simulated examinations are held in clinical
skills rooms or simulation suites at the student’s university campus. Very occasionally they may be
held off site at another location, e.g. a hospital teaching room.

The examination structure may vary dramatically (Bloomfield et al. 2010) and may be:

• Multiple short stations,

• Complex single stations,

• Unmanned station.

Multiple short station OSCEs

These are also known as ‘short case’ OSCE stations. A typical short station OSCE will involve the
student health care practitioner ‘rotating’ around a number of different stations. It is likely that
within each examination room several skills will be assessed at any one time and part of the
assessment will involve moving from station to station to ensure that students complete all
skills/knowledge assessments that are required (see Fig. 2.1). This format allows examiners to
assess a range of skills during one simulated examination period (Ahuja 2009). The number of
stations will depend upon the university’s examination structure but it may be that there are up to
five stations to attend. Some universities ask students to rotate around more than this (in some
occasions up to 20). This type of OSCE is very common in pre-registration nursing OSCEs
(Bloomfield et al. 2010).

Simulated examinations may be held in one room or students may be required to move from room to
room to ensure all skills are assessed.

Complex single station OSCEs

This type of OSCE is usually used to examine the more complex skills and may be used in the final
year to test more complicated skills such as assessment of the sick patient. You should be aware
that you may also be asked to undertake OSCE in your post-registration nurse education. Most post-
registration OSCEs use this approach as they are likely to want to test competency in the
integration of a number of skills, e.g. neurological examination in a physical assessment course. It is
common for knowledge to be tested in this sort of OSCE.

Unmanned station

This may be a component of multiple short station OSCEs. Some universities will require you to
complete either a paper or online assessment examination that tests your knowledge as well as your
ability to undertake a skill. This station is usually still timed so you have to be careful with your time
management but there is usually no one present at this station. Some universities may also ask you
to stay at a waiting station whilst you wait for your colleagues to finish their OSCE. If this approach
is used you are not allowed to discuss the OSCE with other students (discussion during the course
of the OSCE process is often unhelpful as it only serves to make the other students nervous!).
 Figure 2.1 Diagrammatic example of a four OSCE station layout

Layout of the OSCE station

At each OSCE station the student will have one particular simple or complex skill to complete. Some
universities split skills down into very small components, e.g. hand washing only. Other universities
may wish to create a more realistic assessment and require the student to complete all
physiological measurements (blood pressure, pulse, respiration, oxygen saturation and
temperature) within one station. It is important that prior to attending the examination students
find out which sort of approach has been adopted by the university. Regardless of type of approach
the layout of the simulated examination station will be similar (see Fig 2.2 and Fig 2.3).

Each station will usually include:

• A patient,

• An examiner,

• A skill to complete,

• The necessary equipment to complete the skill,

• Documentation if required, e.g. observation chart,

• Filming equipment if used,

• Infection control equipment, e.g. hand gel, aprons, gloves.

 Figure 2.2 Hand washing

Figure 2.3 Physiological measurement station

Roles and responsibilities

The role of the patient

The patient may be required at some stations, e.g. for communication or physiological
measurements. Other stations, e.g. hand washing, may not have a patient present. At some stations,
e.g. injection technique, you may only have a model of the skin. The role of the patient may be
played by:

• Another lecturer,

• A member of staff from a local NHS Trust,

• A fellow student,

• A patient volunteer,

• A simulated patient (see Fig. 2.4).

The student is expected to treat the patient as they would in clinical practice. This is to ensure that
the student can be assessed for appropriate communication skills, interaction with the patient, and
professional attitude. It is also to ensure that the student considers legal issues, e.g. gaining
consent prior to treatment/assessment, and remembers to follow universal precautions to prevent
the spread of infection to the patient.

It is sometimes difficult but essential to treat this role play patient as a real patient in clinical
practice. The role play patient is often involved in marking or judging attitude and communication
skills of the student and will often be involved in assessing how well the student has performed.

Figure 2.4 A simulated patient

Box 2.1 Remember

You will be assessed on your interpersonal skills and how you interact with the patient. This is often
a difficult part of the assessment when you are nervous. At each station where a patient is used you
must:

• Introduce yourself to the patient,

• Communicate throughout the station in a professional manner,

• Gain consent for everything you are doing,

• Explain everything you are going to do in terms that the patient will understand,

• Check the patient’s understanding prior to the procedure,

• Always ensure your patient’s dignity and privacy are respected (it is easy to forget to
draw the curtains in an artificial situation!),

• Maintain the safety of the patient at all times,

• Prevent the spread of infection to your patient (remember to decontaminate your

hands!).

The role of the examiner

The examiner is present to assess the student and will often be a lecturer that students are familiar
with or may be an expert clinician or another lecturer from the university. The role of the examiner
is to:

• Explain the station to the student (see examples in Table 2.1),

• Assess the student throughout the examination using the assessment tool,
 • Provide feedback to the student (either at the end of the examination (formative) or by
written communication (summative)).

Table 2.1 Examples of an examiner’s explanation of an OSCE station to a student

It is unlikely that the examiner will engage in any communication with the student other than to
issue instructions for that station and this may make you feel nervous, but remember the same
instructions will be given to each student to ensure parity of communication (Jones et al. 2010). It
would not be fair to provide one student with complex instructions and another with very little
detail and this is why these standardized instructions are used.

Remember to ensure you understand what is being asked of you at each station; you can, of course,
ask the examiner to repeat the instructions if you are at all unsure.

If any problems occur during the assessment process the examiner may stop the examination. This
is unlikely but may happen if you are causing pain or potential harm to the patient. One common
error, for example, is to leave the blood pressure cuff fully inflated for a long time whilst attempting
to hear the systolic pressure when recording a manual blood pressure. The examiner may ask that
you let the cuff down and rest the ‘patient’ if they appear to be in any discomfort.

The examiner will be looking for safe and competent practice. Doran and O’Neil (2002) suggest that
this may be reflected in:

• Approach,

• The fluency of skills performance,

• Dexterity in performing the skill,

• Application of knowledge,

• Clear communication.

Assessment

Assessment criteria

The examiner will be assessing the performance of that skill against predefined criteria. He or she
will most likely be marking an assessment criteria sheet as you progress through that station.
Some students are alarmed at this, especially if the examiner appears to be writing a lot. Do not
worry about this. Throughout the skill the examiner will assess the student against predefined
criteria that will enable an overall assessment of the competence at the end of your examination
(Ahuja 2009). In some examinations ‘red flags’ may be used; these are points that the students must
cover in order to pass that skill, e.g. appropriate hand decontamination if patient contact is
required. Some universities have particular stations that must be passed in order for you to achieve
an overall pass grade in your OSCE.

Assessment criteria will vary from university to university and it is good practice for the examiners
to allow the students to see the marking criteria prior to the examination to ensure that they are
aware of the criteria that they are being assessed against. Students should also be notified of any
red flag criteria (criteria that must be demonstrated in order to pass).

An example of marking criteria is shown in Table 2.2, but it is stressed that this may vary greatly
and students should familiarize themselves with the marking grid that is to be used.

Box 2.2 OSCE tip

Your tutors will have already highlighted the red flags to you in your OSCE preparation sessions. If
there are going to be any red flags remember to record these in your revision notes so that you do
not forget them on the day of your OSCE.

How will the examiner mark the examination?

This will be very dependent upon the marking style of the university and it is vital that students are
aware how the examination will be graded. There are several different methods that may be used
and it is essential that you understand which marking criteria your own university is using:

• Total mark awarded: Some universities will provide a grade for your OSCE
performance. Where this approach is used the examiner will award you a total mark
depending on how well you have performed aspects of the OSCE. You may be awarded
marks for aspects of the OSCE, e.g. interpersonal skills, professional attitude, and
demonstration of skill and associated knowledge. Alternatively each component will be
awarded a score. Where this approach is used each part of the examination will be
awarded a mark and the mark awarded will be a sum of these marks—it may be calculated
as a percentage of the total score. This approach is often used in universities that
recognize the importance of grading the clinical component of nursing alongside the
academic work.

• Pass/fail: Some examinations will simply be marked as a pass or a fail and this is
perhaps the simplest form of marking (Rushforth 2007). The OSCE checklist will be
broken down into action observed/not observed. Failure to complete all of the components
of the OSCE will result in a fail grade award.

• Global mark: Some examiners give a global grade for the station. In this case
examiners will be asked to identify how well each component of the skill was performed
and this provides a view of the quality of the skills performance (Rushforth 2007).
Examiners will be asked to identify whether the skill performance was
excellent/good/satisfactory/borderline/refer. It is likely that the examiners will have
objective descriptors to help them differentiate between excellent and good. Other
universities may use a Likert scale to determine global rating (see Fig. 2.5).

Table 2.2 Example of examiners’ marking criteria

 Figure 2.5 Likert scale

• Combination approach: Some universities may use pass/fail or grade criteria

alongside a global rating scale (Rushforth 2007; Jones et al. 2010). This combined
approach is thought to be a reliable and fair way of assessing students.

• Red flag criteria met/unmet: If red flag criteria are not met then the student will not
be awarded a pass grade. Common red flag criteria often relate to important issues such
as consent and infection control. These are sometimes overlooked in the stress of an
OSCE examination but are essential components of effective patient care.

Timing within simulated examinations

Students are usually given a stated amount of time in which to complete each skill during a
simulated examination. The timing of the examination is an important component as it is essential
that each student is allowed to have the same amount of time for each station to ensure parity
throughout the assessment.

Most examinations will commence with the examiner telling students when the assessment will
begin. Students are usually also warned either 1 or 2 minutes before the end of the examination as
well. This strict timing can often make the examination feel more stressful and increase anxiety.
However, the examiners have usually carefully calculated how much time a practitioner at any given
level should take to complete the assessment so students should not feel rushed in this situation.

Examination conditions

Simulated examinations are normally held under the university’s examination regulations. This
means that students are expected to adhere to examination rules and behave in accordance with
these regulations. Most universities will require you to wear your uniform for the OSCE so
remember to pack your uniform when preparing for the OSCE and allow plenty of time to change.

Filming

It may be a requirement for the examination to be filmed. The filming serves two purposes:

• It enables the external examiner to check simulated examinations as part of an

examination board process. This is usually only done if the assessment is summative and if
this is a requirement of your university.
 • It enables the student to view their own performance and reflect back on the process as
part of the learning from the simulation. This is normally only used if the examination is
formative.

Where filming is used it is usually unobtrusive (cameras may be located in the ceilings of skills
rooms/simulation suites). On some occasions other cameras will be used. Students may or may not
be required to wear a microphone so that filming will include any verbal interactions throughout the
examination.

Practice sessions

Some universities offer the opportunity for students to attend practice sessions and may schedule
them into your student timetable. If optional practice sessions are offered students are strongly
advised to attend as these will give the opportunity to experience a simulated examination prior to
undertaking a more formalized assessment.

Top tips for preparing for OSCE examinations

Before the OSCE day:

• Familiarize yourself with setting and layout,

• Find out if you are required to wear your uniform,

• Find out how much time there is for each station/skill,

• Look at the marking criteria that is going to be used,

• Find out if there are any red flags in each exam,

• Find out how the exam will be marked,

• Attend any practice sessions that are offered,

• Recognize that you need to treat a patient (real or otherwise) as a patient,

• Find out if the simulation is to be assessed using a low/high fidelity manikin to avoid any
shocks during the examination.

On the day of the OSCE:

• Act professionally throughout the examination,

• Do not expect to have the same relationship with the examiner during the exam as you
do in every-day lectures,

• Communicate with the patient and examiner throughout the examination,

• Ensure that you leave the patient in a comfortable and safe position,

• Try to view the examination as a learning tool.

The next chapter will discuss how you can prepare yourself for the OSCE examination, but before
moving on it may be a good idea to complete the checklist in Table 2.3 to ensure you are aware of
everything that your own OSCE will include.

If you do not know the answers to any of these questions speak to a member of your university’s
skills/OSCE team who will be able to help and reassure you.

Table 2.3 OSCE checklist

Online resource centre

You can find further advice and revision help for your OSCEs by going online now to see
www.oxfordtextbooks.co.uk/orc/caballero/.

References

Ahuja, J. (2009). OSCE: a guide for student practitioners. Practice Nurse, 37(1): 37–39.

Bloomfield, J., Pegram, A. and Jones, C. (2010). How to pass your OSCE: a guide to
success in nursing and midwifery. Harlow: Pearson.

Doran, T. and O’Neil, P. (2002). Core clinical skills for OSCE in medicine. London:
Churchill Livingstone.
Jones, A., Pegram, A. and Fordham-Clarke, C. (2010). Developing and examining an
objective structured clinical examination. Nurse Education Today, 30: 137–141.

Rushforth, H. (2007). Objective structured clinical examination (OSCE): review of the

literature and implications for nursing practice. Nurse Education Today, 27: 481–490.


Chapter 3
Preparation for the OSCE assessment

Fiona Creed

Chapter aims

This chapter will provide an overview of general preparation required. This will include:

• Understanding how preparation will help you in your OSCE,

• Key revision strategies,

• Key practice strategies,

• Key points to help you.

Introduction

The need to prepare adequately for any university examination is beyond refute and students may
struggle with the OSCE assessment if they are unprepared or have unrealistic expectations of the
OSCE process (Bloomfield et al. 2010). Adequate preparation will enable you to:

• Minimize any anxiety related to the examination,

• Understand the requirements of the OSCE,

• Facilitate accurate, systematic and timely performance of the OSCE,

• Enable you to give full justice to your professional ability.

OSCEs represent an important opportunity for you to further develop your nursing knowledge and
skills. Effective preparation will give you a better opportunity to learn effectively from your OSCE
and enable you to view the experience positively (see Chapter 14 Reflecting upon your OSCE).

Preparation for your OSCE will clearly be affected by your own learning style and where and how
you study is likely to be adapted to suit your own learning needs. You may well have completed a
learning style assessment quiz such as Honey and Mumford’s (1986) at university; if not, you are
able to access this online. It may be best to link your study for your OSCE to your learning style.
Honey and Mumford (1986) identified several differing learning styles that are briefly described
here. These include:

• Reflector: Tend to explore issues in depth before reaching a decision,

• Theorist: Logical and enjoy researching and using theory to enable understanding,

• Pragmatist: Like to apply things in practice and experiment with new ideas,

• Activists: Are open to new ideas and learn through experience alongside others.

Therefore you can use your understanding of your learning style to help plan how you may best
revise/prepare for your OSCE. For example:

• Activist: May prepare best by practising for your OSCE with your colleagues and
practising your OSCE in the skills room or in a group outside of university.

• Reflector: May learn best by reviewing your own experience or learning from reflecting
on experiences you have had in clinical practice.

• Theorist: May prepare by reviewing the literature and reading around the subject
matter of your OSCE in appropriate literature, OSCE and clinical skills books.

• Pragmatist: May learn best working alongside your mentor in clinical practice and
reviewing decisions/actions you have taken in practice.

The learning style questionnaire often highlights traits of combinations of styles, e.g. pragmatist
and activist, and you may be able to adapt your revision to meet both styles. For example, using this
combination you may be able to learn by harnessing learning from practice and also working
alongside your colleagues in your cohort in order to practise at university. It is likely that during
your nursing programme you will use all four learning styles, to differing extents.

Understanding what is required

Throughout this book, each chapter will remind you to familiarize yourself with the OSCE
requirements of your university as this ensures you fully understand what is expected of you (Ward
and Barratt 2009). Currently there are no national nursing OSCE standards/proformas so although
many universities utilize similar OSCEs the variation in requirements may vary considerably
between different academic institutions.

Before commencing revision and preparation for your OSCE it is vital to understand how you will be
assessed and what is assessed. Many universities’ OSCE assessment strategies will be linked to
education theory and commonly Bloom’s (1956) taxonomy is used. Whilst this text may appear a
little dated it is considered seminal work in understanding effective learning. Bloom (1956)
identified a number of components to effective learning, stressing the need for education to cover
all components of learning. He identified three components or domains:

1. Cognitive domain (knowledge),

2. Psychomotor domain (practical skills),

3. Affective domain (attitude/professional approach).

It is likely that your OSCE will test all three of these domains and you are likely to be assessed for:

1. Knowledge in relation to skill being assessed (cognitive domain),

2. Actual performance and fluency of skill (psychomotor domain),

3. Appropriate attitude and professional approach (affective domain).

A varied approach is used when testing knowledge and some universities may test knowledge at a
separate station whereas others may test knowledge using a traditional written exam or online
assessment/examination.

A varied approach may also be used when testing skills and some universities will test single skills,
e.g. hand washing, whereas others will test this as part of a more holistic assessment, e.g. patient
assessment (which also includes aspects of infection control).

Before beginning your preparation it is important that you have a clear understanding of the
assessment process. It is likely that the university will have dedicated some timetabled sessions to
help you prepare for the OSCE, and it is important to attend these sessions. Key questions include:

• What are the assessment criteria (it is good practice for the university to provide
students with this)?

• Which skill/skills will be assessed?

• How will the skill be assessed?

• How will the knowledge be assessed?

It is vital that you have a clear understanding of the preparation required as this will enable you to
plan effective preparation strategies.

Preparation for revision of knowledge underpinning your OSCE

The knowledge that is related to the OSCE you are undertaking is vitally important and you will be
expected to demonstrate through observation or questioning that you understand key knowledge
elements of the skill you are undertaking. It is important therefore that you revise this aspect of the
OSCE.

Students may use several strategies to revise theory and it is important that you use revision
strategies that suit your own learning needs. Most universities will have different resources
available to ensure that all learners’ needs are met. Key preparation strategies include:

• Planning time for your revision: You are recommended to begin reading for your
OSCE at least a month before the examination. This allows you time to identify your
learning requirements and knowledge deficits and to be able to fully assimilate the
information before the examination date. Last minute revision is not recommended as this
is likely to increase your anxiety level and detract from your performance at the OSCE.

• Reviewing key texts: Most universities will have adapted a key text or texts that they
recommend for the course/modules. It is wise to review these texts as it is likely that they
will help you to identify the knowledge that you need to learn for your OSCE and
subsequent practice. Several key texts may also have an electronic database which is
updated on a regular basis—it is wise to review this as well as this will be updated much
more frequently and will contain more recent information.

• Reviewing key journals: Most academic journals frequently include updates relating to
skills and knowledge and it is useful to search the university’s online database for recent
articles related to your OSCE. Journals tend to provide more current information than
books. You will, of course, be expected to cite the most recent evidence-based practice
from books and journals.

• Reviewing key websites: There may well be key governmental papers that you are
expected to cite. It is worth viewing the National Institute for Health and Clinical
Excellence (NICE) website, the Department of Health (DOH) and the Scottish
Intercollegiate Guidelines Network (SIGN) websites for key papers.

• Reviewing online university resources: Most universities supplement text

books/journals with online resources and some may have dedicated resources for the
OSCE. If these are available it is essential that you review these as you will be expected to
know information that is readily available.

• Making concise notes: It is important to note key aspects of knowledge that you can
use as an aide mémoire immediately prior to the examination.
Preparation for practising the skills component of your OSCE

The actual performance and sequencing of the skill you are undertaking will be judged, usually
against a set of predetermined stages (the OSCE proformas). It is vital that you are able to practise
the psychomotor or skill aspects of your OSCE. It is important that you are aware of the skills
criteria that you will be assessed against. This may vary between academic institutions and also
may be slightly different to how you have seen a skill performed in practice.

The timing of your OSCE will influence the practising of the psychomotor component of the OSCE
and different strategies will need to be adapted if your OSCE is organized before, after or during
your practice placement.

Some universities may require you to undertake an OSCE before you go out into a practice area
(Hart 2010). If this is the case your opportunity to practise will be limited to simulated classroom
sessions. You will need to develop your psychomotor skills using the range of learning opportunities
available to you at your university. These may include:

• Attending teaching sessions that prepare you to undertake the psychomotor element of
the skill.

• Making effective use of any practice sessions that may be run.

• Using self-directed skills sessions as an opportunity to practise.

• Identifying any difficulties that you experience and discussing them with a member of
the university’s skills team or with your personal tutor.

• Reviewing university electronic resources, e.g. videos/DVDs to review key components

of the skill.

• It may be useful to get together with colleagues to practice skills in the skills laboratory
if you are able to organize this.

• Visiting the website www.oxfordtextbooks.co.uk to view electronic resources available

alongside this book (see www.oxfordtextbooks.co.uk/orc/caballero/).

• Some universities offer virtual semi-structured assessments that guide you through the
assessment of the OSCE on a computer link.

If the timing of your OSCE is during or after your practice placement then you are also able to use
this opportunity to further develop your skill in the clinical area. Your clinical mentor may be able to
assist you by organizing, supervising and assessing your practice (NMC 2008; Hart 2010). It is
recommended that you:

• Discuss your need to adequately prepare for your OSCE with your mentor and
endeavour to include elements of this in your learning contract.

• Try to observe the skill in clinical practice to enable you to build your confidence before
further developing your own clinical ability.

• Try to gain clinical experience of the skill, and where appropriate seek constructive
feedback from the clinical staff that will enable you to further develop your skill.

• Practise the skill as often as is appropriate. Few nurses can perfect a skill instantly and
recognition of the need to take time to develop your skills is essential.

Developing the appropriate attitude and professional approach for your OSCE

A key element of the OSCE is the assessment of the affective domain. This domain is related to
feelings, attitudes and caring (Quinn 2007). These can be difficult to develop, especially if you are a
novice in health care, but your examiners will be looking for effective interpersonal skills and a
professional approach. This is an area where many nurses struggle within an OSCE situation
because they are not in a clinical area with real patients.
Many students struggle to adopt the correct approach to the ‘patient’ particularly if the ‘patient’ is a
lecturer or clinical colleague. It is important that you prepare yourself by:

• Finding out who the ‘patient’ will be,

• Finding out if a manikin will be used.

If the patient is someone whom you know well it is important not to be overfamiliar with them in the
examination. It is important that you remember that this is an examination and the normal
conversations and relationships that you have with your tutor are different in an examination
situation. You should endeavour (it is difficult) to treat the ‘patient’ as you would in clinical practice
and try to demonstrate how you would effectively interact with a patient in a real clinical situation
(even where a manikin is being used in the place of a patient).

Additionally your OSCE will be testing ethical aspects of the affective domain, so it is important to
always seek consent from your ‘patient’ prior to the delivery of any clinical care. A common pitfall is
to forget to gain consent and in some universities failure to gain consent will prevent a pass grade
from being awarded.

If your university requires you to attend in uniform remember that your professional appearance
will be judged. You should ensure that a full correct uniform is worn and strict uniform policy
adhered to. This will include appropriate hairstyling and removal of jewellery, excessive make up,
nail varnish and artificial nails. If you are required to attend in uniform ensure you leave sufficient
time to change into your uniform at the university prior to the commencement of the OSCE.
Remember to bring pens, watches and any other equipment that you will need for the OSCE with
you.

Key points for preparation

• Identify your learning style and adopt a strategy that will suit you.

• Understand what is expected of you during the OSCE by discussing the examination
with the academic staff that are responsible for organizing the OSCE.

• Review the key knowledge (cognitive) requirements of the skill.

• Review the key practical (psychomotor) requirements of the skill.

• Make the most of practising the skills within the university’s skills laboratories.

• Take the opportunity to develop the skill in clinical practice and gain constructive
feedback from your mentors.

• Ensure you prepare your correct uniform in advance.

• Psychologically prepare for the change in relationship with your examiners during the
OSCE.

• Remember to gain consent and communicate effectively throughout the OSCE.

• Remember that you may be asked questions by the ‘patient’ and the examiner.

Box 3.1 Remember

• The examiners are examining for safe and effective practice; they want you to pass and
for you to learn and develop from the OSCE experience.

• Effective preparation will increase your ability to pass the OSCE—reflect upon your own
abilities and learn from the experience!

Table 3.1 Revision plan

Revision plan
It may be useful to complete the revision plan in Table 3.1 and identify your own study requirements
for each OSCE that you will undertake. It will be useful to develop ideas depending upon your own
circumstances and learning style.

What happens after your OSCE

Once you have completed your OSCE assessment you will be informed of the outcome of the
assessment. This may be on the day if it is a formative assessment or sometime afterwards if it is a
summative examination that has to be processed through an examination board. You should be
provided with detailed written feedback about your performance at the OSCE and it is useful to
review this alongside your recollections of the experience as this will help you to learn from it. It is
important that you are able to learn from the OSCE experience to enable further development of
your skills and knowledge. For more information relating to learning from your OSCE please see
Chapter 14.

Online resource centre

You can find further advice and revision help for your OSCEs by going online now to see
www.oxfordtextbooks.co.uk/orc/caballero/.

References

Bloom, B. (1956). The taxonomy of educational objectives: the classification of educational

goals, handbook 1. New York: McKay.

Bloomfield, J., Pegram, A. and Jones, C. (2010). How to pass your OSCE: a guide to
success in nursing and midwifery. Harlow: Pearson.

Hart, S. (2010). Nursing: study and placement learning skills. Oxford: Oxford University
Press.

Honey, P. and Mumford, A. (1986). Using your learning styles. Maidenhead: Peter Honey.

Nursing and Midwifery Council (2008). Standards to support learning and assessment in
practice. London: Nursing and Midwifery Council.

Quinn, F. (2007). Principles and practice of nurse education. Cheltenham: Nelson Thornes.

Ward, H. and Barratt, J. (2009). Passing your advanced nursing OSCE: a guide to success
in advanced clinical skills assessment. Oxford: Radcliffe Press.


PART II
Skills



Chapter 4
Interpersonal communication

Sue Sully

Chapter aims

This chapter will enable you to:

• Recognize the fundamental importance of effective interpersonal communication in

nursing,

• Review key ideas in developing helpful interpersonal communication,

• Adapt key interpersonal skills in a variety of contexts,

• Understand how to prepare for this OSCE,

• Recognize the importance of maintaining professional boundaries.

Introduction

Nursing is an interpersonal profession (Ellis and Whittington 1981) which is to say that the majority
of the goals of the profession are met through the quality and nature of relationships the nurse is
able to form. Effective interpersonal communication which underpins the therapeutic relationship is
a complex set of skills which require the nurse to understand the context and purpose of the
interactions, in addition to being aware of their own agendas and factors which might form a
barrier to effective working relationships. Historically, interpersonal communication was implicit
within nursing care and by the 1980s writers such as Morrison and Burnard (1991) and Porritt
(1990) had identified and explored the nature of the therapeutic relationship and interpersonal
skills within nursing care. Now authors such as Stein-Parbury (2009), Burnard and Gill (2008),
Maben and Griffiths (2008), Freshwater (2005) and Greenhalgh and Heath (2005) have studied and
written about this area in great depth. Both the Department of Health (DOH) (2010) and the
Nursing and Midwifery Council (2008) have identified the centrality of patient-led care and the
nurses’ ability to develop effective working relationships that enhance dignity and treat the person
with compassion and care.

A therapeutic relationship is significantly different from relationships that are formed socially
amongst colleagues and friends. In order to establish a relationship which is helpful it is necessary
to be aware of the assumptions, expectations and feelings you carry into each new professional
relationship. Without this awareness there is a real danger that your own ‘noise’ will make it
difficult for you to be present and experience the other person as they are. In order to understand
the emotional needs and concerns of the person it is necessary for you to try to understand the
world of the person that you are caring for—from that person’s own perspective. The nearer you can
come to this the more effective will be the relationship, and the assessed needs of the patient will be
more accurate and relevant. Learning about interpersonal communication within the context of
nursing and the therapeutic relationship means that you will have the opportunity to develop your
skills and adapt them for the purpose of caring for others.

As effective interpersonal communication can be seen as the ‘bed-rock’ of quality nursing care, most
universities undertake this OSCE in the first year of your nursing programme. Some universities do
not do a specific OSCE in this area and assess it as integral to every OSCE. You will need to check
your university guidelines. The full range of interpersonal communication and developing
therapeutic relationships can be assessed throughout each year of a three year undergraduate pre-
registration programme with increasing degrees of complexity that reflect the complex nature of
the skills involved. This chapter deals with undertaking an OSCE in the first year.

It is likely that you will be allowed between 15 and 30 minutes for this assessment and therefore
you will need to have thought about the key ideas beforehand so that they can be adapted to a
variety of settings both within the OSCE and in clinical practice. An OSCE is a reflection of your
practice and it cannot be emphasized enough how important effective working relationships are to
successful nursing care.

Key revision for your simulated examination

There are three areas that you need to focus on in order to undertake a specific interpersonal
communication OSCE or if interpersonal communication is going to be assessed as part of another
OSCE:

• Your interpersonal skills,

• Your own ability to relate to others,

• Your assessment of the other person.

These are assessed together and explored in the following sections.

Effective interpersonal communication

Active, sensitive listening

Hargie (2006) clearly identifies the need for effective interpersonal skills for purpose in social
interactions. Firstly, active listening—this is the ability to be present for the other person and to be
able to shift the focus from yourself to the other person. Active, sensitive listening is a complex skill
and not one to be taken lightly as it is essential to effective working relationships with others.
Active listening is a skill that needs to be honed and the skills that an effective listener displays are
to:

• Put the talker at their ease,

• Limit their own talking,

• Be attentive,

• Remove distractions,

• Show patience and do not interrupt,

• Watch for feeling words,

• Be aware of their own biases,

• Listen to paralinguistics,

• Be aware of body language,

• Use eye contact appropriately.

The phrase ‘listening with a third ear’ is often used to show the importance of being ‘present’ when
listening to others. Often nurses perceive themselves as having many demands upon them and are
thinking and planning ahead which means that they are only partly present for the person they are
listening to. It is an art to develop the ability to be present for the other person and some of the
principles that Hargie (2006) has identified are:

• Have a reason or purpose for listening,

• Suspend judgments,

• Resist distractions and fidgeting,

• Wait before responding,

• Rephrase the message accurately,

• Reflect content and search for meaning,

• Be ready to respond.

Box 4.1 shows some of the benefits of engaging in active listening which can enhance care delivery.

You may well have picked up poor listening habits and in Box 4.2 there are some points to look out
for and things to avoid.

Reflecting

Geldard and Geldard (2005) see reflecting as one of the main skills involved in empathy. Simple
reflection or paraphrasing is often concerned with the content of what people are saying—where
the content means the ‘what’. Reflection is about the feelings—the process, the ‘how’. Reflecting
feelings accurately depends on trying to understand how the person is feeling.

Reflecting involves both listening and trying to understand and then communicating that effort to
understand. Reflecting can show that you are accepting of people.

It is not about talking down to the other person.

To reflect effectively

1. Observe facial and body movements,

2. Listen to the words and their possible meanings,

3. Tune into your own emotional reactions,

4. Sense the meaning of the communication,

 5. Respond appropriately,

6. Use expressive, not stereotyped, language,

Box 4.1 Active listening

1. Trying to understand the person’s world—what is going on for the other person.

2. Listen for total meaning. Some useful questions to ask yourself as a listener are:

• What is this person trying to tell me?

• What does this mean to this person?

• How does this person see this situation?

3. Note all the cues, particularly the non-verbal and paraverbal cues, e.g.

• Body posture

• Eye movements

• Hand movements

• Inflections

• Stressed words

• Breathing changes

• Facial expressions

• Hesitancies

• Mumbled words

4. Remember—you can only note these. Try not to make your own interpretations of them
and thus seem clever. Check them out and your interpretation with the person.

For example, a person who is hunched up in a chair, with their legs tucked under them,
avoiding eye contact except to stare at you, mumbling and monosyllabic—they may be
cold and tired, not angry or anxious.

Box 4.2 Active listening—what not to do

Poor listening habits

1. Not paying attention,

2. Pretend listening,

3. Listening but only hearing what you want,

4. Rehearsing what to say,

5. Interrupting the speaker in mid-sentence,

6. Hearing what is expected,

7. Feeling defensive, expecting to be attacked,

8. Listening for something to disagree with.

Things to avoid

1. Trying to persuade people that you are right and so only hearing what you want to hear
rather than what the other person might be saying.

2. Taking responsibility for the other person, acting like a parent. People need to be
involved in decision making about their care.
 3. Passing judgement on others, either critical or favourable. You will make judgements
about others, everyone does; it is about thinking how those judgements affect your ability
to work with the other person.

4. Platitudes and clichés show that you have not been listening to the person—this tends
to be about your agenda rather than the other person.

5. Reassuring people, rather than listening to what is worrying and concerning them, can
feel dismissive of what people are going through.

7. Ensure your vocal and bodly language agree with each other,

8. Check the accuracy of your understanding.

It could be considered pointless to actively listen to someone and for them not to know that this is
occurring. The skill of simple reflecting or responding is one that is close to active listening. Other
words for this type of simple reflection are paraphrasing and responding.

Simple reflection means mirroring the literal meaning of someone’s words. Sometimes simple
reflection is necessary; at others the skill of empathy is more appropriate where reflection of
content and feeling is used.

When listening, focusing on content is usually the first step—listening to what the other person
says. It is useful to think about the following framework when listening:

1. What—do you think you understand what they are saying?

2. Why—do you have a sense of why they are saying what they are saying?

3. Where—do you have a sense of where events took place?

4. When—do you have a sense of when things happened?

5. How—do you have a sense of how they are feeling? Angry? Happy? Sad? Frightened?

If you cannot answer these questions then further clarification may be needed. These five questions
can help you to organize details and to know if the person may be leaving anything out.

You need not respond by repetition or parroting what the other person said but by paraphrasing in
your own words, which captures the main points in a brief statement and thus checks out your
understanding with the other person.

Examples of this may be (although you will probably use your own similar phrases):

‘It sounds like......’

‘So you are saying that.....’

‘In other words......’

Paraphrasing, responding or simple reflection are all the terms that are used to discuss the
reflection of content and are considered the first stage in skills development for an empathic
response.

Questioning

Hargie (2006) and Stein-Parbury (2009) recognize the importance of questions as tools to obtain
information. They can be overused by nurses who often feel under pressure and that they have little
time and therefore ask questions as a way of gaining information quickly. This is not always helpful
because information gets missed and it means that there is a shift of focus away from the other
person back to the nurse.

The following can be helpful:

1. Use open questions. This allows the person to choose the direction that the
conversation will take. If the person has something that they want to ‘get off their chests’
it can be infuriating if the nurse is constantly steering the conversation away; constantly
asking questions is one of the most effective ways of preventing effective interpersonal
communication.
 2. Wrongly used, questions can create an expectation that nurses will provide solutions to
other people’s problems. The emphasis is on using questions as aids to problem solving.

3. Are there so many questions that it seems like an interrogation?

4. Who are you asking the question for?

Is it idle curiosity?

Is it to gain information?

Is it to avoid an uncomfortable subject?

Is it to lead the person in the direction that you want to go?

Open questions can help to:

• Seek clarification,

• Encourage exploration,

• Establish understanding,

• Gauge feelings,

• Establish some clarification.

Things to avoid:

• Closed questions—unless you want to elicit information or establish facts,

• Curiosity questions,

• Questions which begin with ‘is’, ‘are’, ‘do’, ‘did’,

• Too many questions that give the impression of an interrogation,

• Questions which put the words into people’s mouths,

• Probing questions which the other person is not yet ready to answer,

• Poorly timed questions that interrupt and hinder the other person’s conversation.

Clarifing and summarizing

Clarifying and summarizing are two interpersonal skills that are linked to listening and questioning.
They help to show the person who is talking that the nurse is trying to listen and understand what is
being said.

Clarifying shows the other person what you are struggling to understand as you check out your
understanding of what is being said. Here are some handy thoughts:

1. If you are not sure what the person means by what they are saying, it is important to
get them to explain further to avoid confusion.

2. Again this helps to confirm to the person that you are actually listening and interested
in what they have to say (provided you are not doing it too often).

3. If you do not clarify statements you are unsure of, there is a chance that you will
respond inappropriately, or ask questions that the other person feels they have already
explained. In this case the person may be justifiably angry and lose confidence in your
relationship.

4. An important part of clarification is listening to the client’s feedback and then making
adjustments accordingly.

5. Clarification is particularly useful in developing empathy.

6. Effective clarification provides a model on which clients may model their

communication.
Summarizing can indicate what you have understood from what the other person was saying and
can include both what is said and how it is said. It does not mean that you have to accurately repeat
everything that has been said but is about trying to convey your understanding. Most people do not
actually listen to what they are saying and having a summary repeated to them can also help them
to clarify what the issues might be for them.

1. It allows you to tie up all the pieces that you have heard so far before going any further.

2. It shows the person that you are paying attention to what they are saying and
reinforces your commitment to listening (it may also show the person that you are not
listening and gives them the opportunity to put you straight).

3. It allows the person to hear repeated to them what they have said, probably in a more
concise way. This can be extremely valuable.

4. When people are distressed they can seldom see the aspects of their difficulties clearly.
To hear the problems clearly stated can often put things into focus and help the person
realize that the problems are not as overwhelming as they had thought.

5. Summarizing allows for a break and a review. It creates space and can slow things
down.

6. It provides a basis to plan care.

7. It helps you when feeling stuck.

8. It helps people to view their problems from a different perspective.

Box 4.3 Interpersonal skills self-assessment sheet (adapted from work by Sarah Brown)

Attitudes

1. How much respect and acceptance of others do I feel? How do I know I communicate
these attitudes?

2. Am I at one with myself, and how do I know I communicate this genuineness?

3. Which judgmental attitudes that could make listening to others difficult am I aware of
having, and how will I deal with them?
 4. What are my strengths as a person using interpersonal skills, and what skills do I use
well now?

5. What are my limitations as a person using interpersonal skills, and what skills do I need
to learn/improve?

6. What stops me giving people my full attention?

7. What can I do so that I can give people my full attention?

Action

List two areas that you hope to change and for each area identify two ways in which you will know
that you have changed.

1. I would like to change/improve ...................................................................

I will know that I have achieved this by:

(a)

(b)

2. I would like to change/improve ...................................................................

I will know that I have achieved this by:

(a)

(b)

Utilizing these approaches in your OSCE examination

At this station it is likely that you will be given an outline of a scenario setting the scene and a
written scenario before being asked to meet the person you are to work with. Some universities may
use ‘actors’ or members of staff for this station and you will need to check the guidelines for your
course. In some universities they do not specifically assess this element of nursing care and instead
include as part of every OSCE and again you will need to check the guidelines for your course. This
can be a formative or a summative assessment of your abilities and the aim is to provide a relatively
safe environment to explore your abilities and recognize what you do well as well as areas that you
might want to develop during your education programme. You will be assessed on:

1. Your ability to use interpersonal skills appropriately and for purpose,

2. Your ability to recognize your own processes and how you might be influencing the
situation,

3. Your ability to work with the person,

4. Your recognition of the impact of verbal and non-verbal skills,

5. Your professional attitude,

6. Dignity and respect shown to the person,

7. Ability to report back your findings and assessment of the situation.

It can be helpful to do a self-assessment of your interpersonal skills in preparation for the

assessment. Remember to be as honest as you can and also not to be too hard on yourself. It can
help to think what someone who knows you might say in filling in the questions.

You will be given the time constraints for the OSCE and you need to be aware of timing the
interaction and remember not to go over the time. Examples of OSCEs are in Boxes 4.4 and 4.5.

Example of an interpersonal communication OSCE



Box 4.4 Written scenario

You are working on a stroke rehabilitation ward for four weeks and on this day have been asked to
look after Mr Birch. You have not looked after Mr Birch before as you have been working in other
parts of the ward.

The patient

Mr Geoffrey Birch is a 76 year old retired bank manager who was admitted with a stroke and left
sided hemiparesis.

He had worked as a bank manager in the local town for 25 years and retired 11 years ago. He
nursed his wife who had had breast cancer for 5 years and who died 3 years ago. They have no
children and he has one sister who has lived in South Africa for 50 years. He has no other living
relatives.

Until his stroke he had played golf 3–4 times a week and is a member of the local Masonic lodge.

He is trying to decide whether to go home to his large detached house with a substantial garden
which his wife used to look after or to go into a warden controlled flat.

In handover, the nurse in charge asked if you would talk with Mr Birch about his decision as it
seems he is finding it difficult to decide what to do.

Step by step guide

Setting up an effective working relationship with a person you are nursing starts from the moment
that you and the patient can see each other as you will start to make decisions about how they
might be feeling, what they might be thinking and your response to them and, of course, they will
be doing the same. This is an interaction with purpose and that will influence what you do and how
you do it. This means the other person has an issue and you have been asked to explore this with
them. It may be that Mr Birch will not reach a decision when talking with you; however, the aim is
to help him in that decision making process. Be aware of barriers to effective interpersonal
communication such as deafness or noise in the environment.

Remember that you will need to decontaminate your hands before approaching the person.

Introduction

It can help to acknowledge the person with either a nod or a smile before you decontaminate your
hands. When you approach the person, greet them and introduce yourself, who you are and why you
are there. Ask the person how they would like to be addressed.

Find a place to sit near them, drawing up a chair if necessary, face them and do not stand over
them.

Remember that the interaction is time limited and you need to think about ending as you start.

Active listening and being present are essential in developing effective working relationships with
people.

It can be useful once you have introduced yourself to ask an open question.

‘I have 15 minutes and I was wondering how you are feeling today.’

Or an alternative could be to summarize what you know.

‘I have 20 minutes with you now, and I understand that you are thinking about
moving and maybe living in a warden controlled flat. I would imagine that is a
hard decision for you to make.’

Quick summary

1. The interaction starts from the moment you see each other,

2. Decontaminate your hands,

 3. Introduce yourself,

4. Ask what the person would like to be called,

5. Sit facing them,

6. Tell the person how long you have with them.

Moving forward

Whilst the conversation needs to be led by the other person (a reflection of patient centred care)
you have a reason for being there as well and it can be hard at times to manage the balance
between these two. You have been asked to talk to him about making a decision so that is your
‘agenda’ and this might not be the same for Mr Birch. It is important to respond to the person and
what they want to talk about and also remember that you want to talk about his decision to move.

Do not talk over the other person or interrupt them with words. Let them finish what they are
saying or if you feel that you need to say something, then give a non-verbal cue such as leaning
forward, using a facial expression, or when they take a breath then say:

‘I just wanted to say something, if that is OK…’

Your non-verbal communication is important as it can convey that you are listening to what is being
said and nodding in response can be helpful, although avoid looking like a ‘nodding-dog’. Paraverbal
responses such as ‘hrm’ can also be used sparingly. Check out what you might be conveying:

1. Are you fidgeting?

2. Is your mind wandering?

3. Are you rushing?

It can be helpful to take a deep breath and bring your attention back to Mr Birch. Remember to do
this ‘check out’ on yourself regularly during the OSCE.

Think about Mr Birch’s non-verbal cues as well, e.g.

• His breathing,

• Facial expressions,

• His eye movements,

• Sentences left unfinished,

• Words that are stressed,

• Hand movements.

All of these can you help you try to understand what is going on for Mr Birch and give you some
indication of how he might be feeling, as well as his thought processes. You can only note these
behaviours and think about what they might mean. You do not know what they mean, only what you
think they mean.

Keep the balance towards reflection rather than questioning. If asking questions think about why
you are asking them—is it to help the other person understand or idle curiosity?

Clarifying your understanding can be more helpful than asking questions.

‘So, if I understand what you are saying, Mr Birch, you would like to give up your
house because it is too big for you now and you cannot manage the garden;
however, you are worried and sad because it was the house that you and your wife
lived in together for such a long time and it has memories of her.’

Remember it is not just what the other person is saying, but also about their emotions and you need
to acknowledge those as well.

It is not about agreeing with what Mr Birch says, it is about:

1. Helping him to explore the options that he thinks that he might have,
 2. Responding to questions that he might have,

3. Recognizing the limits of your knowledge and finding out the appropriate information
for him and letting him know,

4. You being able to give an account to the nurse in charge of what Mr Birch said and
having a plan to help him to decide.

Quick summary

1. Actively listen,

2. Be present for the other person,

3. On balance it is more about them than you,

4. Be aware of your body language and that of the other person,

5. Ask questions sparingly,

6. On balance, reflect and clarify more than ask questions,

7. Be led by the other person and remember you have a reason for being there,

8. The interaction is time limited.

Ending

Keep an eye on the time and when there is about 2–3 minutes left, tell Mr Birch that you are coming
to the end of time. It might be helpful to say something like:

‘Mr Birch, I have just noticed that we have about 3 minutes left and I thought it
might be helpful if I summarize what I think we have talked about.’

Remember a summary can help the other person as well as you. People do not always listen to what
they say and having someone summarize that can be useful and can help to clarify points and could
help Mr Birch think about the way forward. It can be a way of showing that you were listening to Mr
Birch and he can correct any misunderstandings or inaccuracies which are inevitable when you
listen and make sense of the other person’s story. It is also a way for you to acknowledge some of
the difficulties that Mr Birch might be facing and a way forward to deal with those. It can be the
basis for a plan.

‘This seems like a really difficult decision for you. You know that you have a
weakness in your right leg and arm that means that managing at home will be
very difficult for you because it is such a large house and garden. However, this is
your home and was your home with your wife. She died there and that makes
leaving very hard. These are not easy decisions to make. You seem to be nearer to
making a decision to move into a warden controlled flat and you know that you
have until the end of the week to make the final decision. However, you are
finding the time pressure hard as well. I have agreed to chat with your named
nurse and tell her where you are in terms of making a decision today and that it
might be useful for you to go and see the warden controlled flat. I will speak to
the occupational therapist about arranging a visit and also for her to come and
see you today when she visits the ward. I will be with her so that we can all talk
together. I appreciate you being so honest with me, thank you.’

Quick summary

1. Let the person know when there are about 2–3 minutes left,

2. Offer a summary or let them summarize and you add what you think is important when
appropriate,

3. Include what the person has said and also how they might be feeling (angry, happy, sad
or frightened),

4. Be tentative in the summary because you may be wrong,

 5. It is a collaboration so be prepared to be corrected,

6. Tell the person you will be talking to other relevant people about what you have
discussed,

7. Say what you think you have agreed,

8. State what the plan is,

9. Thank them.

When you have finished the interaction with the person, you may need to report back to the
examiner as though they were the nurse in charge although this is not always the case and you will
need to check the university guidelines. When reporting back then you need to be:

1. Clear,

2. Concise,

3. Give the highlights that are relevant in a professional manner,

4. At this point you are the patient’s representative,

5. Say what the plan is and the way forward.

So an example might be:

‘Hello, I have chatted with Mr Birch and he is closer to making a decision about
moving. He has moved towards living in the warden controlled flat however he
has not finally decided. He is finding it a hard decision to make and although he
is finding it hard he knows he has to decide by the end of the week. I know the
occupational therapist is on the ward today and he would like to talk to her about
arranging a visit and I have said that I will be with him when he chats to her. If it
works out would it be OK for me to go on the visit to the flat as well?’

If your interpersonal communication is to be assessed as part of another OSCE, e.g. clinical skills,
then there are some additional things that you can think about.

Example of interpersonal communication within a clinical skills OSCE

Step by step guide

All effective nursing care is based on a working relationship between the nurse and the person and
therefore it could be that in your university they do not assess interpersonal communication directly
in an OSCE but as an integral part of what is being assessed (see OSCE example box 4.5). It can be
helpful to complete the self-evaluation form from earlier in the chapter as a way of preparing
yourself for this element (see Table 4.1). The three areas identified here are a useful guide:

1. Introduction,

2. Moving forward,

3. Ending.

Box 4.5 Written scenario

You are asked to undertake physical parameter observations and recordings of blood pressure,
temperature, respirations, pulse and oxygen saturation in the OSCE room and your interpersonal
communication will be assessed as part of this OSCE.

The patient

Miss Mary Pierce was admitted during the afternoon with abdominal pain following a period of 4
months of seeing her General Practitioner (GP) for investigations. During that time her abdominal
pain had become more intense and her abdomen had become distended. Her dress size has gone
from a size 10 to a size 14 to accommodate her increased girth measurement. She has lived in the
same house that she was born in and had worked in the local primary school as a teacher until she
retired 10 years previously.

Whilst you are undertaking and recording the data that you have gathered, Miss Pierce says that
she is scared as she has not been in hospital before although she visited on numerous occasions
when her mother and father had been in the same hospital. In fact her mother had died in the same
ward five years ago. Her mother had died of liver cancer when she was 93 years old and although
Miss Pierce is not the same age she is worried.

Setting up an effective working relationship with a person you are nursing starts from the moment
that you and the patient see each other as you will start to make decisions about how they might be
feeling, what they might be thinking and your response to them and, of course, they will be doing
the same.

Introduction

After you have decontaminated your hands, greet Miss Pierce and introduce yourself and ask
permission to undertake the observations. Ask her how she would like to be addressed, e.g.

‘Hello Miss Pierce, I am student nurse ........ I need to record your blood pressure,
temperature, pulse and respirations if that is OK? I am not sure what to call you.
Do you prefer Miss Pierce or Mary?’

Be aware of standing next to rather than ‘over’ Miss Pierce.

Quick summary

1. Introduce yourself,

2. Say why you are there,

3. Ask how the person would prefer to be addressed,

4. Be aware of standing next to rather than over the person.

As stated Miss Pierce engages you in conversation and you will need to respond to her as well as
carry out the recordings that you have been assigned to undertake. The difficulty will be the
balance between listening and engaging with what is being said and doing the tasks.

Moving forward

Depending on the timing of the station you need to decide if you will respond to what is being said
directly or whether you will carry out the assigned tasks and let Miss Pierce know that you have
heard what she has said and arrange to come back. If the timing of the station is short as it is likely
to be, then acknowledging what has been said and arranging to come back may be the most
appropriate option. This recognizes the patient-led nature of care and also that you have a purpose
for being with the person that also needs to be taken into account.

Active, sensitive listening is necessary and recognizing that Miss Pierce says that she is scared
about two things—that she might have cancer and that her mother died in the same ward that she is
in now.

Remember that this is about listening to what is said and also about how the person seems to be
emotionally and responding to both elements. You will need to be aware of Miss Pierce’s non-verbal
communication as well as what words she is using. You will also need to be aware of your own
response to what is said.

Remember that reassuring is not appropriate (as it disregards people’s concerns and their
importance) and that acknowledgement is reassuring. So you may say something such as:

‘That sounds really horrible for you, Miss Pierce, to be in the same ward as where
your mother died. I would imagine that it brings back memories.’

‘I would imagine that this is a scary time for you—not knowing what is going on
and having to come into hospital for investigations and then find yourself on the
same ward as where your mother died.’

The focus of the station needs to be addressed and you need to also think about why Miss Pierce
has told you, rather than another team member, and told you when she did. Often people worry that
others will think them ‘silly’ or they are dismissive of what they are feeling and it is important that
you acknowledge in your own words what is said and make a plan for coming back if appropriate.
You will need to communicate the information you have gained to the relevant person on the ward,
either the named nurse or the nurse in charge.

Quick summary

1. Acknowledge what is said and how the person seems to be feeling,

2. Avoid the use of questions,

3. Do not reassure them that everything will be OK,

4. Draw on the skill of reflection,

5. Be aware of your own response to what is said.

Ending

Complete the task at hand and then summarize for Miss Pierce what you have heard and if
appropriate make a plan with her. So you may say something like:

‘I have to record your blood pressure, etc., Miss Pierce, and then I need to go. I
wish I could stay a little longer because this seems a difficult and frightening
time for you. However, I can come back later and we can have a chat if that suits
you?’

It is alright to leave as not all difficult issues have to be dealt with immediately. However, it is
important to let the person know that you have heard what they have said and how they might be
feeling as this shows respect and compassion for what the person is going through. You are not
responsible for how they feel but you are responsible for how you react to the situation.

Quick summary

1. Recognize that you are there for a purpose,

2. Not all difficulties have to be addressed straight away,

3. You are not responsible for how someone feels,

4. You are responsible for what you do in response to the situation,

5. It is OK to come back if the person wants you to,

6. Either report the information to the examiner or state that you would report the
information to the nurse in charge, whichever is appropriate within the context of the
station.

Examiners’ marking criteria

Table 4.1 Example of examiners’ marking criteria

Examiners’ questions

Questions that the examiner might ask will be related to your performance. Examples are provided
in Box 4.6.

Box 4.6 Example of examiners’ questions

1. What was the most important moment for you in this interaction?

2. How did you feel during the interaction and how did this impact on your ability to relate
to the other person?

General questions might include:

1. What makes interpersonal communication effective?

2. Why is it important to try to develop effective nurse–patient/client relationships?

3. How might effective nurse–patient/client relationships be established?

See the end of the chapter for answers.

Common errors at this station

Some of the common errors at this station are a failure to:

• Decontaminate your hands,

• Greet the other person,

• Introduce yourself,

• Ask what the other person likes to be called,

• Be aware of non-verbal cues,

• Be aware of your own responses to the other person,

• Actively listen,

• Recognize that you are there for a purpose,

• Offer patient-led care,

• Have a plan that is negotiated with the other person for a way forward if appropriate,

• Keep good timing,

• Report clearly and concisely.

Top tips for passing this station

Try to avoid the common errors and also think about the following:

• Always speak in the first person when referring to yourself—so ‘I understand that you
are…’

• Use the word ‘and’ instead of ‘but’—but often sounds like a prelude to criticism.

• Take a deep breath before you think—OSCEs can be stressful and you can forget to
breathe into the base of your lungs and you need oxygen to think.

• Think before you speak—although time at the station can be short, do not rush—develop
a measured pace.

• Do not ask too many questions—remember the other useful skills such as reflecting,
clarifying and summarizing.

• Do not fidget.

• Do not concentrate on paperwork rather than the other person—people are important.

References

 Burnard, P. and Gill, P. (2008). Culture, Communication and Nursing: A Multicultural
Guide. Harlow: Pearson Education.

Department of Health (2010). Front Line Care: the future of nursing and midwifery in
England. Report of the Prime Minister’s Commission on the Future of Nursing and
Midwifery in England 2010. London: Department of Health, Her Majesty’s Stationery
Office.

Ellis, R. and Whittington, D. (1981). Guide to Social Skills Training. London: Croom and
Helm.

Freshwater, D. (2005). Counselling Skills for Nurses, Midwives and Health Visitors.
Oxford: Oxford University Press.

Geldard, K. and Geldard, D. (2005). Practical Counselling Skills Training: An Integrative

Approach. London: Palgrave Macmillan.

Greenhalgh, T. and Heath, I. (2005). Measuring Quality in the Therapeutic Relationship.

London: Kings Fund.

Hargie, O.D.W. (ed.) (2006). Handbook of Communication Skills. London: Routledge.

Maben, J. and Griffiths, P. (2008). Nurses in Society: Starting the Debate. London: Nursing
Research Unit, King’s College London.

Morrison, P. and Burnard, P. (1991). Caring and Communicating: Interpersonal

Relationship in Nursing. London: Palgrave Macmillan.

Nursing and Midwifery Council (2008). Code of Conduct for Nursing and Midwifery.
London: Nursing and Midwifery Council.

Porritt, L. (1990). Interaction Strategies: An Introduction for Health Professionals (2nd

edn). London: Churchill Livingstone.

Stein-Parbury, J. (2009). Patient and Person: Interpersonal Skills in Nursing (4th edn).
London: Churchill Livingstone.

Appendix: answers to examiners’ questions

Answers to general questions might include:

1. What makes interpersonal communication effective? Think about the following for
example:

• My ability to actively listen to the other person

• My ability to try to understand the other person

• My ability to use interpersonal skills effectively such as reflecting, summarizing and

clarifying

• That the other person feels that they have been heard and taken seriously
• My ability to attend to the patient’s emotional needs

• My ability to convey complex information in a way that is understood

2. Why is it important to try to develop effective nurse–patient/client relationships? Think

about the following for example:

• Because nursing care relies on effective working relationships with patients

• Because nurses work with people

• Because effective working relationships are the bedrock to nursing care

• Because the patient matters

3. How might effective nurse–patient/client relationships be established? Think about the

following for example:

• By the nurse being aware of how they are and how others might see them

• By the nurse being able to attentively listen

• By the nurse using questions sparingly and with purpose

• By the nurse drawing on other interpersonal skills such as reflecting when appropriate

• By the nurse attending to the content and process of the interaction

• By the nurse being able to convey complex information in a way that can be understood


Chapter 5
Hand hygiene and infection control

Jane Lovegrove

Chapter aims

This chapter will provide an overview of hand hygiene and infection control. This will enable you to:

• Understand why this important skill is assessed using OSCE,

• Revise key material in relation to this skill,

• Follow a step by step guide to effective hand washing,

• Understand how to prepare and revise for this OSCE,

• Highlight common problems at this station and identify how these may be avoided.

Introduction

Each year hundreds of millions of people contract an infection while in the receipt of heath care. At
any time 1.4 million people worldwide are suffering from an infectious complication associated with
health care (WHO 2005). Health care acquired infections not only lead to pain discomfort,
disability, and possible death for the recipient but also place a huge emotional and physical burden
on relatives and carers. In England and Wales an average of one in 11,000 people die of a hospital
acquired infection (HAI) each year; this figure rises to 1 in 300 for patients over the age of 80
(Bandolier 2006). Hospital admission is now a major risk factor for health care related infection
(Gould 2009). In 2007 around 9,000 people in England died with an MRSA bloodstream infection or
related Clostridium difficile infection (National Audit Office 2009). These figures do not include
deaths from other HAIs so in fact the number of deaths from HAIs could be greater. In addition, it is
also believed that many people die from a health care acquired infection which is not identified on
the death certificate. In England, health care related infections have been estimated to cost a billion
pounds annually (WHO 2005).

The World Health Organization has identified hand hygiene as the primary measure to reduce
infections (WHO 2009). Everyone involved in the provision of health care must be trained in
effective hand decontamination (NICE 2003). Unclean hands move microorganisms from one place
to another. Transmission of infection by hands has been identified with recent hospital outbreaks of
MRSA and Clostridium difficile. Good hand hygiene is one of the most effective methods of reducing
hospital acquired infections. Hand decontamination removes transient bacteria acquired from
recent contact with an infected item or person. While hand decontamination is advocated before
contact with every patient regardless of setting, patients in hospital are at greatest risk of acquiring
an infection. In the UK 7.6% of patients admitted to hospital become infected. In England the figure
is even higher at 8.19% (Nazarko 2008).

It is essential for health care students to not only be able to perform effective hand washing, but
also understand the principles of the procedure, as well as the possible physical, emotional and
financial consequences of failing to perform hand hygiene.

Key revision for your simulated examination

While the evidence that the simple act of hand washing reduces infection and saves lives has been
known for a long time, compliance among health care workers remains an issue throughout the
world (WHO 2005). Health care staff continue to fail to wash their hands with the result that
thousands of patients in England and Wales die each year of an infection acquired in hospital
(Nazarko 2008).

Microorganisms on the hands

Microorganisms cannot be seen by the naked eye. The term microorganisms includes bacteria,
viruses and some fungi. Typically there are between 10,000 and 10 million bacteria on each hand
(HPA 2011). The skin forms a protective layer which prevents these microorganisms from entering
the body. However, if the skin integrity is breached, bacteria that are harmless on the outside of the
skin may enter the deeper tissues of the body and cause infection. Some of these bacteria are found
on the skin at all times and these are termed ‘resident bacteria’. Resident bacteria live permanently
in hair follicles and sebaceous glands (Horton 1999). Other bacteria are picked up and carried by a
person for a limited period of time; these are termed ‘transient bacteria’. Transient bacteria are
acquired by contact with another person or object (Parker 1999) and are found on the surface of the
skin in the stratum corneum (WHO 2009). Escherichia coli, Staphylococcus aureus and
Pseudomonas are examples of transient bacteria that may be found on the skin. During the 1970s,
research found that infections found in patients were frequently caused by the same strains of
bacteria found on health workers’ hands (Gould 2009). The majority of transient bacteria may be
physically removed by hand washing or killed by bactericidal solutions such as alcohol rubs. The
purpose of hand hygiene is to remove dirt and reduce the number of bacteria on the hands.

When hand hygiene should be performed

To assist health care workers conceptualize the risk of infection, the WHO (2009) divides the health
care setting into the patient zone and the health care area. The patient zone contains the patient
and his/her immediate surroundings, for example the bed, linen, locker, bed table, call bell, etc. It
also contains all equipment touched by health care workers when in the vicinity of the patient, that
is infusion pumps, intravenous infusions, oxygen flow meters, monitors, etc. The health care area
contains all surfaces outside the patient zone, which should be viewed as being covered in
microorganisms potentially harmful to the patient.
In 2006 the WHO identified the following five key moments for hand hygiene in health care
contexts:

• Before patient contact: To reduce the risk of exogenous infection, hand hygiene
should be performed after last contact with an object outside the patient zone and before
the first contact within the patient zone, for example after closing the curtains and before
moving the patient’s bed table.

• Before an aseptic task: Once in the patient zone there is a risk of endogenous
infection by the transfer of microorganisms from a surface or skin to an open wound or
intravenous infusion site, for example if a health care worker moves the bed table and
then proceeds to touch an intravenous infusion site.

• After exposure or risk of exposure to body fluid (and after glove removal): After
contact with body fluid or any site where there may be body fluids hand hygiene should be
performed. This reduces the risk of transmission of microorganisms from a ‘colonized’ site
to a clean site. Gloves are used by health care workers as a ‘second skin’, but they are not
a sufficient barrier and hand hygiene needs to be performed after glove removal.

• After patient contact, i.e. after touching a patient: When a health care worker
moves out of the patient zone, there is a risk of transmission of microorganisms from the
patient to the health care area. To prevent this, the health care worker should clean their
hands after the final contact with the patient.

• After contact with patient surroundings: After touching any object or furniture in
the patient’s immediate surroundings, even without touching the patient, hand hygiene
should be performed, for example a health care worker may move one patient’s chair in
order to access another patient. This also raises the issue that all objects taken from a
patient zone should be destroyed, or cleaned prior to being used for a second patient.

How hand hygiene can be performed

If hands are not soiled the use of an alcohol based solution is preferred. The WHO has identified the
following situations when hands should be washed as opposed to cleaned using alcohol rub (WHO
2005).

Hands should be washed with soap and water when:

• Visibly dirty,

• Contaminated with proteinaceous material,

• Visibly soiled with blood or any other body fluid,

• Where exposure to spore forming bacteria is suspected or evident,

• Following urination or defecation.

Hand washing with soap and water

Water alone is not suitable or acceptable as water will not remove substances such as fats and oils
(WHO 2009). Hand washing with plain soap and water will physically remove microorganisms and
prevent them being transferred to a patient or inanimate object, but does not kill bacteria. Hand
washing with soap and water is acceptable in low risk situations such as blowing the nose and
visiting the lavatory in the home. This is called a social hand wash (Horton 1999). In this situation
liquid soap is preferable to bars of soap as bars of soap are difficult to dry and may crack providing
space for bacteria to reside. Patients in a hospital environment should be encouraged to use liquid
soap. However, if patients insist on using bars of soap, the bar should be rinsed after use and stored
in a manner that allows the bar to dry between use. Disposable liquid soap dispensers are
preferable and refilling of soap dispensers discouraged.

Antiseptic handwashing

Antiseptic agents such as chlorhexidine gluconate or povidone iodine have bactericidal action.
Chlorhexidene gluconate continues to kill bacteria after being applied, but is more effective against
gram positive bacteria than gram negative bacteria, tubercle bacteria, fungi and viruses.
Lodophores, solutions that contain iodine, have a wide range of action and are effective against both
gram negative and gram positive bacteria, tubercle bacillus, fungi and viruses (Horton 1999). An
antiseptic agent should be used prior to invasive procedures such as aseptic technique and urinary
catheterization (Gould 2009). Antiseptic solution is also advocated where patients are vulnerable,
i.e. those with low resistance to infection, the new born, those in intensive care and patients who
are immunosuppressed.

Bare below the elbow, rings, wrist watches and nails

In 2007 in an attempt to clarify uniform policy, the Department of Health issued guidelines for
developing policies for uniforms and work wear (DOH 2007). The guidelines state that short sleeved
clothing should be worn as cuffs have been found to become heavily contaminated with bacteria and
are more likely to come into contact with patients. Wrist watches and jewellery harbour infection as
do long and false nails and therefore should not be worn. Nails should be no longer than 0.5 cm
(WHO 2005). Skin under rings has been shown to be more heavily colonized with microorganisms
than skin on fingers without rings (WHO 2009). Rings with sharp surfaces are not acceptable in any
health care setting as they are more likely to harbour microorganisms, may puncture gloves and
present a risk of scratching a patient. A smooth plain ring may be acceptable if it can be moved and
the finger washed beneath; however, even these are not acceptable in high risk situations such as
an operating theatre (WHO 2009). While these guideline are primarily targeted at staff who have
direct contact with patients, they are also advocated for non-clinical staff (DOH 2007).

Hand hygiene using soap/antiseptic solution and water

When washing with soap or an antiseptic solution and water the following actions are advocated by
the National Patient Safety Agency (NPSA 2007):

• Wet hands,

• Apply sufficient soap to cover all surfaces of the hands,

• Rub hands palm to palm,

• Rub back of each hand with the palm of the other hand with fingers interlaced,

• Rub palm to palm with fingers interlaced,

• Rub backs of fingers with opposing palms,

• Rub each thumb clasped in opposite hand using rotational movement,

• Rub tips of fingers in opposite palm in a circular motion,

• Rub each wrist with opposite hand,

• Rinse hands under running water,

• Take care not to contaminate hands on the tap or sink,

• Prevent contamination by using elbows to turn off taps,

• Dry thoroughly with a single use towel.

This procedure should take 40–60 seconds.

Drying

Drying of hands is important as damp hands spread 1,000 times more microbes than dry hands
(HPA 2011). Cloth towels are not advocated for the health care setting as they are difficult to dry
between use and damp environments increase the risk of bacterial growth. Cloth towels may
increase the risk of cross infection when used repeatedly or by more than one person. If cloth
towels are used repeatedly, e.g. in a patient’s home, they should be thoroughly dried between use
and ideally changed daily (Parker 1999).

Hot air dryers are effective if hands are held under the dryer until dry, but this takes longer than
drying hands using towels, so they are not advocated for use in clinical areas, where hands need to
be dried quickly. In addition hand dryers are very noisy and may disturb patients, particularly at
night.
Absorbent paper towels dry the hands quickly and effectively. Hands should be dried from fingers to
wrists and the towel discarded to avoid recontamination from skin above the wrist that has not been
washed. Foot operated bins are required to avoid the need to touch the bin with the hand. Paper
towels should be soft to encourage use and avoid damage to the skin that may result from frequent
hand drying using harder more abrasive towels. Patting the hands dry has also been advocated as a
means of reducing the risk of abrasion (WHO 2009).

Studies comparing the efficacy of hand dryers versus paper towels have been found to be
inconclusive. Further studies are required.

Hand hygiene using alcohol hand rub

Hand rubs should only be used on hands that are physically clean (WHO 2005). Alcohol hand rubs
usually contain both alcohol and a bactericidal agent. Alcohol kills bacteria more effectively than
other agents but needs to dry before full effect is obtained (Horton 1999). Alcohol solutions
containing 60–80% alcohol are the most effective; however, although alcohol has a rapid action it
has negligible residual bactericidal effect. For this reason alcohol solutions are normally combined
with an antiseptic agent for prolonged activity against pathogens (WHO 2009).

When using alcohol hand rubs, the hands should be dry before application. A small amount of hand
rub sufficient to cover all surfaces of the hands should be applied to a cupped hand. Having applied
the alcohol rub, the same actions to those advocated for a soap and water hand wash should be
performed until the hands are dry. The more gel applied the longer the hand rub is required. Once
the hands are dry they are safe and ready for use. The advocated time taken for hand hygiene using
alcohol hand rub is 20–30 seconds (NPSA 2007).

Alcohol kills many different types of bacteria, including MRSA (Gould 2009). It also has a high
capacity to kill viruses such as the flu virus, the common cold and HIV although it is not effective
against Novovirus. In addition endospores of some bacteria such as Clostridium difficile are
relatively resistant to alcohol hand rubs.

The NPSA and WHO advocate the use of alcohol rubs in health care settings as they are quick to
use and may be placed wherever there is a need to perform hand hygiene (NPSA 2007; WHO 2009).
This facilitates compliance as staff are more likely to clean their hands if the means of doing so is
immediately available. In addition some studies have shown that the use of alcohol based hand rubs
is more effective in reducing the risk of pathogen transmission than soap and water (WHO 2009).

Skin care

Health care workers who have hand dermatitis have been found to colonize bacteria for prolonged
periods of time (WHO 2009). It is therefore essential that the skin on health workers, hands is intact
and in good condition. Hand lotions should be used to keep skin in good condition but should only
be provided in dispensers to avoid the risk of contamination.

Use of gloves

The use of gloves does not replace the need for hand hygiene. Hands should be cleansed prior to the
use of gloves using the criteria in ‘Hand hygiene using soap/antiseptic solution and water’. Gloves
should be worn when there is contact or risk of contact with any body fluid, mucous membranes or
non-intact skin. Gloves may also be worn to reduce the risk of transmission of germs from one
person to another or to reduce the risk of hands being contaminated from a contaminated surface
as hand washing may not remove all pathogens. Gloves should be removed immediately after use
and should not be worn for the care of more than one patient or for contact with more than one
body site of a patient (WHO 2005). Hand hygiene also needs to be performed after removal of
gloves as gloves may become inadvertently punctured. In addition hands sweat while gloves are
being worn causing bacteria to move from areas under the nails and deeper layers of skin thus
increasing the number of bacteria on the surface of the skin (Burd 2006). It is also possible that
hands may be contaminated with the exterior of the gloves on their removal. Gloves should never be
reused in first world health care settings where gloves are always readily available.

Cost

In England, health care related infections have been estimated to cost £1,000 million annually
(WHO 2005). In June 2009, the DOH estimated some £120 million had been spent on initiatives to
attempt to reduce health care related infections. These initiatives together with actions taken by
individual NHS Trusts were estimated to have saved between £141 and £263 million in addition to
reducing discomfort, distress and deaths that may have been caused by hospital acquired infections
(National Audit Office 2009).

Utilizing these approaches in your OSCE examination

An overview of the station

It is likely that you will be asked to demonstrate hand washing or hand decontamination in your
OSCE. This may be assessed alone or it may be assessed as a component of another OSCE such as
aseptic technique (see Chapter 6). You are advised to check your university guidelines as some may
assess this skill formatively using groups of students whilst others may assess individual students
using either a summative or formative approach. Whatever the approach the commonalties are:

• You will be asked to demonstrate understanding of effective infection control. This will
include:

Effective hand washing,

Use of alcohol gel to decontaminate hands.

• You will also be questioned on your knowledge related to hand washing and infection
control.

The next section provides step by step guidance for each of these areas.

Demonstrating effective hand washing

Step 1

As stated earlier (NPSA 2007) you will need to wet your hands first. This allows a lather to be
created and facilitates effective hand washing (see Fig. 5.1a). You should apply sufficient soap to
cover all surfaces of the hands.

Figure 5.1a Wet your hands before applying soap

Step 2

Once your hands are sufficiently wet you should use the following techniques to clean every area of
your hand.

A video of this technique is included on the online resource centre

www.oxfordtextbooks.co.uk/orc/caballero.
All steps of this process are vital and it is important that you fully understand and are able to
demonstrate each step in your OSCE.

• The palms of each hand should be rubbed together as in Fig 5.1b,

• You should then rub the back of each hand with the palm of the other hand with fingers
interlaced as in Fig 5.1c,

• You then rub each palm together with fingers interlaced,

• You should then rub the back of your fingers with opposing palms as in Fig 5.1d,

• To clean your thumbs you should rub each thumb clasped in opposite hand using
rotational movement as in Fig 5.1e,

• You should then clean your fingertips by rubbing the tips of your fingers in opposite
palm in a circular motion as in Fig 5.1f.

• You should finally cleanse your wrist by rubbing each wrist with the opposite hand as in
Fig 5.1g.

Step 3

Once you have washed your hands using this technique for approximately 40–60 seconds your
hands should then be adequately rinsed under running water, taking care not to contaminate your
hands on the tap or the sink as in Fig 5.1h.

Step 4

To prevent recontamination from the taps you should always use your elbows to turn off taps as in
Fig 5.1i. Some universities may have taps with sensors; if this is the case there is no need to turn off
the taps as they will automatically shut off once you have finished washing your hands. Hands
should be dried with a paper towel as in Fig 5.1j.

Figure 5.1b Each hand should be rubbed together

 Figure 5.1c Rub the back of each hand with the palm of the other hand with fingers interlaced

Step 5

Hands should now be dried thoroughly with a single use towel and the towel discarded in an
appropriate bin. Again you should take care not to contaminate your hands when drying them (see
Fig 5.1j).

Hand gel

If you are required to demonstrate using hand gel this should be rubbed in as per manufacturer’s
guidance.

Figure 5.1d Rub the back of your fingers with opposing palms

Figure 5.1e Clean your thumbs with each thumb clasped in opposite hand using rotational
movement
 Figure 5.1f Clean fingertips by rubbing the tips of your fingers in opposite palm in a circular
motion

Figure 5.1g Cleanse wrist by rubbing each wrist with the opposite hand

Figure 5.1h Take care not to contaminate hands on the tap or the sink
 Figure 5.1i Prevent recontamination from the taps by always using your elbows to turn off taps

Figure 5.1j Hand drying

Examiners’ marking criteria

Table 5.1 shows typical marking typical marking criteria for this OSCE.

Table 5.1 Example of examiners’ marking criteria

Some universities may assess your knowledge in relation to infection control and hand hygiene and
it is useful to prepare for that if that is a requirement. Some typical questions are included here.
Answers are found in the appendix of this chapter.

Examiners’ questions

Typical questions that the examiner might ask are provided in Box 5.1.

Box 5.1 Typical examiners’ questions

1. What is meant by the term HAI?

2. What is meant by the term ‘microbe’?

3. When should hand hygiene be performed?

4. When should hands be cleaned using soap and water?

5. When may hands be cleaned using alcohol rub?

6. How long should a hand wash take using soap and water?

7. How long should a hand wash take using alcohol rub?

8. When should an antiseptic soap be used?

9. What advantage do antiseptic hand wash solutions have over non-antiseptic soap?

10. Why are bars of soap not advocated for the health care setting?

11. If bars of soap are the only cleaning material available, what precautions should be
taken?

12. How many deaths per annum are currently attributed to HAIs in the UK?
 13. When should non-sterile gloves be worn?

14. When should sterile gloves be worn?

15. Why should hands be cleaned prior to putting on gloves?

16. Why should hands be cleaned after the removal of gloves?

17. What is the current advocated cost of HAIs in the UK?

Answers are provided at the end of the chapter.

Common errors at this station

• Students do not follow the bare below the elbows guidance,

• Students frequently apply soap before wetting hands,

• Students run tap water too slowly to thoroughly rinse hands,

• Students run water too fast and cause splashing,

• Students fail to wash hands for the advocated time,

• Students fail to complete each of the advocated manoeuvres,

• Students turn off taps with their bare hands,

• Students dry hands rubbing towel from above wrists back to hand.

Online resource centre

You can find further advice and revision help for your OSCEs including a video for this skill by going
online now to see www.oxfordtextbooks.co.uk/orc/caballero/.

References

Bandolier, (2006). Risk of death from hospital acquired infection in the UK.
http://www.medicine.ox.ac.uk/bandolier/booth/Risk/HAI.html accessed 4th February 2011.

Burd, M. (2006). Hygiene in hand. World of Irish Nursing & Midwifery, June: 31–32.

Department of Health (2007). Uniforms and workwear: an evidence base for developing
local policy. London: Department of Health. http://www.dh.gov.uk/publications accessed
 4th February 2011.

Gould, D. (2009). Infection control: hand hygiene. British Journal of Healthcare Assistants,
3, 3: 110–113.

www.hpa.org.uk accessed 4th February 2011. www.dh/gov.uk/pandemicflu accessed 4th

February 2011.

Health Protection Agency (2011).

http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Handwashing/accessed 4th
February 2011.

Horton, R. (1999). Handwashing: the fundamental infection control principle. British

Journal of Nursing, 4, 16: 929–933.

National Audit Office (2009). Reducing Healthcare Associated Infections in Hospitals in

England, Executive Summary. www.nao.org.uk accessed 4th February 2011.

National Patient Safety Agency (2007). Clean your hands campaign.

www.npsa.nhs.uk/cleanyourhands accessed 4th February 2011.

Nazarko, L. (2008). Standard precautions: how to help prevent infection. British Journal of
Healthcare Assistants, March, 02, 03: 119–123.

Nice (2003). Infection Control and Prevention of Healthcare-Associated Infections in

Primary and Community Care. London: NICE

Parker, L. (1999). Importance of hand washing in the prevention of cross infection. British
Journal of Nursing, 8, 11: 716–720.

World Health Organization (2005). Guidelines on Hand Hygiene in Health Care (Advanced
Draft): A Summary. Geneva: World Health Organization.

World Health Organization (2006). My 5 Moments for Hand Hygiene. Geneva: World
Health Organization.

World Health Organization (2009). Guideline on Hand Hygiene in Health Care. Geneva:
World Health Organization.

Appendix: answers to examiners’ questions

1. The DOH defines the term HAI as ‘healthcare associated infection; this term covers
‘any infection by any infectious agent acquired as a consequence of a person’s treatment
by the NHS or which is acquired by a health care worker in the course of their NHS
duties.’

2. A microbe is a living organism that may only be seen with a microscope and cannot be
seen with the naked eye.

3. Hand hygiene should be performed in line with the WHO ‘My 5 Moments of Hand
Hygiene’.

4. Soap and water should be used when hands are visibly soiled, where there has been
contact with body fluid or where exposure to spore forming bacteria is suspected.

5. When hands are visibly clean.

6. The WHO recommends 40–60 seconds.

7. The WHO recommends 20–30 seconds.

8. In high risk situations, e.g. prior to invasive procedures, prior to use of aseptic
technique, when in contact with patients with reduced defence to infection.

9. Antiseptic solutions are bactericidal and some continue to kill bacteria after hand
washing.

10. Soap may harbour microorganisms.

11. If bars of soap are used they should be used for one patient only and allowed to dry
between use.

12. Approximately 5,000 deaths per year are attributed to HACIs in the UK (WHO 2005).

13. Non-sterile gloves should be worn when handling any body fluid or where there is a
risk of contact with body fluid.

14. Sterile gloves should be worn when there is a break or potential break in the body’s
integument or when bypassing the body’s natural defences, e.g. when passing a urinary
catheter.

15. Health care workers have been found to colonize bacteria for prolonged periods of
time (WHO 2009) and so care should be taken to ensure minimum contamination.

16. There is always a risk of gloves being punctured, hands may be contaminated on
removal, hands sweat and bacteria may move from under nails while hands are contained
within gloves.

17. Current cost of HAIs to the NHS in the UK is estimated to be £1,000 million per
annum.


Chapter 6
Aseptic non-touch technique (ANTT)

Catherine Caballero

Chapter aims

This chapter will enable you to:

• Revise key material in relation to this skill,

• Follow a step by step guide to the aseptic technique,

• Understand how to prepare and revise for this OSCE,

• Highlight common problems at this station and identify how these may be avoided.

Introduction

During the aseptic technique simulated examination students may be asked to demonstrate a
clinical skill, usually a wound dressing, using an aseptic technique. This is becoming increasingly
common in all universities as it has been identified as a mandatory simulated assessment in the
essential skills clusters (NMC 2007).

This skill is probably one of the most complex skills assessed during simulation and it is vital that
students understand the principles of aseptic non-touch technique and are able to demonstrate
application of these principles throughout the examination.

Revision of this key material will enable the student to understand and apply the key principles of
aseptic non-touch technique throughout the examination.
Key revision for your simulated examination

Nosocomial

This is defined as an infection acquired in hospital at least 72 hours after admission to hospital
caused or precipitated whilst the patient is in hospital. Health care acquired infections (HAIs) have
become a serious concern over recent years, costing the NHS an estimated £1 billion a year and
contributing to some 5,000 deaths a year (Aziz 2009). One factor that has been identified as
impacting on the increase in HAIs is the variation of techniques used in wound care. Two of the
most common HAIs of recent times are MRSA (methicillin resistant Staphylococcus aureus) and C.
Diff (Clostridium difficile). MRSA is a species of bacterium commonly found on the skin and/or in
the noses of healthy people. Although it is usually harmless at these sites, it may occasionally get
into the body (e.g. through breaks in the skin such as abrasions, cuts, wounds, surgical incisions or
indwelling catheters) and cause infections. These infections may be mild (e.g. pimples or boils) or
serious (e.g. infection of the bloodstream, bones or joints). C. Diff is a species of bacterium that
causes diarrhoea and other intestinal disease when competing bacterium are wiped out by
antibiotics. This bacterium can have major consequences for patients once contracted. However, a
number of less profiled infections are contributing to the rise in HAIs e.g. urinary tract infection.

Aspetic non-touch technique (ANTT) is the term given to carrying out procedures which require
attention to minimizing the risk of cross contamination that could potentially lead to an infection.
Rowley (2001) first identified the ANTT as a way of standardizing the process of aseptic technique
used in clinical practice. Aziz (2009: 29) states that the aims of the ANTT are to:

• Improve aseptic technique in the NHS,

• Standardize aseptic technique in the NHS,

• Protect patients by reducing HAIs.

Definition

The term asepsis means the absence of any infectious agents such as pathogenic microorganisms
(disease producing). However, as we do not live or work in environments where this is routinely
possible we use the aseptic technique as a means of achieving asepsis, as close as we can. Aseptic
techniques prevent cross contamination of wounds and other susceptible sites by organisms that
could cause infection. In the literature you will find many ways in which the ANTT is carried out to
reduce the risk of cross contamination during clinical procedures but there are three main
principles to which you must always adhere. These are:

Never contaminate:

• Yourself,

• Your equipment,

• Your patient.

This can be achieved by ensuring all key parts of the procedure are free from contaminates. Key
parts are usually parts of equipment which come into direct contact with the patient’s internal
structures (Rowley 2001), e.g. sterile gloved hand, dressings, swabs and irrigation equipment in
simple wound cleansing and/or dressing. If these key parts are contaminated by infectious materials
there is an increase in the risk of infection.

When should an ANTT be used?

The ANTT must be used during any invasive procedure that bypasses the body’s natural defence
mechanisms, e.g. the skin or mucous membranes (Dougherty and Lister 2008). These procedures
include:

• Catheterization,

• Wound cleansing/dressing changes of clean or dirty wounds,

• Removal of sutures/clips/drains etc.,

• Intravenous dressings (IV),

• Total Parenteral Nutrition (TPN),

• Intravenous (IV) drug administration.

There is some debate in the nursing literature as to the effectiveness of using an ANTT for all
procedures; however, if there is a potential risk that the patient may acquire an infection during the
procedure an ANTT must be used. It is important that each patient is assessed for the probability of
acquiring an infection—in effect an infection risk assessment. You may then want to think about the
patient’s immune status, nutritional status, age and/or medical condition (Xavier 1999).

Principles of the ANTT

The six main principles of the ANTT are:

1. Being aware of sources of contamination,

2. Keeping the environment free from pathogens,

3. Effective hand decontamination,

4. Creating a sterile field,

5. Exclusive use of sterilized equipment,

6. Using a non-touch technique.

Being aware of sources of contamination

It is vitally important that you are aware of sources of contamination in the clinical setting. These
can be from:

• Not washing your hands,

• Not cleaning your trolley or surfaces properly,

• Out of date or contaminated sterile equipment,

• Touching sterile equipment with non-sterile equipment or hands,

• Touching your sterile field with contaminated materials.

Or airborne contamination such as:

• Dust from bed making/cleaning,

• Droplets,

• Nebulizers/humidifiers,

• Air conditioning,

• Sneezing and coughing,

• Open windows and fans.

Keeping the environment free from pathogens

It is essential when carrying out the ANTT for wound cleansing and dressing that you pay particular
attention to the environment as bacteria are dispersed into the air by a number of practices. For
example, close windows, turn off fans and carry out the wound cleaning and dressing once the dust
has settled following cleaning and bed making.

Effective hand decontamination

Is essential to reduce the risk of cross contamination. The recognized Royal College of Nursing
(RCN) (2004) and the National Patient Safety Agency (NPSA) (2008) hand washing technique should
be used at the beginning and end of every ANTT (see Chapter 5 and Fig 6.1a).

Creating a sterile field

This includes preparing your area and using the appropriate materials. In an acute setting a
dressing trolley should be made available for you to do this as this enables transfer of materials
with ease, thus reducing the risk of contamination. However, they are not essential as any
impermeable clean surface can be used as a platform for your sterile field to be laid. Initially clean
the dressing trolley with soap and water (see Fig. 6.1b) as this will not only clean any visible
dirt/dust but also remove the C. Diff spores which are not killed by 70% alcohol. Following this,
clean the trolley with a 70% alcohol solution to kill any remaining microorganisms (Pratt et al.
2007) (see Fig 6.1c).

Figure 6.1a Hand washing

Figure 6.1b Cleaning a trolley with soap solution

Then once you have opened your sterile dressing pack, using fingertips only around the edge, you
have a sterile field on which to work (see Fig. 6.1d). If, however, you are in a community setting this
is more difficult to achieve (Hallett 2000) and it is necessary for you to either clean an item of the
patient’s furniture (with their consent) or devise a surface suitable to place your sterile material on
and so minimize the possibility of contamination from microorganisms.

Figure 6.1c Cleaning a trolley with alcohol

Figure 6.1d Creating a sterile field

Figure 6.1e Checking sterile equipment

Exclusive use of sterilized equipment

As the main goal of the ANTT is to minimize the risk of cross contamination it is essential that all
equipment to be used for the wound cleansing and/or dressing is sterile. Each piece of equipment
will come in packaging, which ensures the internal equipment is sterile. It is your responsibility
when using this equipment to check for its expiry date and ensure the outer packaging has not been
tampered with or damaged, thus potentially making the internal equipment contaminated (see Fig.
6.1e). If you come across outdated or potentially contaminated equipment discard it immediately or
inform the manufacturers if a manufacturing problem.

Using a non-touch technique

This is used to prevent direct and indirect contact of key parts of equipment which if touched either
directly or indirectly could result in infection (Rowley 2001).

It is therefore essential to carry out a risk assessment prior to carrying out a procedure to
ensure you choose the appropriate equipment to minimize the risk of contamination
(Preston 2005).
Personal protective clothing

Note: It is necessary for you when carrying out the ANTT in wound dressing that you wear
the appropriate protective clothing.

In relation to simple wound cleansing and dressing you only need to wear a single use disposable
apron, a pair of non-sterile gloves to remove the old dressing, and sterile gloves to carry out the
wound cleansing and dressing (see Fig. 6.1f). If, however, there is a risk of splashing of bodily fluids
you may be required to wear other protective clothing such as masks and goggles (Hart 2007). As
you progress through your pre-registration programme the wound cleansing and dressings will
become more complex and the risk of splashing of bodily fluids may increase.

Figure 6.1f Putting on sterile gloves

Box 6.1 Remember

1. Effective hand decontamination is the single most effective way of preventing cross
contamination.

2. ‘The first priority of any non-emergency clinical procedure is to ensure safe aseptic
practice’ (Rowley and Simon 2009: 23).

3. Always use the ANTT when there is a risk of cross contamination and you will never
contaminate yourself, equipment or patient.

Wound assessment

One of the things you will be expected to do during your OSCE is to assess the wound. The
examiner will expect you to assess the need for the wound to be cleansed and for you to be able to
recognize signs of infection (see Fig. 6.1g).
 KEY POINT! Not all wounds need to be cleansed and there is evidence (Tomlinson 1987)
that cleaning wounds ritualistically can be damaging to new tissue growth. Therefore
wound cleansing should only be carried out if the wound is visibly dirty or there are signs
of infection, i.e. local redness, swelling or pain etc.

If signs of infection are present a wound swab will need to be taken before cleansing begins. You
will also need to identify if the wound has a localized infection, i.e. one that is contained in one area,
or a systemic infection, i.e. one that has spread throughout the body. The type of wound will also
enable you to decipher if you are going to irrigate the wound or use swabs to clean the edges of a
wound.

Figure 6.1g Assessing the wound

Figure 6.1h Cleaning the wound

Wound cleansing

You will be expected to clean the wound during your OSCE to demonstrate your ability to clean a
wound whilst maintaining an aseptic non-touch technique (see Fig. 6.1h).

The aim of wound cleansing is to remove foreign material, e.g. dead tissue, microorganisms causing
infection, faecal or urine contamination.

Irrigation of the wound should be used when there is exposed tissue, e.g. pressure sore, leg ulcer or
lacerations. Swabs may be used for the removal of physical matter but be mindful that using gauze
swabs may serve to redistribute bacteria and could also damage granulating skin and therefore
delay healing (Tomlinson 1987). In addition, small particles of gauze/cotton wool balls may be left in
the wound, thus creating an area for bacteria growth. Swabs, however, can be used to clean the
edges of closed wounds, e.g. surgical wounds.

Figure 6.1i Dressing the wound

KEY POINT! Wounds should be exposed for the shortest time possible to prevent
contamination from airborne materials.

It is recommended by Xavier (1999) that when you are faced with a patient who has more than one
wound, the clean non-infected wound should be cleaned first to prevent cross contamination of
infected material passing to a clean wound. However, if you are using the principles of the ANTT
then cross contamination should not happen whichever wound you clean first. Once the wound is
clean and dry apply an appropriate sterile dressing (see Fig. 6.1i).

Dressing a wound is a very complex skill that is difficult to depict in its entirety by still photographs.
 To increase your understanding a video of the procedure and a PowerPoint presentation
are available on the online resource centre: www.oxfordtextbooks.co.uk/orc/caballero/

The video includes step by step guides and includes:

• Introduction to asepsis,

• Setting up of the procedure,

• Carrying out the procedure,

• Post procedural responsibilities.

The OSCE is likely to be performed in a clinical skills laboratory at your university campus, and you
will generally have a time limit of between 20 and 30 minutes to complete the skill. The room will be
set up with a bed and a patient who could be either a manikin, a volunteer from outside the
university, or a member of the wider teaching staff from your university school of nursing. In
addition the room will have all the relevant equipment for you to carry out the procedure, such as
dressing packs, aprons and gloves.

You will be expected to talk to the ‘patient’, gain their consent and ask any other relevant questions.
You will then be expected to carry out a simple wound cleansing procedure, wound assessment and
dressing change. Following the completion of the procedure you may be asked some questions
about the ANTT or infection control issues so be prepared!

Examiners’ marking criteria

The criteria used to assess your aseptic non-touch technique will vary between universities and will
depend upon the type of wound that you are dressing. An example of simulated examination criteria
is given in Table 6.1.

Table 6.1 Example of examiners’ marking criteria

Examiners’ questions

 Note: Some universities may assess your knowledge in relation to aseptic non-touch
technique and it is useful to prepare for that, if it is a requirement.

Some typical questions are included in Box 6.2.

Box 6.2 Example of examiners’ questions

1. What is asepsis?

2. What is an aseptic technique?

3. When should an aseptic technique be used?

4. Identify four principles of asepsis.

5. What is a nosocomial infection?

6. What are the consequences of nosocomial infection?

7. What are the most common nosocomial infections?

8. What is a non-touch technique?

9. What signs might indicate that a wound is infected?

10. What is a localized infection?

11. What is a systemic infection?

12. What are the three most common ways of spreading infection?

13. Why should you wear protective clothing?

14. What can cause airborne contamination?

15. What should you clean a dressing trolley with?

See the end of the chapter for answers.

Common errors at this station

A number of errors occur at this station. These include failure to:

• Introduce yourself to the patient,

• Gain consent from the patient,

• Check patient documentation or care plan for recommended procedure and dressing,

• Check windows are shut/check for cross contamination,

• Follow university/NHS Trust dress code,

• Check need for analgesia,

• Clean trolley effectively,

• Dispose of equipment appropriately,

• Prevent contamination of sterile field:

Placing non-sterile equipment on sterile field,

Touching field with uniform/hands,

Placing ‘dirty’ equipment/dressings on sterile field.

• Prevent contamination of sterile equipment:

Gloves touched and contaminated,

Touching equipment whilst opening packages,

Forgetting which bits of equipment are sterile/not sterile.

• Carry out correct wound cleaning techniques,

• Decontaminate hands or more commonly too frequent hand decontamination,

• Carry out appropriate glove technique and contamination of gloves,

• Avoid ripping gloves,

• Avoid panicking if mistake made and trying to cover up.

Top tips for passing this station

• Practise, practise, practise the procedure prior to taking the OSCE, using any resources
your university provides such as DVDs, and skills laboratories. In addition practise under
the direct supervision of your mentor whilst on clinical placements.

• You could mock up a sterile pack at home by using a tea towel as your sterile field, an
egg cup as your fluid receptacle, some kitchen paper as sterile gauze and a pair of
 household rubber gloves as sterile gloves and follow the DVD step by step to develop your
ability to carry out the procedure.

• Revise the underpinning knowledge in relation to this station as you may be asked
questions at the end of carrying out the procedure. Please refer to the section on
questions in this chapter to guide your revision.

• If during the OSCE you rip or contaminate your gloves or any aspect of your sterile field
do not panic; just stop, explain to the examiner what you have done and start again.

• If you need to start again be aware that you may well be under a time constraint but
again do not panic carry out the procedure as best you can.

• If you run out of time you will be referred (i.e. not passed yet) at this attempt but be
assured it is better you run out of time rather than not recognize a contamination of the
sterile field.

• If you are referred (i.e. not passed yet) at your first attempt do not panic; you will be
given another opportunity to pass.

• If you pass, congratulations—you have mastered one of the most fundamental

techniques that underpin your nursing practice.

Online resource centre

You can find further advice and revision help for your OSCEs by going online now to see
www.oxfordtextbooks.co.uk/orc/caballero/.

References

Aziz, A.M. (2009). Variations in aseptic technique and implications for infection control.
British Journal of Nursing, 18, 1: 26–31.

Dougherty, L. and Lister, S. (eds) (2008). The Royal Marsden Hospital Manual of Clinical
Nursing Procedures. 7th edn. Oxford: Blackwell Publishing.

Hallett, C. (2000). Infection control in wound care: a study of fatalism in community

nursing. Journal of Clinical Nursing, 9: 103–109.

Hart, S. (2007). Using an aseptic technique to reduce the risk of infection. Nursing
Standard, 21, 47: 43–48.

National Patient Safety Agency (2008). Clean hands save lives. Patient Safety Alert ref
0773 2nd edn. 2nd September, www.npsa.nhs.uk.

NMC (2007). Essential Skills Clusters. London: NMC.

Pratt, R.J., Pellowe, C.M., Wilson, J.A., Loveday, H.P., Harper, P.J., Jones, S.R.L.J.,
McDougall, C. and Wilcox, M.H., (2007). Epic 2. National evidence based guidelines for
 preventing health care associated infection in NHS hospitals in England. Journal of
Hospital Infection 65S: S1–S64.

Preston, R.M. (2005). Aseptic technique: evidence-based approach for patient safety.
British Journal of Nursing, 14, 10: 540–546.

Rowley, S. (2001). Aseptic non-touch technique. Nursing Times Plus, 97, 7: PV1–V111.

Rowley, S. and Simon, C. (2009). Improving standards of aseptic practice through an

ANTT trust-wide implementation process: a matter of prioritization and care. Journal of
Infection Prevention, September, 10, Supplement 1.

Royal College of Nursing (2004). Hand Washing Technique Poster. London: RCN.
Publication code: 002 277.

Tomlinson, D. (1987). To clean or not to clean? Cleaning discharging surgical wounds.

Nursing Times, 83, (9): 71, 73, 75.

Xavier, G. (1999). Asepsis. Nursing Standard, 13, 36: 49–53.

Appendix: answers to examiners’ questions

1. What is asepsis?

• Freedom from pathogenic microorganisms,

• The absence of disease producing microorganisms.

2. What is an aseptic technique?

• A collective term of methods used to maintain asepsis and designed to interrupt the
transmission of infection.

• A technique that reduces the risk of cross contamination during clinical procedures.

• Effort taken to keep patient as free from microorganisms as possible.

• Method to prevent cross contamination of wounds and other susceptible sites by

organisms that could cause infection.

• The prevention of microbial contamination of living tissue or fluid or sterile materials by

excluding, removing or killing microorganisms.

3. When should an aseptic technique be used?

Any invasive procedure that bypasses the body’s natural defences, e.g.

• Catheterization,

• Dressings,

• Removal of sutures/clips etc.

• IV dressings,

• TPN,

• IV drug administration.

4. Identify four principles of asepsis.

• Effective hand decontamination,

• Creating a sterile field,

• Exclusive use of sterilized equipment,

• Using a non-touch technique,

• Being aware of sources of contamination,

• Keeping environment free from pathogens.

5. What is a nosocomial infection?

• A hospital acquired infection,

• An infection not present on admission.

6. What are the consequences of nosocomial infection?

• Financial cost to the NHS Trust,

• Increased patient days in hospital,

• Increased morbidity,

• Increased mortality,

• Pain,

• Inconvenience to patient,

• Increased hospital waiting lists,

• Increased suffering of patient.

7. What are the most common nosocomial infections?

• Catheter related infections,

• Surgical sites,

• Pneumonias,

• Bloodstream (IV lines).

• MRSA

• C. Diff

8. What is a non-touch technique?

A technique that prevents contamination of the area by microorganisms on the hands. It

involves the following:

• Always wash hands effectively,

• Never contaminate key parts,

• Touch non-key parts with confidence,

• Take appropriate infective precautions,

• Maintain asepsis and a non-touch approach.

9. What signs might indicate that a wound is infected?

• Local redness,

• Swelling,

• Pain,

• Pyrexia,

• Increased white cell count.

10. What is a localized infection?

• Infection that is contained in one area, e.g. wound.

11. What is a systemic infection?

• Infection that has spread throughout the body.

12. What are the three most common ways of spreading infection?

• Poor hand hygiene,

• Inanimate objects,

• Dust particles.

13. Why should you wear protective clothing?

• Protection from splashes during procedure,

• Protection from direct contact during procedure,

• Protection of skin and clothing during procedure,

• Prevent transfer of pathogens from nurse to patient,

• Prevent nurse acquiring infection from patient.

14. What can cause airborne contamination?

• Bed making,

• Cleaning,

• Droplets,

• Nebulizers/humidifiers,

• Air conditioning,

• Sneezing,

• Coughing.

15. What should you clean a dressing trolley with?

• 70% ethanol alcohol.



Chapter 7
Measuring, assessing and recording: pulse,
body temperature, respirations and oxygen
saturation

Paula Deamer and Tina Attoe

Chapter aims

This chapter will enable you to:

• Revise key material in relation to physiological assessment,

• Follow a step by step guide to each observation,

• Understand how to prepare and revise for this OSCE,

• Highlight common questions and problems at this station and identify how these may be
avoided.

Introduction

As part of the measuring physical observations simulated examination, students will be asked to
measure, assess and record pulse, body temperature, respirations and oxygen saturation. This
assessment is becoming more common in all universities as it has been identified as a mandatory
simulated assessment within the NMC Essential Skills Clusters (NMC 2007).

Although this chapter will focus upon each observation in turn, it is imperative that when
undertaking physical observations the findings are not assessed in isolation. Like a jigsaw, each
result, alongside the patient’s appearance, pallor, demeanour and responsiveness, link together to
form an overall picture of the patient’s condition. The skill of undertaking these observations may
sometimes be reviewed as being routine, but the skill has important clinical significance. Students
have to demonstrate their underpinning knowledge and to make sense of the relevance of the
observations—this can be complex and challenging. Some student nurses will have previous
experience, prior to commencing their nurse education training, of taking patients’ physical
observations, but the ability to demonstrate an understanding of the underpinning knowledge
differentiates between the role of a health care support worker and a student nurse.

Revision of key material will enable the student to understand, undertake and assess the relevance
of measuring pulse, body temperature, respirations and oxygen saturation. The importance of the
professional nurse’s ability to accurately assess, record and evaluate pulse rate, body temperature,
respirations and oxygen saturation cannot be underestimated.

Concern has been raised that NHS staff are failing to recognize patient deterioration in a timely
manner. In a study by the National Patient Safety Agency (NPSA 2007) factors for this lack of
recognition included failure to take physical observations, not acknowledging the significance of the
observations and finally not reporting on issues that were of concern, or acting upon these findings.
Guidelines on recognizing and managing patient deterioration have been issued by NICE (2007)
alongside competencies for recognition and management of a deteriorating patient, which all staff
working in acute settings should achieve (DOH 2009). Throughout these the importance of
assessing, recording, evaluating and appropriately reacting to the results of physical observations
cannot be denied.

When undertaking all observations a student nurse should have an awareness of the standard
acceptable ranges of the physical assessment measurements. The first recorded measurements are
frequently referred to as the patient’s baseline readings. Each individual will have their own unique
baseline measurements, which are normal for them. Physical measurements are influenced by
lifestyle, age, personal fitness levels, diet, alcohol consumption and cigarette smoking. The baseline
measurement results allow the nurse to make a more accurate judgement about the observation
findings based upon specific individual circumstances.

Note: If a patient is stressed due to hospital admission, being in pain or from the influence
of a disease process this may also cause the baseline measurements to be outside the
acceptable ranges. Therefore, the student should have knowledge of the acceptable range
for each of the observations in order to aid evaluation and recognition of abnormal
findings.
Key revision for your simulated examination

Measuring, assessing and recording pulse rate

Pulse rate is considered to be one of the four vital signs of life alongside blood pressure, body
temperature and respiratory rate. A pulse is created by a pressure wave being generated
throughout the arterial system, following the expansion and recoil of the arteries with each
contraction of the left ventricle (Marieb and Hoehn 2007). Fingertip compression of the artery
against the underlying bone will enable the pulse to be located; this action is called palpation. The
pulse indicates that the heart is pumping and moving blood around the body to perfuse the tissues
(Diggens 2009). Therefore, absence of a pulse may indicate that the heart is not pumping or blood is
not reaching the peripheries.

There are a number of sites which can be utilized to measure pulse; however, when completing
physical observations the radial pulse is commonly used, since it is easily accessed and the pulse
at this site, in healthy individuals, has a discernable strength. Table 7.1 outlines the indications for
using specific pulse sites.

Guidance for effective measurement of the pulse

Note: Remember to wash your hands prior to undertaking this skill. If there is a risk that
your patient may have an infection you should consider wearing gloves and apron, in
accordance with local policy guidelines.

The pulse is measured by palpation of the radial artery by placing the index and middle fingertip
pads along the radial artery in line with the base of the patient’s thumb whilst simultaneously
counting the number of beats felt during one timed minute (see Fig. 7.1). Sufficient pressure to feel
the pulse should be applied without causing discomfort. When palpating the pulse you must not
place your thumb on the underside of the patient’s wrist. The thumb pad has a discernable pulse of
its own and could be misinterpreted as being the patient’s pulse rate. Whilst completing this task
you should also assess the rhythm and amplitude of the pulse. This would not be identifiable if using
an electronic means to assess the patient’s pulse rate. A full minute is required since it allows you
to discern subtle changes in rate, rhythm and amplitude (strength) which may be missed if the
assessment was completed in a shorter time period.

Table 7.1 Indications for palpating specific pulse sites

Figure 7.1 Palpation of the radial artery

Box 7.1 Ranges for pulse

60–100 beats per minute (bpm) normal range,

60 bpm bradycardia (slow pulse),

> 100 bpm tachycardia (fast pulse).

Pulse rate is expressed as beats per minute. When assessing and evaluating the patient’s pulse rate
you should have an awareness of the normal acceptable range and the patient’s baseline
measurement, when obtainable. Box 7.1 identifies normal and abnormal ranges.

Documentation of pulse
It is important to document your findings immediately after taking the patient’s pulse, to ensure
accuracy. Most clinical care settings will require the documentation to be completed using black
ink. Your written documentation will be accessed by all members of the care team and may be
utilized to inform patient treatment decisions; therefore it is imperative that your measurements
cannot be misinterpreted.

Table 7.2 provides an example of how you would document a patient’s pulse which was found to be
124 bpm at 08.00 am. You should document the actual reading in figures as well as placing a clear
dot between 120 and 130 where 124 would be approximately located.

Note: Not all care settings will have documentation that differentiates the pulse readings
by units of ten. Therefore prior to completing the OSCE you should familiarize yourself
with the local documentation.

Table 7.2 How to document a patient’s pulse

In this example the patient’s pulse rate is above the acceptable range (indicated in white as
between 60 and 100 bpm) and the patient’s pulse rate falls within the light grey coloured section;
this indicates that the patient’s condition could be of concern for the nurse. Note: Some NHS Trusts
will not use colour coded charts and you will be expected to score the pulse according to local
policy. Whenever a reading is found to be outside the acceptable range you would always be
expected to bring this to your mentor’s attention and follow local policy regarding actions that
should be taken. In this case the patient should be kept under close observation and the pulse rate
should be monitored more frequently.

Frequently asked question related to measuring pulse rate

Q) I am unable to locate the radial pulse site.

It is very common when completing this skill that students place their fingers on the inner aspect of
the wrist rather than the radial pulse site which is located on the outer aspect. You may also be
placing your index and middle fingertip pads too far up the arm.

Many students believe that this is a simple skill and it appears evident that they have not been
practising this in the clinical setting, but relying upon electronic means for assessing a patient’s
pulse rate. You should therefore familiarize yourself with the correct technique and practise this
skill before the OSCE, following the guidelines for measuring pulse rate as described in this
chapter.

Measuring, assessing and recording body temperature

Body temperature is the balance between heat production and heat loss in response to metabolic
reaction within the body. It is possible to measure a patient’s surface and core body temperature.
For the purpose of this OSCE the reading you obtain will be identified as the core body
temperature. The core temperature reading indicates the heat of arterial blood and body tissue heat
from metabolic activity. A core body temperature provides the most accurate reading. Surface
temperature will be cooler than core body temperature as heat loss occurs through the skin.

Note: The patient’s body temperature can be influenced by internal and external factors;
therefore significant variances could be an indication that your patient’s condition is
deteriorating and should be investigated. Like all physical observations, there is an
acceptable range for body temperature, and if the patient’s temperature was within this
range it would not necessarily be a cause of concern. Measurements between 36°C–
37.5°C (Centigrade) are all considered to be within the acceptable range (see Box 7.2).

Whilst completing this skill you should be maintaining communication with the patient, and this may
assist you to gain more insight into the patient’s personal awareness of whether their temperature
is normally low or high in relation to the acceptable range. For some patients a measurement that
indicates a body temperature of 37.5°C may be acceptable, whereas another patient may state that
their usual body temperature is on the lower end of the spectrum and for this patient it may indicate
that they are pyrexial. The term pyrexia is applied to a patient whose temperature is above the
acceptable parameters. There are a number of sites that can be used to measure body temperature,
including the ear, the mouth, under the arm and rectally (see Table 7.3). Box 7.2 identifies normal
and abnormal ranges.

Guidance for effective measurement of body temperature

To assess a patient’s body temperature you can use any one of the many available thermometers,
including tympanic, digital or chemical/heat reactive strips, to obtain your reading. Your choice
should be influenced by patient condition and the range of available equipment.

Box 7.2 Ranges for temperature

Measurements between 36°C and 37.5°C normal range

35.5°C hypothermia (low),

> 38°C pyrexia (high).

Table 7.3 Indications for selection of specific temperature sites

Remember to wash your hands and clean your equipment prior to commencing this skill. If there is
a risk that your patient may have an infection or risk of personal contamination you should consider
wearing gloves and apron, in accordance with local policy guidelines.

Note: If using a tympanic or digital thermometer a new probe cover must be used prior to
each temperature assessment and should be correctly disposed of as clinical waste after
each use. Chemical/heat reactive strips are sterile and wrapped and should be carefully
opened, to avoid contamination. These are single use only and should also be disposed as
clinical waste.
Tympanic

Tympanic membrane thermometers are inserted into a patient’s ear canal (see Fig. 7.2). The probe
must be covered and placed snugly into the patient’s ear. The thermometer needs to be close to the
tympanic membrane in order to ensure the reading obtained is accurate. Once in position the scan
button should be pressed and when an audible beep is omitted this indicates that the temperature
has been read.

Oral

Digital

The covered probe is inserted sublingually into the buccal pouch, under the patient’s tongue (see
Fig. 7.3). The patient should be asked to close their mouth to create a seal. The timing for
accurately obtaining a digital temperature may vary according to type of digital thermometer used
in the care setting; this can range between a few seconds and a few minutes. You should familiarize
yourself with the required timings for your selected digital thermometer before undertaking the
skill.

Figure 7.2 Using a tympanic thermometer

 Figure 7.3 Using a digital thermometer

Chemical/heat reactive strips

The chemical/heat reactive strip is also inserted sublingually into the buccal pouch. The patient
should be asked to close their mouth and create a seal. The timing for accurately obtaining a
temperature using a chemical/heat reactive strip may vary between 1 and 3 minutes (see Fig. 7.4).
You should ensure that you are familiar with the manufacturer’s instructions prior to commencing
this assessment.

Figure 7.4 Chemical/heat reactive strips

Axilla

Digital

The digital thermometer is inserted into the axilla (armpit). The patient should be asked to place
their arm across their chest, to ensure that the digital thermometer is kept in position and therefore
enable an accurate reading to be achieved. The timing for accurately obtaining a digital
temperature may vary according to type of digital thermometer used in the care setting; this can
range between a few seconds and a few minutes. You should familiarize yourself with the required
timings for your selected digital thermometer before undertaking the skill.

Chemical/heat reactive strips

The chemical/heat reactive strip can be inserted into the axilla (armpit). The patient should be
asked to place their arm across their chest, to ensure that the strip is kept in position and therefore
enable an accurate reading to be achieved. The timing for accurately obtaining a temperature using
a chemical/heat reactive strip may vary between 1 and 3 minutes. You should ensure that you are
familiar with the manufacturer’s instructions prior to commencing this assessment.

Documentation of body temperature

 Note: It is important to document your findings immediately after measuring the patient’s
body temperature, to ensure accuracy. Most clinical care settings will require the
documentation to be completed using black ink. Your written documentation will be
accessed by all members of the care team and may be utilized to inform patient treatment
decisions; therefore it is imperative that your measurements cannot be misinterpreted.

Table 7.4 provides an example of how you would document a patient’s body temperature that was
identified as 37.5°C at 08.00 am. You should document the actual reading in figures as well as
placing a clear dot centrally between 37°C and 38°C. Not all care settings will have documentation
that differentiates the temperature readings by units of ten; therefore prior to completing the OSCE
you should familiarize yourself with the local documentation.

Table 7.4 How to document a patient’s body temperature

In this example the patient’s body temperature is within the acceptable range (indicated in white as
between 36°C and 37.9°C). Note: Some NHS Trusts will not use colour coded charts and you will be
expected to score the temperature according to local policy. The patient’s body temperature should
not cause any concern to the nurse. However, if a reading is found to be outside the acceptable
range the student nurse would always be expected to bring this to their mentor’s attention and
follow local guidance regarding actions that should be taken. In this case the patient’s body
temperature would be monitored as per their individual care pathway requirements.

Frequently asked question related to measuring body temperature

Q) Why have I obtained an unexpectedly low tympanic temperature reading, when my patient does
not seem to be hypothermic?

Have you ensured that the mode setting of the tympanic thermometer is correctly set for the type of
measurement required? It is easy to accidentally change this setting when holding and pressing the
scan button. The setting should always be tympanic oral when measuring core body temperature. If
the tympanic thermometer has been accidentally set on surface mode the result indicated will be
inaccurately low.

If you are nervous your hands may visibly shake and can be felt by the patient or OSCE assessor
taking the patient role. This can result in the thermometer not being inserted correctly to gain an
accurate reading and invariably you will find that the thermometer indicates a low reading.

Note: Always ensure that you have inserted the tympanic thermometer far enough into the
ear, without causing the patient discomfort, to enable the thermometer to detect the true
temperature from the tympanic membrane. If this is not done it will also give an
inaccurate reading.

Students frequently identify that they have obtained a low reading, e.g. 35.8°C, but are not able to
articulate that this is below the acceptable range and what might have caused this low reading.
Some students simply state that this is not within the acceptable range. If this happens in your
OSCE you should retake the temperature taking into consideration the previously mentioned points.

If the reading remains low you should consider utilizing the other ear and/or using an alternative
means of temperature measurement, such as digital or a chemical/heat reactive strip.

You should familiarize yourself with the correct technique and practise this skill before the OSCE,
following the guidelines for measuring body temperature as described in this chapter.

Measuring, assessing and recording respiration

Definition

Ventilation is when a patient inhales air into and exhales air from the lungs, a process that
facilitates gaseous exchange. Measuring this in nursing is commonly known as assessing
respiration. The respiratory system includes the nasal cavity, pharynx, larynx, trachea, bronchi and
lungs (Marieb and Hoehn 2007). The purpose of respiration is to supply the body with oxygen
during inhalation and remove carbon dioxide by exhalation. During inhalation the diaphragm and
external intercostal muscles are contracted causing the rib cage to rise and therefore increasing the
volume of the thorax (Marieb and Hoehn 2007). Exhalation is a passive response caused when the
muscles relax and the lungs recoil.

Respiration is assessed by observing the rise and fall of the chest and counting each cycle of
inhalation and exhalation as one single respiration. This observation must take a full timed minute.
Whilst completing this observation you should also be noting the effort, depth and sound of each
breath, as well as the patient’s pallor. A patient’s normal respirations are almost silent. Increased
rate and depth of respiration is described as hyperventilation. Any measurement findings that are
outside the acceptable range for respiration, as well as any change in the depth, rate and sound of
the ventilation process must be reported to a senior member of nursing staff, for close monitoring.
You should also assess for good perfusion of oxygen to the skin, by ensuring that the patient’s lips
and nose do not have a tinge of blue.

Guidance for effective measurement of respiration

To assess a patient’s respiration you will need to be able to view the rise and fall of the patient’s
chest. This is a difficult skill to complete as patients’ breathing rates can be affected if they become
aware that you are closely monitoring their respiration. Some patients may reduce their respiratory
rate, whilst others may increase the number of breaths per minute or exaggerate their respiratory
behaviour. A commonly used technique to overcome this is to take the patient’s pulse for one
minute, maintain the finger positioning for a further minute, and then discreetly count their
respiratory rate. Since the patient will be unaware that you are now monitoring their respiration it
is more likely that you will obtain an accurate reading. Box 7.3 identifies normal and abnormal
ranges.

Box 7.3 Ranges for respiration

Respiratory rate per minute between 11 and 20 normal range

11 bradypnoea (low),

> 20 tachypnoea (high).

Documentation of respiratory rate

It is important to document your findings immediately after measuring the patient’s respiratory
rate, to ensure accuracy. Most clinical care settings will require the documentation to be completed
using black ink. Your written documentation will be accessed by all members of the care team and
may be utilized to inform patient treatment decisions; therefore it is imperative that your
measurements cannot be misinterpreted.

Table 7.5 provides an example of how you would document a patient’s respiratory rate that was
identified as being 13 respirations per minute at 08.00 am. The reading should be documented in
figures. There may be differences between each care setting’s chart format. Therefore prior to
completing the OSCE you should familiarize yourself with the local documentation.

In this example the patient’s respiration rate is within the acceptable range (indicated in white as
between 11 and 20 respirations per minute). At this point the patient’s respirations would not cause
any concern. However, if a reading is found to be outside the acceptable range the student nurse
would always be expected to bring this to their mentor’s attention and follow local policy regarding
actions that should be taken. In this case the patient’s respirations would be monitored as per their
individual care pathway requirements.

Frequently asked questions related to measuring respiratory rate

Q) I feel self conscious watching the rise and fall of a patient’s chest.

It is possible to discreetly assess a patient’s respiration without staring directly at the patient’s
chest. By not staring you will feel less self conscious. The patient will not be made to feel
uncomfortable and will be less aware of the assessment being completed. This will also result in the
respiratory measurement being more accurate.

As you become more skilled at undertaking this observation you will develop your own methods to
facilitate this more easily, such as taking the respiratory rate whilst providing other personal care,
washing or whilst in the vicinity of the patient.

Q) I find it difficult to co-ordinate counting the respirations whilst trying to monitor the time.

Many students find having to check their fob watch and count simultaneously difficult to do, as they
miss the rise and fall of a patient’s chest when they are monitoring the timing. You could place your
fob watch on the patient’s bedside table (never on the bed) so that it is within your eye line and you
can therefore concentrate solely upon counting the respiratory rate.

Table 7.5 How to document a patient’s respiratory rate

Note: You should familiarize yourself with the correct technique and practise this skill
before the OSCE, following the guidelines for measuring respiratory rate as described in
this chapter.

Measuring, assessing and recording oxygen saturation measurement

Definition

Oxygen saturation is measured using a pulse oximeter. It is a common fallacy that a pulse oximeter
indicates the level of oxygen in the blood. The majority of oxygen carried in the blood is bound to
haemoglobin. Therefore having reduced haemoglobin level, as with anaemia, will result in less
oxygen in the blood.

The pulse oximeter emits a red light which detects the colour difference between oxygenated and
deoxygenated blood whilst identifying the pulse of the artery. It then uses this information to
calculate the percentage of oxygen combined with haemoglobin. The measurement is always
expressed as a percentage and the acceptable range is usually above 94% (BTS 2008). If the
percentage rate indicated was less than 94% you would be expected to bring this to your mentor’s
attention and follow local policy guidelines.

Guidance for effective measurement of saturation

Always wash your hands and clean your equipment prior to commencing this skill. If there is a risk
that your patient may have an infection or risk of personal contamination you should consider
wearing gloves and apron, in accordance with local policy guidelines. Usually the oxygen saturation
is measured by attaching the appropriate probe to either the patient’s fingers, toes or ear lobes.

The pulse oximeter probe should be attached like a peg onto the patient’s fingertip (see Fig. 7.5).
You should be aware that the probe must be placed the correct way up; there may be a diagram on
the equipment to indicate this. You should ensure that the patient’s selected finger is warm, has no
nail varnish and they should be advised to keep their digit still whilst the measurement is being
completed. Movement of the probe on the patient’s finger, dirt or poor circulation will all affect the
reading and could provide an inaccurate measurement. If the patient has symptoms of shock or
trauma, peripheral shutdown may occur and this will reduce blood flow to the fingertips and other
peripherals, therefore causing an inaccurate or unrecordable oxygen saturation reading. In
peripheral vascular disease or diabetes blood flow may also be reduced to the peripheries.

Figure 7.5 Using the pulse oximeter

Box 7.4 identifies normal ranges.

Box 7.4 Ranges for oxygen saturations

Measurements above 94% on room air are considered within normal range.

Documentation of oxygen saturation measurement

It is important to document your findings immediately after measuring the oxygen saturation, to
ensure accuracy. Most clinical care settings will require the documentation to be completed using
black ink. Your written documentation will be accessed by all members of the care team and may be
utilized to inform patient treatment decisions; therefore it is imperative that your measurements
cannot be misinterpreted.

Table 7.6 provides an example of how you would document a patient’s oxygen saturation (SaO2) that
was found to be 96% on 2 L oxygen at 08.00 am. You should document the actual reading as a
percentage on the chart, as well as indicating the flow rate or percentage of oxygen being
administered. If a patient is not receiving additional oxygen you must still document their oxygen
saturation, noting that the patient is breathing air. Prior to completing the OSCE you should
familiarize yourself with the local documentation.

In this example the patient’s oxygen saturation is within the acceptable range (indicated in white as
between 96 and 100%). At this point the patient’s oxygen saturation should not cause any concern.
However, if a reading is found to be outside the acceptable range the student nurse would always be
expected to bring this to their mentor’s attention and follow local policy regarding actions that
should be taken. In this case the patient’s oxygen saturation level would be monitored as per their
individual care pathway requirements.

Table 7.6 How to document a patient’s oxygen saturation (SaO2)

Frequently asked question related to measuring oxygen saturations

Q) I have noticed that the pulse oximeter identifies the patient’s pulse rate as well as their oxygen
saturations. Is it alright for me to record the pulse rate for my OSCE assessment based on this
reading, so that I do not have to manually assess the pulse?

No, the OSCE assessment requirements stipulate that you must be able to demonstrate your ability
to manually assess the patient’s pulse rate. Therefore your OSCE assessor is likely to ask you to
measure the pulse manually prior to measuring the oxygen saturation.

Putting it all together!

The OSCE is likely to be performed in a clinical skills laboratory at your university campus, and you
will generally have a time limit of between 20 and 30 minutes to complete all the observations. The
room will be set up with a bed and a patient who could be either a manikin, a volunteer from
outside the university, or a member of the wider teaching staff from your university school of
nursing. In addition the room will have all the relevant equipment for you to carry out the
procedures, such as thermometers and pulse oximeter.
 Note: You should always ensure that your hands are clean prior to commencing the
physical observation skills. This may be achieved by washing your hands using soap and
water or by the application of cleansing hand gel, according to local policy.

The equipment must be cleaned using hard surface wipes before and after use on each individual
patient according to local policy guidelines. Please ensure that the equipment has dried prior to use
as damp equipment can encourage growth of microorganisms and will be uncomfortable for the
patient.

You should approach the patient in a professional manner, providing an introduction including your
name and role. You should also confirm how the patient would like to be addressed.

Prior to measuring the physical observations you should always gain the patient’s consent by
providing a clear explanation of what you are about to do and why the observations are required
(NMC 2008).

You should identify if:

• The patient has rested for at least 5 minutes,

• They have eaten food or had any hot or cold fluid in the last 15 minutes,

• They have they been smoking.

Any of the above may create inaccuracy in your findings.

Box 7.5 Putting it all together

You will be expected to:

• Talk to the ‘patient’, gain their consent and ask any other relevant questions,

• Take the ‘patient’s’ pulse, temperature, respiration rate and oxygen saturation.

Following the completion of the procedures you may be asked some questions about physiological
measurements, so be prepared!

Having measured the physical observations (as outlined in the criteria in Table 7.7) the results
should be accurately recorded using approved documentation. You will be assessed on your ability
to accurately document your patient’s physical observations as part of the OSCE.
Examiners’ marking criteria

Table 7.7 Example of examiners’ marking criteria

Examiners’ questions

Note: Some universities may assess your knowledge in relation to physiological

measurement and it is useful to prepare for that, if it is a requirement.

Example of typical questions an examiner may ask are provided in Box 7.6.

Box 7.6 Example of examiners’ questions

1. Could you tell me the normal heart rate ranges?

2. Could you identify three normal sites for measuring pulse rates?
 3. Could you identify three conditions where the heart rate may be high?

4. Could you identify three conditions where the heart rate may be low?

5. Could you explain the complications of tachycardia (at least two)?

6. Could you explain the complications of bradycardia (at least two)?

7. Could you explain when you would report an abnormal finding?

8. Could you tell me the normal respiratory rate (range)?

9. Could you describe the normal depth and rhythm of respiration?

10. Could you identify three conditions where the respiratory rate may be high?

11. Could you identify three conditions where the respiratory rate may be low?

12. Can you tell me normal oxygen saturation value?

13. When would you start saturation monitoring in practice?

14. Could you describe three situations when oxygen saturation may be abnormal?

15. Could you state three potential sources of error with oxygen saturation recording?

16. Could you explain when you would report abnormal findings?

17. Could you tell me the range for normal temperature?

18. Could you describe which sites can be used for temperature measurement and
contraindications for each site?

19. Could you identify three conditions where the temperature may be high?

20. Could you identify three conditions where the temperature may be low?

21. Can you describe two complications of pyrexia?

22. Can you describe two complications of hypothermia?

23. Explain when you would report an abnormal finding?

Answers are provided at the end of the chapter.

Common errors at this station

A number of errors occur at this station; these include failure to:

• Wash hands and decontaminate equipment prior to taking the observations,

• Place their fingers on the radial pulse site when taking the patient’s pulse rate,

• Assess the strength and rhythm of the pulse as well as the rate,

• Use appropriate thermometer for type of patient,

• Ensure mode of tympanic thermometer is set correctly,

• Leave the thermometer in situ for the recommended time,

• Correctly position the pulse oximeter probe,

• Maintain communication with the patient throughout the OSCE,

• Document findings,
 • Practise the correct technique before the OSCE.

Top tips for passing this station

Ensure that you understand and follow any local guidelines and policies that relate to your OSCE.

• Make the most of any opportunities provided for practising the OSCE skills; this may be
offered in clinical practice settings, as well as by the university lecturing team.

• Come to the OSCE dressed in appropriate uniform as per local guidelines.

• Maintain a professional attitude towards the ‘patient’ and the OSCE assessor.

• It is expected that you maintain communication with the ‘patient’ and assessor
throughout the OSCE, including gaining consent, giving reassurance and providing an
explanation of the readings obtained. Simply stating that an obtained result is fine does
not demonstrate the required level of understanding the assessor is expecting to see.

• Ensure that the ‘patient’s’ comfort is confirmed and maintained both during and after
completion of the skill. You should provide an opportunity for the ‘patient’ to state if they
found the assessment uncomfortable or too invasive.

• Always choose the equipment you are most familiar with.

• Try not to panic and keep calm.

• Remember, although the OSCE assessment is timed, you are permitted to reassess any
one or more of the observations within the allotted time. This will allow you to confirm or
retrieve any observations you may have experienced difficulty obtaining.

• It is good practice to always document each result as you go along; this will ensure that
your documentation is accurate.

Please bear in mind, demonstrating ability to complete these skills is not just to enable you to pass
the OSCE, but is a professional requirement as a practising registered nurse (NMC 2008).
Therefore you will be expected to maintain the skills and associated knowledge throughout your
nursing career.

Online resource centre

You can find further advice and revision help for your OSCEs by going online now to see
www.oxfordtextbooks.co.uk/orc/caballero/.

References

 British Thoracic Society (2008). Guideline for Emergency Oxygen Use in Adult Patients.
London: British Thoracic Society.

Department of Health (2009). Competencies for Recognising and Responding to Acutely ill
Adults in Hospital. Draft guidelines for consultation. London: Department of Health,
HMSO.

Diggens, P. (2009). Vital Signs. In: Glasper, A., McEwing, G., Richardson, J. and Weaver M.
(eds) Foundation skills for caring, using student centred learning. London: Palgrave
MacMillan.

Marieb, E.N. and Hoehn, K. (2007). Human Anatomy and Physiology, 7th edn. San
Francisco: Pearson Education.

National Institute of Health and Clinical Excellence (2007). Acutely Ill Patients in Hospital:
Recognition of and Response to Acute Illness of Adults in Hospital. London: HMSO.

Nursing and Midwifery Council (2007). Essential Skills Clusters (ESCs) for Pre-
registration Nursing Programmes. London: Nursing and Midwifery Council.

National Patient Safety Agency (2007). Recognising and Responding Appropriately to

Early Signs of Deterioration in Hospitalized Patients. London: National Patient Safety
Agency.

Nursing and Midwifery Council (2008). The Code Standards of Conduct, Performance and
Ethics for Nurses and Midwives. London: Nursing and Midwifery Council.

Appendix: answers to examiners’ questions

1. Normal pulse range: 60–100 beats per minute (average 80 bpm).

• Bradycardia: 60 bpm,

• Tachycardia: > 100 bpm.

2. Sites for pulse palpation: where artery travels over bone

• Temporal,

• Carotid,

• Femoral,

• Popliteal,

• Posterior tibial,

• Brachial,

• Radial,

• Dorsalis pedis,
• Heart rate auscultation—apical/apex/apex-radial (atrial fibrillation).

3. Conditions where heart rate may be high:

• Anxiety/sympathetic nervous system response,

• Hyperthyroidism,

• Shock (include all types),

• Pyrexia,

• Vasodilation,

• Heart disease,

• Incompatible blood transfusion,

• Drug therapy,

• Fluid loss/dehydration,

• Pain.

4. Conditions where heart rate may be low:

• Drugs—beta blockers,

• Drugs, e.g. digoxin, amiodorone,

• Athletes/physically fit,

• Asleep,

• Myxoedema,

• Cardiac conduction problems,

• Heart disease,

• Cerebral bleeds (raised ICP).

5. Complications of tachycardia:

• Reduced blood pressure as cardiac output reduced with reduced ventricular filling time,

• Angina,

• Myocardial infarction,

• Syncope (fainting),

• Increased O2 requirement (increased respiratory rate).

6. Complications of bradycardia:

• Reduced blood pressure as cardiac output = respiratory heart rate × stroke volume,

• Dizziness,

• Fainting.

7. Report when:

• Overtly changed from baseline or patient’s normal values,

• > 100 bpm,

• 60 bpm,

• Irregular/thready,
• Patient unwell.

8. Normal respiratory rates (range): Male adult 14–18 breaths per minute, female adult
16–20 breaths per minute.

9. Depth: Tidal volume is approximately 500 ml/breath; use of spirometer to measure.

Rhythm: Regular disorders in respiratory pattern often found in respiratory control centre
disorders. Hyperventilation: increased rate and depth (exertion/fear/anxiety/fever/hepatic
coma/midbrain and brainstem lesions/acid-base balance disturbance, e.g. diabetic
ketoacidosis (DKA) or salicylate overdose—Kussmaul’s respirations).

> 20 bpm moderate, > 30 bpm severe

Apneustic respirations = prolonged, gasping inspiration with short inefficient expiration

(pons lesions).

Cheyne-Stokes = periodic breathing

Also, postoperative respirations/opiates/critically ill.

10. High respiratory rate: tachypnoea:

• Extreme exertion,

• Fear and anxiety,

• Fever,

• Hepatic coma,

• Brainstem lesions,

• Acid-base balance disturbances, e.g. DKA/salicylate overdose,

• Alteration in blood gas concentrations,

• Sepsis,

• Chest or heart diseases in which pCO2 rises or which cause hypoxia, e.g. COPD or
pulmonary oedema.

11. Low respiratory rate: bradypnoea:

• Respiratory depressants (drugs/opiates/anaesthesia),

• Alcohol,

• Sedation,

• Brainstem lesions,

• Head injury,

• End of life (Cheyne-Stokes).

12. Normal oxygen saturation:

• ≥ 94% and above, but seen in light of patient’s medical history (e.g. COPD (Chronic
obstructive pulmonary disease), respiratory history).

13. Indications for measuring oxygen saturation:

• Monitoring oxygen therapy received,

• During sedation/anaesthesia/mechanical ventilation,

• Transport of the unwell patient/critically ill patient,

• Haemodynamic instability: MI(myocardial infarction)/cardiac failure,

• Assessment of respiratory illness/monitoring of same: COPD/asthma/bronchiectasis etc.

• Any concerns over respiratory function or condition of the patient,

• Monitoring during administration of respiratory depressant drugs, e.g. opiate

epidurals/PCA (patient controlled analgesia),

• Patient acutely unwell.

14. Situations when oxygen saturations may be abnormal:

• Respiratory depression—drugs/head trauma/brainstem lesions,

• Airways disease—asthma/bronchiectasis/COPD,

• Acute changes in patient’s condition: ill patient/sepsis,

• Overdoses/anaesthetics/sedatives,

• Carbon monoxide inhalation,

• Hypoventilation,

• Neuromuscular weakness, e.g. GBS (Gullian-Barre Syndrome), myasthenia gravis, etc.

15. Sources of error:

• Nail varnish,

• Dirt,

• Foreign objects,

• Bright or fluorescent room lighting,

• Inappropriate probe, e.g. finger probe used on earlobe,

• Movement—rigors/shivering,

• Peripherally cold patient,

• Peripheral vascular disease,

• Low Hb.

16. Report:

• Any concern about patient’s condition,

• Saturations which vary from patient’s normal values.

17. Normal temperature range: 36–37°C (36–37.5°C in some texts).

18. Usual sites for temperature measurement:

• Oral/p.o. (contraindications: confused patient/ingestion of hot or cold fluid or food, oral

surgery/mouth injuries/general anaesthesia),

• Rectal/p.r. (contraindications: rectal ulceration/perforation/soft stool/closed rectum),

• Axillary (contraindications: thin patient/confused patient),

• Tympanic (contraindications: positioning/hearing aids/tympanic membrane

perforation/ear infection/ear wax).

19. Conditions where the temperature may be high: pyrexia/hyperthermia

• Blood transfusion/blood products reaction,

• Fever due to sepsis/infection/inflammation,

• Hot environment: heat stroke/central heating/too many covers,

• Neurological disturbance, e.g. damage to hypothalamus,

• Post trauma,

• Hyperthyroidism.

20. Conditions where the temperature may be low: hypothermia

• Exposure/uncovered patient/damp patient,

• Post surgery/general anaesthesia/cardiac surgery/neurosurgery,

• Liver failure,

• Hypothyroidism,

• Cold infusions.

21. Complications of pyrexia:

• Increased metabolic rate,

• Increased oxygen requirements,

• Seizures in children,

• Discomfort,

• Excess fluid loss (sweating),

• Catabolic state.

22. Care includes:

• Treat underlying condition (e.g. antibiotics for infection),

• Antipyretics,

• Tepid sponging,

• Reducing environmental temperature,

• Increasing nutrition if required,

• Fanning may be mentioned,

• Taking blankets off etc.

23. Complications of hypothermia:

• Dysfunction of all organs especially central nervous and cardiovascular systems,

• Listlessness,

• Confusion,

• Cardiac output initially rises with shivering, but then falls,

• 28°C—spontaneous ventricular fibrillation,

• Metabolism with falling temperature: increased blood glucose and increased potassium,

• Kidneys cool—causes renal diuresis—hypovolaemia.

24. Care includes:

• Passive warming: insulating blankets, hats,

• Active warming: Bair Huggers,

• Increasing environmental temperature,

• Warming fluids,

25. Report any concern with temperature variation from patient’s norm

• Temperature > 37.5°C,

• Temperature 36°C.


Chapter 8
Measuring blood pressure

Kate Devis

Chapter aims

This chapter will enable you to:

• Revise key material relating to this skill,

• Follow a step by step guide to taking blood pressure readings both manually and
electronically,

• Understand how to prepare and revise for this OSCE,

• Highlight common problems at this station and how they may be avoided.

Introduction

Blood pressure measurements are one part of a circulatory assessment (Docherty and McCallum
2009). Treatments for raised or low blood pressure may be initiated or altered according to blood
pressure readings; therefore correct measurement and interpretation of blood pressure is an
important nursing skill.

Blood pressure should be determined using a standardized technique in order to avoid

discrepancies in measurement (Torrance and Serginson 1996).

Both manual and automated sphygmomanometers may be used to monitor blood pressure. The
manual auscultatory method of taking blood pressure is considered the gold standard (MRHA
2006), as automated monitoring can give false readings (Coe and Houghton 2002), and automated
devices produced by different manufacturers may not give consistent figures (MRHA 2006). So,
although automated sphygmomanometers are in common use within health care settings in the UK,
the skill of taking blood pressure measurement manually is still required by nurses.

As a fundamental nursing skill, blood pressure measurement, using manual and automated
sphygmomanometers, and interpretation of findings are often assessed via an OSCE.

Within this chapter revision of key areas will allow you to prepare thoroughly for your OSCE, in
terms of practical skill and understanding of the procedure of taking blood pressure.

Key revision for your simulated examination

Systolic and diastolic values

Blood pressure is defined as the force exerted by blood against the walls of the vessels in which it is
contained (Docherty and McCallum 2009). A blood pressure measurement uses two figures—the
systolic and diastolic readings. The systolic reading is always the higher figure and represents the
maximum pressure of blood against the artery wall during ventricular contraction. The diastolic
reading represents the minimum pressure of the blood against the wall of the artery between
ventricular contractions (Doughetry and Lister 2008). You will need to be able to accurately identify
systolic and diastolic measurements during your OSCE.

Korotkoff’s sounds

When a blood pressure cuff is applied to the upper arm and inflated above the level of systolic blood
pressure no sounds will be detected when listening to the brachial artery with a stethoscope. The
cuff clamps off blood supply. As the cuff is deflated a noise, which is usually a tapping sound, will be
heard as the pressure equals the systolic blood pressure—this is the first Korotkoff’s sound. It is
important to listen carefully and note the reading on the sphygmomanometer when the first
Korotkoff’s sound is heard to ensure an accurate systolic reading.

As the cuff pressure is further released additional Korotkoff’s sounds will be heard via the
stethoscope, which are the noise of blood turbulence within the brachial artery (see Box 8.1). The
sounds may be described as swishing and eventually become quite muffled. At the point when the
sounds disappear completely the reading taken is the diastolic blood pressure. At this point the cuff
no longer causes any resistance to blood flow. The Korotkoff’s sound quality and type will not be
identical for every person, which can be challenging for those learning how to measure blood
pressure.

Recognition of hypotension and hypertension

Interpreting blood pressure measurements involves an understanding of normal values. In adults

normal systolic blood pressure is within the range 100 to 139 millimetres of mercury (mmHg), and
normal diastolic is between 60 and 90 mmHg (NICE/British Hypertensive Society 2006). It is
important to be able to recognize any abnormalities in the blood pressure readings taken which are
outside these ranges. There is no single normal blood pressure reading so it is important to
compare findings with an individual’s normal or baseline readings, to detect change or stability.

Hypertension, or high blood pressure, may be chronic or acute. NICE/British Hypertensive

Society (2006) state that a constantly raised blood pressure above 140/90 mmHg is considered
hypertension, and ongoing measurements of 160/100 mmHg require antihypertensive medications.
Acute hypertension usually resolves once the cause has been addressed, e.g. this could be physical
activity or anxiety.

Box 8.1 The five phases of Korotkoff’s sounds

1. Faint but clear tapping sounds which increase gradually in intensity,

2. Softening of sounds which may become swishing,

3. The return of sharper sounds,

4. The distinct and abrupt muffling of sounds which become softer,

5. The point at which all sounds disappear.

Beevers et al. (2001)

Hypotension, or low blood pressure, is usually considered a symptom rather than a disease.
Hypotension can be dangerous, particularly if diastolic pressure levels fall very low as then core
body organs will not be well perfused with blood.

During the OSCE you will need to identify if the blood pressure measurements you take are normal,
or if they indicate hypertension or hypotension.

Factors affecting blood pressure

A client’s actual blood pressure, and therefore the reading taken, is affected by many factors. Some
of these influences can be offset by a nurse’s actions when taking non-urgent blood pressure
measurements.

During an OSCE, as in practice, students should speak with the client and observe for signs of
anxiety in recognition of ‘white coat hypertension’ (MRHA 2006). Speaking with the client and
offering reassurance can help them relax. Nurses should also check if the client has been resting
and if they are comfortable before taking measurements, as both exercise and pain can increase
blood pressure (Tortora and Derrickson 2007). The client’s physical position also influences blood
pressure so nurses should check if previous measurements were taken in a lying or sitting position.
Readings are lower when a client is seated (Neata et al. 2003).

Inaccuracies in measuring blood pressure

Inaccurate measurement of blood pressure has been attributed to several factors (a full list may be
found in Box 8.2). Human error accounts for many inaccuracies so nurses should be aware of these
factors in order to avoid them. Student nurses can perceive OSCE assessments as stressful and may
consequently feel they will make a mistake, but practice and concentration can help minimize
human error.

Box 8.2 Reasons for inaccurate blood pressure measurement

• Human (nurse) error:

Incorrect reading of the sphygmomanometer—unfamiliar with device,

Position of nurse when taking readings—unable to view manometer easily,

Lack of concentration,

Hearing problems,

Failure to interpret Korotkoff’s sounds accurately,

Rounding off readings, e.g. commonly to zero, should not be done (e.g. 132/68 recorded as
 130/70),

Observer prejudice, e.g. recording lower than measured figure for a young adult patient,

Failing to palpate for estimated blood pressure.

• Inappropriate cuff size for the client,

• Faulty or inadequately maintained equipment, e.g. leaking tubes or valves,

• Noisy workplace.

Alexis (2010); Beevers et al. (2001); MRHA (2006)

Putting it all together!

You may be given a choice of manual or automated sphygmomanometer to use when measuring
blood pressure, or you may be advised which device to use. Listen carefully to the information you
are given by the examiner as an introduction to the assessment. An automated adult skills model or
an actor may be used to represent a client—in both situations the examiner will check the readings
you take.

Ensure you use infection prevention strategies throughout the assessment. After you have received
an introduction to the scenario remember to use appropriate hand hygiene before approaching the
client. You should also clean equipment before use, particularly areas that may come into contact
with the client including diaphragm and earpieces of the stethoscope and sphygmomanometer cuff.
Alcohol/chlorhexadine wipes can be used to clean equipment as per local guidelines.

Step by step

Communication

• Consider the client’s privacy.

• Explain the need to measure the client’s blood pressure with him/her, discuss the
procedure and check if consent is given.

• Ascertain how long the client has been resting in their current position. If the client has
 just been mobilizing or changed position advise the examiner and client that you will wait
for 3 minutes before taking a reading.

• Check if any prior blood pressure measurements have been taken, and if so whether the
client was seated or lying and which arm was used.

• Observe for any indicators which will allow you to determine which arm to use to take
blood pressure measurements, e.g. the client may have an intravenous infusion running
into one arm, or one arm may be oedematous or injured—so you would select the
unaffected arm.

• Remember to continue to explain what you are doing to the client as you carry out the
procedure.

Manual blood pressure measurement

Equipment

• Collect a stethoscope, sphygmomanometer with appropriate sized cuff and observation

chart to ensure you are prepared properly.

• Check when the sphygmomanometer was last serviced and calibrated.

• Check the stethoscope chest piece is turned to amplify the diaphragm (plastic disc)
rather than the bell side, and turn the earpieces so they fit comfortably. Position the
stethoscope in your ears so that earpieces tilt forward. It is recommended that ‘sounds are
heard more clearly when the attachments follow the direction of the ear canal’ (Kozier et
al. 2008: 366).

Procedure

• Check that tight clothing is not constricting the client’s arm.

• Apply the blood pressure cuff smoothly and firmly to the client’s upper arm above the
level of the brachial artery and in direct contact with skin.

• Check that the cuff bladder covers 80% of the arm circumference and that the cuff is
aligned with the brachial artery, using the symbols or information on the cuff (sometimes
an arrow; see Fig. 8.1a).

• The cuff should be positioned 2–3 cm above the antecubital fossa.

• Ask the client to rest their arm at heart level, and support their arm with a pillow if
necessary.

• Palpate a radial pulse and inflate the cuff until this pulse can no longer be felt (see Fig.
8.1b).

• Empty the cuff of air and allow the client to rest for a minimum of 30 seconds.

• Palpate for the brachial pulse (see Fig. 8.1c) and place the diaphragm of the
stethoscope directly where the brachial pulse was palpated. The stethoscope should not
be tucked under the cuff.

• Inflate the cuff to 30 mmHg above the radial pulse reading for systolic pressure
(Dougherty and Lister 2008).

• Deflate the cuff slowly at a rate of 2 mmHg per second whilst listening for Korotkoff’s
sounds (see Fig. 8.1d).

• Take care to avoid leaving the cuff inflated for prolonged periods as this will cause
significant discomfort to your patient.

• Note the systolic and diastolic blood pressures and then completely deflate the cuff.

• If you have not heard either or both pressures correctly then allow the patient to rest for
3 minutes and repeat the procedure.
Post procedure

• Ensure the client is left in a comfortable position and offer them information on your
findings.

• Clean equipment as appropriate, and then wash your hands.

• Record your measurements by documenting accurately on the observation chart and be

prepared to discuss interpretation of findings with the examiner.

• You should look for any baseline reading with which to compare your measurement.

Figure. 8.1a Fitting the cuff bladder

Figure 8.1b Palpate the radial pulse

Figure 8.1c Palpate the brachial pulse

Automated blood pressure measurement: step by step guide

Equipment

• Collect an automated sphygmomanometer.

• Check when it was last serviced and calibrated.

• If necessary change the cuff to one of an appropriate size for the client you have been
asked to assess.

• Ensure you also have an observation chart to record your findings.

Figure 8.1d Listen for Korotkoff’s sounds

Procedure

• Check pulse rhythm at the radial artery. If arrhythmias are present inform the examiner
as this can cause an inaccurate reading when using an automated sphygmomanometer.

• Switch the sphygmomanometer on and check the display panel illuminates.

• Ask the client to rest their arm at heart level, and support with a pillow if appropriate.

• Apply cuff smoothly and firmly to the client’s upper arm so it fits snugly above the level
of the brachial artery and is in direct contact with skin. Some automated devices require
positioning of the cuff bladder over the brachial artery so ensure cuff is correctly in place.

• Advise the patient to keep still whilst the machine is working.

• Press the button to inflate the cuff.

• Once the device has taken the reading note systolic and diastolic pressures.
 • If a repeat reading is required wait at least 1 minute before re-inflating the cuff.

Post procedure

• Remove the cuff promptly and ensure the client is left feeling comfortable.

• Offer the client information on your findings.

• Clean equipment as appropriate, ensure automated device is left plugged in to charge,

and then wash your hands.

• Record your measurements accurately on the observation chart and be prepared to

discuss interpretation of findings with the examiner.

• You should look for any baseline reading with which to compare your measurement.

Recording blood pressure measurements

• The systolic and diastolic pressures should be recorded as a double-ended arrow on the
appropriate section of the observation chart.

• It is not necessary to add the figures, as the points of each arrow will indicate them. In
addition, using only arrows allows trends in blood pressure to be easily visualized.

Examiners’ marking criteria

Table 8.1 Example of examiners’ marking criteria

Examiners’ questions

You may be asked questions to assess your knowledge underpinning blood pressure measurement.
Possible questions are provided in Box 8.3.

Box 8.3 Example of examiners’ questions

 1. What is the normal range for blood pressure in adults?

2. What does systolic pressure represent?

3. What does diastolic pressure represent?

4. Can you identify three conditions where the blood pressure may be high?

5. Can you identify three conditions where the blood pressure may be low?

6. What are two of the complications of hypotension?

7. What are two of the complications of hypertension?

8. Explain when you would report an abnormal finding.

9. How do you decide which cuff is the correct size for this patient?

10. How do you decide where to place the cuff?

Answers are provided at the end of the chapter.

Common errors at this station

As measuring blood pressure involves a number of important steps, and measurement using a
manual sphygmomanometer involves technical skill, there are numerous possible problems that
students may experience. The following section provides extra tips, but these are some of the
common mistakes students may make:

• Not cleaning hands before approaching the client,

• Forgetting to estimate the systolic pressure using radial pulse occlusion, before listening
for blood pressure,

• Not cleaning equipment before and after using with the client,

• Not fitting cuff snugly enough or placing it too low on the client’s arm,

• Forgetting to palpate the brachial artery,

• Not knowing the anatomical position of brachial artery,

• Putting the stethoscope in wrong position,

• Not identifying Korotkoff’s sounds correctly and so making inaccurate readings,

• Falsifying readings as cannot hear Korotkoff’s sounds adequately,

• Not taking client’s comfort into account, e.g. leaving their arm suspended in mid-air,

• Leaving the cuff inflated for far too long, so that, e.g., the client’s fingers begin to turn
blue,

• Not using hand hygiene after patient contact,

• Not documenting results accurately,

• Stethoscope not placed correctly in ears,

• Misreading the figures on the dial—some are marked in single digits and some in twos.

Top tips for passing this station

These are some suggestions to help you prepare and pass this station, based on experience
assessing students taking blood pressure measurements during OSCE.

• It can be difficult to remember the client when you are trying hard to remember the
procedure, but do speak to the client when you are taking blood pressure measurements
and check their comfort.

• Make sure you position the cuff high enough up the client’s upper arm, so that it will not
cover the diaphragm of the stethoscope when in position.

• It is not possible to hear Korotkoff’s sounds, and therefore blood pressure, if the
stethoscope is not correctly located. Always palpate for brachial pulse before placing the
diaphragm of the stethoscope in position.

• Use your dominant hand for pumping up and deflating the cuff—this will allow you more
control so you can deflate the cuff steadily.

• Do not deflate the cuff too quickly—a steady pace of 2 mmHg a second will allow you to
take accurate readings.

• If you have not been able to hear the Korotkoff’s sounds or you are unsure about the
readings, advise the client and the examiner that you will need to retake the blood
pressure measurements. For safety reasons it is always best to be honest if you are
unsure. If you are confident you have accurately estimated the systolic blood pressure
using radial pulse occlusion you will not need to repeat this step.

• Infection prevention is important—remember to clean your hands and your equipment

before and after use.

Online resource centre

You can find further advice and revision help for your OSCEs including a video of measuring blood
pressure by going online now to see www.oxfordtextbooks.co.uk/orc/caballero/.

References

Alexsis, O. (2010). Providing best practice in manual blood pressure measurement. British
Journal of Nursing, 18(7): 410–415.

Beevers, G. et al. (2001). Blood pressure measurement. British Medical Journal, 322:
1043–1047.

Coe, T. and Houghton, K. (2002). Comparison of the automated Dinamap blood pressure
monitor with the mercury sphygmomanometer for detecting hypertension in the day case
pre-assessment clinic. Journal of Ambulatory Surgery, 10: 9–15.

Docherty, C. and McCallum, J. (eds) (2009). Foundation Clinical Nursing Skills. Oxford:
Oxford University Press.
 Dougherty, L. and Lister, L. (2008). The Royal Marsden Manual of Clinical Nursing
Procedures, 7th edn. Chichester: John Wiley & Sons.

Kozier, B., Erb, G., Berman, A., Snyder, S., Lake, R. and Harvey, S. (2008). Fundamentals
of nursing, concepts, process and practice. Harlow: Pearson Education.

MRHA (2006). Device Bulletin—Blood Pressure Measurement Devices DB2006(03)

[Published online].
http://www.mhra.gov.uk/Publications/Safetyguidance/DeviceBulletins/CON2024245.

Neata, R. et al. (2003). Both arm and body position significantly influence blood pressure
measurement. Journal of Human Hypertension,17: 459–462.

NICE/British Hypertensive Society (2006). NICE Clinical Guideline 34. Hypertension:

management of hypertension in adults in primary care [Published online].
http://www.nice.org.uk/nicemedia/live/10986/30114/30114.pdf.

Torrance, C. and Serginson, E. (1996). Student nurses’ knowledge in relation to blood

pressure measurement by sphygmomanometery and auscultation. Nurse Education Today,
16: 397–402.

Tortora, G. and Derrickson, B. (2007). Principles of Anatomy and Physiology 12th edn.
New York: John Wiley & Sons.

Appendix: answers to examiners’ questions

1. What is the normal range for blood pressure in adults?

100/60 mmHg–140/90 mmHg

Hypertension: systolic blood pressure ≥ 140 mmHg and diastolic blood pressure > 90
mmHg

Hypotension: systolic blood pressure 100 mmHg

2. What does systolic blood pressure represent?

It is the peak pressure of blood against arterial walls caused by ventricular contraction.

3. What does diastolic blood pressure represent?

It is the minimum pressure of blood against arterial walls following closure of aortic valve.

4. Can you identify three conditions where the blood pressure may be high?

Select from:

• Arteriosclerosis,

• Familial hypertension,

• Stress/anxiety/sympathetic nervous system response,

• Thyrotoxicosis,

• Fever,

• Physical exertion,

• Obesity,

• Retention of sodium and water,

• Increased fluid volume,

• Vasoconstriction,

• Pregnancy,

• Renal problems,

• Cerebral haemorrhage,

• Pain,

• High caffeine intake,

• History of smoking.

5. Can you identify three conditions where the blood pressure may be low?

Select from:

• Postural hypotension,

• Shock—including cardiogenic/septic/hypovolaemic/anaphylaxis/toxic shock syndrome,

• Fluid/plasma loss—vomiting/diarrhoea/dehydration/burns,

• Cardiac drugs—antihypertensives, beta blockers, ace inhibitors,

• Opiate drugs,

• Spinal blockade/epidural,

• Bradycardia,

• Tachycardia,

• Cardiac damage,

• Vasodilatation.

6. What are two of the complications of hypotension?

These include:

• Reduced tissue/organ perfusion,

• Reduced mean arterial pressure (MAP),

• Fainting/syncope/light-headedness/pallor/pre-renal failure,

• Decreased urine output.

7. What are two of the complications of hypertension?

These include:

• Renal damage,

• Headaches,

• Visual disturbance,
• Vessel damage,

• Myocardial infarction,

• Cerebrovascular accident,

• Embolism,

• Aneurysms.

8. Explain when you would report an abnormal finding.

Report when one or more of the following occur:

• Deviation from normal values for patient,

• When indicated by MEWS or observations,

• Any concern about the patient,

• If the patient appears unwell.

9. The cuff should be able to cover 80% of the circumference of the upper arm.

10. Assess whether any of the limbs are inappropriate for the recording of blood pressure
(such as intravenous infusion site).

• Place the cuff 2–3 cm above the antecubital fossa,

• Ensure that the cuff is aligned with the brachial artery, using the symbols or information
on the cuff (sometimes an arrow).


Chapter 9
Urinalysis

Jane Lovegrove

Chapter aims

This chapter will enable you to:

• Revise key material relating to this skill,

• Follow a step by step guide to performing both macroscopic and chemical analysis,

• Understand how to prepare and revise for this OSCE,

• Highlight common problems at this station and how they may be avoided.

Introduction

Urinalysis simply means analysis of urine. It is an easily performed investigation that can detect a
wide variety of abnormalities within a few minutes at low cost. Urinalysis is an investigation which
all nurses should be competent to perform and is identified by the NMC (2007) as being an example
of an essential skill nurse students should be competent to perform before entering their branch
programme.

Urinalysis may be performed in a wide variety of clinical settings. It should be performed on every
patient entering the acute care setting. Additionally, the National Confidential Enquiry into Patient
Outcome and Death (NCEPOD (2009), stresses the need for urinalysis to be performed on all
emergency admissions to an acute hospital. It may also be performed in outpatient and general
practice clinics, and community areas.
To obtain the most accurate information from the test, students need to know how to obtain and
assess a sample of urine and be aware of factors that may influence the reliability of the
investigation.

Key revision for your simulated examination

Urine may be tested in three different ways:

• Macroscopic urinalysis,

• Microscopic urinalysis,

• Chemical analysis.

Macroscopic and chemical analysis are the investigations performed in the clinical setting which
may be tested by OSCE. Microscopic investigation requires samples to be sent to a laboratory.
Macroscopic analysis is the analysis of the urine by the naked eye. Chemical analysis may be
performed by use of a plastic diagnostic reagent strip or ‘dipstick’ which contains small pads of
chemicals which react to substances that may be found in urine.

Obtaining a sample of urine

For purposes of testing urine at random, clients are asked to urinate into a clean but not sterile dry
container with no precautions regarding contamination. In females in particular this may result in
samples being contaminated by vaginal fluids, such as blood or mucus. Due to the risk of
contamination a mid-stream specimen of urine may be required if an abnormality is found in a
random sample. A mid-stream specimen requires cleaning of the external urethral meatus prior to
urination, passing the first half of the bladder contents into the lavatory, and passing the second
part of the urine flow into a sterile container. The second half of the urine flow is then used for
analysis. This method is also used to obtain a sample for microscopic analysis in the laboratory.
Having obtained the sample it should be tested as soon as possible, and within 2 hours of obtaining
the sample (Siemens Healthcare Diagnostics 2008).

Macroscopic urinalysis

The appearance of urine is examined by visual inspection. Normal urine is pale to dark yellow in
colour and clear. Any cloudiness or debris in the urine should be noted together with any change in
colour. Cloudiness may be caused by cell debris, or may be due to infection. Red brown urine may
be caused by eating beetroot, drugs or the presence of red blood cells, haemoglobin or myoglobin, a
pigment found in muscle. Very yellow/orange urine may be due to the presence of urobilinogen or
drugs such as Rifampicin. Changes in urine colour need to be reported as some causes may result in
damage to tissue. Haemaoglobin and myoglobin may block renal tubules. Infected urine may smell
of fish. Urine that has stood for some time may smell of ammonia. Normally urine should not smell.

Chemical analysis

Routine chemical analysis may be performed with the use of a diagnostic reagent strip of a variety
of substances, the range of which varies according to which type of strip is selected. The most
commonly used tests are listed here:

• pH,

• Specific gravity,
 • Protein,

• Glucose,

• Ketones,

• Blood haemolysed and non-haemolysed,

• Nitrates,

• Urobilinogen,

• Bilirubin.

pH

Normal range—4.5 to 8.0

The pH scale measures the hydrogen ion concentration. Urine pH is normally found to range from
7.4 to 6; however, depending on the acid base status, urinary pH may range from as low as 4.5 acid
urine, to 8.0 alkali urine. The pH of the blood should be 7.35—7.45; to maintain this, the kidneys in
health are able to excrete excess acid or alkali ingested or created, which then appears in the urine.

Specific gravity

Normal range—1.001 to 1.035

Specific gravity measures urine density, that is the concentration of solute within the urine. Low
specific gravity indicates dilute urine with low solute concentrations. This may be as a result of use
of diuretics, but may indicate renal impairment or diabetes insipidus. High specific gravity indicates
concentrated urine usually due to dehydration, but may indicate high levels of glucose or presence
of other contaminants.

Glucose

Normal range—negative

Urine should not contain glucose. While glucose does pass through the glomerulus it should all be
reabsorbed in the proximal convoluted tubule. However, glucose will appear in urine if the blood
glucose level rises.

Protein

Normal range—negative

Urine should not normally contain protein. Small amounts of protein may be filtered by the
glomerulus but all should be reabsorbed by the renal tubules. Protein may be found due to
contamination of urine by mucus. Protein may also be due to infection, presence of blood or
glomerular damage. If protein is found when testing a random sample, a mid-stream specimen
should be requested; if this is also positive to protein further investigation is required.

Blood—non-haemolysed

Normal range—negative

Normally no blood is detectable in urine. Normal red blood cells are too large to pass through the
glomerulus. If non-haemolysed blood is present in urine it may have entered the urinary tract after
the glomerulus as a result of urinary stones or trauma of the urinary tract. Other causes are
glomerular damage or kidney trauma. Red blood cells may also contaminate urine from the vagina
in menstruating women.

Blood—haemolysed

Normal value—negative

As previously stated normal red blood cells are too large to pass through the glomerulus. However,
haemoglobin may be released from red blood cells when damaged as free haemoglobin and this may
pass through the glomerulus and enter the urine. Urine positive to haemolysed blood requires
further investigation.

Bilirubin

Normal value—negative

Bilirubin is formed from the breakdown of haemoglobin. Excess bilirubin may be formed due to
excessive breakdown of red cells, e.g. following large blood transfusion. High blood levels of
bilirubin may also occur as a result of liver disease or bile duct obstruction. Reagent strips measure
conjugated bilirubin. Conjugated bilirubin is water soluble bilirubin which is normally excreted into
the bowel and converted to urobilinogen by intestinal bacteria, giving faeces their brown colour.
Bilirubin in the urine is abnormal and may indicate liver disease or biliary disease.

Urobilinogen

Normal range—trace

Urobilinogen is formed in the gut by breakdown of conjugated bilirubin by intestinal bacteria.

Urobilinogen is normally excreted in faeces but small amounts may be reabsorbed and excreted in
urine. Small amounts of urobilinogen are normally present in urine.

Large amounts of urobilinogen may occur in hepatic disease or excessive breakdown of red blood
cells.

Ketones

Normal value—negative

Ketones which comprise acetone, acetoacetic acid and beta-hydroxybutyric acid are produced from
the burning of fat to produce energy. Ketones may be present in urine resulting from diabetes
mellitus or starvation. If ketones are found then blood glucose should also be tested.

Nitrite

Normal value—negative

A positive nitrite test indicates bacteria may be present in the urine in significant numbers. Nitrite
is created by the conversion of nitrate from the diet to nitrite by Gram negative bacteria. Where
urine is positive to nitrite, a mid-stream specimen of urine should be sent to the laboratory for
culture and sensitivity.

Leucocytes

Normal range—negative

A positive result test results from the presence of white blood cells which may be whole white cells
or lysed white cells. A positive test indicates infection and requires further investigation using a
midstream specimen of urine. A negative test indicates that infection is unlikely and that without
further evidence of infection there is no requirement for further investigation.
Putting it all together!

An overview of urinalysis procedure can be seen in Box 9.1.

Box 9.1 Putting it all together!

1. Urine is a body fluid and universal precautions should be taken. Put on a plastic apron
and clean gloves (see Fig. 9.1a).

2. Collect a fresh urine sample—note for the purpose of OSCEs samples are generally
provided (see Fig. 9.1b).

3. Check expiry dates of diagnostic reagent strips (see Fig. 9.1c).

4. Dip all the test pads of the reagent strip into the urine and remove immediately (see
Fig. 9.1d).

5. Drag the edge of the strip against the container rim to remove excess urine (see Fig.
9.1e).

6. Read each pad at the designated time shown on the side of the bottle containing the
reagent strips (see Fig. 9.1f).

7. Dispose of reagent strip in appropriate waste bin.

8. Remove gloves and record results (see Fig. 9.1g).

9. Remove apron (see Fig. 9.1h).

10. Wash hands using soap and water (see Fig. 9.1i)
 Figure 9.1a Put on plastic apron and gloves

Figure 9.1b Collect fresh urine sample

Figure 9.1c Check expiry dates on diagnostic reagent strips

 Figure 9.1d Dip test pads into urine

Figure 9.1e Remove excess urine

Figure 9.1f Read each pad against the side of the bottle
 Figure 9.1g Record results

Figure 9.1h Remove apron

Figure 9.1i Wash hands using soap and water

Examiners’ marking criteria

Various tools will be utilized to assess your competence when performing urinalysis. As stated in
earlier chapters it is advisable to review your own university’s marking criteria. An example of
marking criteria is included in Table 9.1.

Table 9.1 Example of examiners’ marking criteria

Examiners’ questions

You may be asked questions to assess your knowledge underpinning urinalysis. Possible questions
are outlined in Box 9.2.

Box 9.2 Example of examiners’ questions

1. Name three normal constituents of urine.

2. What is the pH range of normal urine?

3. What does specific gravity measure?

4. What is the normal range of specific gravity for urine?

5. What would a specific gravity of 1.003 indicate?

6. What would a specific gravity of 1.030 indicate?

7. If glucose is found in the urine what action should be taken?

 8. If ketones are found in the urine what action should be taken?

9. State two reasons why ketones may be found in urine.

10. What does the pH scale measure?

11. When may bilirubin be found in urine?

12. What is urobilinogen?

13. What does the presence of nitrites in the urine indicate?

14. What action should be taken if the test for leucocytes is positive?

15. What is the difference between non-haemolysed and haemolysed blood?

Answers are provided at the end of the chapter.

Common errors at this station

A number of errors can occur at this station and these include:

• Failure to wear an apron,

• Failure to check expiry date of reagent strips.

Very common errors include:

• Leaving the reagent strip in the urine too long,

• Failure to time readings of reagent pads,

• Contamination of watch by handling with gloved hand which previously held reagent
strip,

• Contamination of pen by handling with gloved hand,

• Failure to record pH and specific gravity,

• Forgetting results.

Top tips for passing this station

• Urine is a body fluid, so gloves and apron must be worn when performing urinalysis.

• A fresh sample of urine is required. Samples over 2 hours old should be discarded.

• Urinalysis reagent strips should be stored as directed by the manufacturer and not used
after the expiry date.

• Reagent strips should not be held in urine but removed immediately once pads are
covered in urine.

• Reagent strips should be held horizontally to prevent fluid from one pad running into
another.

• Reagent pads must be read at time specified.

• To avoid cross infection. watches and pens should not be handled with a gloved hand
that has held a reagent strip or reagent strip bottle.
 • A value must be entered when recording results for pH and specific gravity.

• Paper that has been placed on a sluice surface to record results should not be taken into
the clinical area.

Online resource centre

You can find further advice and revision help for your OSCEs by going online now to see
www.oxfordtextbooks.co.uk/orc/caballero/.

References

NCEPOD (2009) Adding Insult to Injury: A Review of the Care of Patients Who Died in
Hospital with a Primary Diagnosis of Acute Kidney Injury.. London: NCEPOD.

Nursing and Midwifery Council (2007). Essential Skills Clusters. London: Nursing and
Midwifery Council.

Siemens Healthcare Diagnostics (2008). Data sheet for diagnostics reagent strips for
urinalysis. Dcerfield, Ille Siemens.

Appendix: answers to examiners’ questions

1. Answer could include water, urea, creatinine and sodium potassium among others.

2. The range of pH is 4.6–8.0.

3. Specific gravity measures the density of the urine, the water to solute ratio.

4. The range of specific gravity for urine is 1.001 to 1.035.

5. A specific gravity of 1.003 indicates dilute urine; this may be due to excessive fluid
intake, diuretics or diabetes insipidus.
6. A specific gravity of 1.030 indicates concentrated urine. This may be due to
dehydration, reduced fluid intake, high glucose levels or contamination by substances
such as radio opaque dyes.

7. If glucose is found in the urine, blood glucose should also be taken.

8. If ketones are found in the urine, investigations should be made to establish whether
the person is in a state of starvation or has diabetes mellitus. Blood glucose should be
tested.

9. Ketones are found in urine due to the metabolism of fat to provide energy; this may be
due to starvation or diabetes mellitus.

10. The pH scale measures the hydrogen ion concentration, the degree of acidity or
alkalinity.

11. Bilirubin may be found in urine in liver disease.

12. Urobilinogen is derived from bilirubin which is converted to urobilinogen by bacteria

in the gut. Urobilinogen gives faeces their yellow brown colour.

13. Nitrite in the urine indicates the presence of bacteria. Nitrates derived from the diet
are converted into nitrite by the bacteria.

14. Leucocytes indicate the presence of whole or lysed white blood cells. Therefore a
specimen should be sent to the laboratory for testing.

15. Non-haemolysed blood is whole red blood cells; these are too large to pass through
the glomerulus in normal circumstances. Haemolysed blood is lysed red blood cells which
release their haemoglobin. Haemoglobin is small enough to pass through the glomerulus.


Chapter 10
Assessment of medication calculation skills

Terry Stubbings

Chapter aims

This chapter will enable you to:

• Revise key material relating to this skill,

• Understand how to prepare and revise for this OSCE by providing opportunities to
calculate medication.

Introduction

Accuracy with medication dosage calculation is key to safe practice for a nurse. However, errors are
not uncommon and seem to be increasing in frequency and some of them lead to harm or death to
patients (NPSA 2009).

The NMC (2010), in its essential skills clusters, requires baseline skills for calculating medicines,
nutrition and fluids. It also requires that, by completion of a nursing course, an individual will be
competent in the process of medication related calculation involving tablets and capsules, liquid
medicines, injections and IV infusions. Part of this competence is making judgements about what
calculations to use, how to do them, what degree of accuracy is appropriate and what the answer
means in relation to the context.

Passing an assessment of medication dosage calculation skills should be seen as only one aspect of
developing the competence to practise safely.

Your medication dosage calculation assessment



There are three possible approaches to assessment on nursing courses:

Practice based assessment

If this is how medication related calculation skills are assessed on your course, you should feel
confident that it has a high degree of validity (that is, the assessment is very real, since it is done in
a real clinical environment). However, the many variables in a clinical setting mean that the
assessment can be considered low in reliability (that is, that the same level of medication related
calculation skill would be assessed each time). If your course requires this sort of assessment,
ensure you find out exactly what is being assessed. Is the assessment just about calculation of
medication dosages, or are other aspects of medication administration also being tested (e.g.
assessment of patient prior to administration, interpersonal skills with patients, administration,
documentation)? Documentation of medication administered is very important in nursing practice,
so this aspect is likely to be included.

Objective structured clinical examination (OSCE)

If this is how medication related calculation skills are assessed on your course, you should feel
confident that it has a high degree of reliability (that is, assessment can be carried out in the same
way with each student) and the level of validity is quite high too (that is, it will be set up like a real
clinical environment).

If your course requires this sort of assessment, ensure you find out exactly what is being assessed.
Some universities include a medication dosage calculation element within an ALS or Trauma OSCE.
You need to be sure if the assessment is just about calculation of medication dosages, or are other
aspects of medication administration also being tested (e.g. interpersonal skills with a mock patient,
administration, documentation)?

A computer based assessment process

If this is how medication related calculation skills are assessed on your course, you should feel
confident that it has a high degree of reliability and validity (as shown by Hutton et al. 2010). Many
nursing courses utilize computer programs such as that supplied by Authentic World®. If your
course requires this sort of assessment, ensure you take opportunities to familiarize yourself with
the software, as well as practising calculation of medication dosages.

For any type of assessment you need to know whether calculators and/or written formulae and/or
paper and pen can be used during the assessment.

Don’t forget that clinical areas are ideal for practising medication dosage calculation since the
context in which calculations are performed contributes to accuracy (Jukes and Gilchrist 2006), so
practice in a wide range of clinical settings would be helpful.

The increasingly technological nature of nursing means that calculators are a useful tool to reduce
arithmetical errors, but if you rely on one, you must ensure that you know exactly what calculations
you are attempting, since many errors in nursing calculations are conceptual errors (Sabin 2001).

Key revision for your simulated examination

The metric system and SI units

In 1960 there was widespread international agreement to adopt a system of metric weights and
measures and British health care settings generally follow this Système International (SI).
Unfortunately the USA has not adopted such SI units and therefore they are not used in many
American textbooks.

The SI system is a metric system. When it comes to medication there are only two units that you
need to know: the unit of mass (weight) which is the gram (g) and the unit of volume which is the
litre (l).

Multiples of units or fractions of units are expressed through prefixes

You also need to know the prefix milli, which means one thousandth of and micro which means one
millionth of, i.e.

• 1 milligram (mg) is a thousandth of a gram (g). There are 1,000 milligrams in a gram.

• 1 microgram (sometimes abbreviated to mcg but ideally written in full) is a millionth of a

gram (g). There are 1,000,000 micrograms in a gram.

• 1 microgram (mcg) is a thousandth of a milligram (mg). There are 1,000 micrograms in

a milligram.

• 1 millilitre (ml) is a thousandth of a litre (l). There are 1,000 millilitres in a litre.

Because the metric system is all about tens, hundreds, thousands etc. and about tenths, hundredths,
thousandths etc., converting one set of units to another is all about multiplying or dividing by ten, a
hundred, a thousand etc.

Converting

This can be done by moving the decimal point.

To multiply by 10 move the decimal point 1 place to the right (e.g. 0.15 × 10 = 01.5).

To multiply by 100 move the decimal point 2 places to the right (e.g. 0.15 × 100 = 15).

To multiply by 1,000 move the decimal point 3 places to the right (e.g. 0.15 × 1,000 = 150).

To divide by 10 move the decimal point 1 place to the left. (e.g. 0.15 ÷ 10 = 0.015).

To divide by 100 move the decimal point 2 places to the left. (e.g. 0.15 – 100 = 0.0015).

To divide by 1,000 move the decimal point 3 places to the left (e.g. 0.15 ÷1,000 = 0.00015).

In conversions related to medication, you will usually be dividing or multiplying by 1,000 (moving
decimal point 3 places, left or right).

Note: What if there isn’t a decimal point in the number? It doesn’t matter because any
whole number can be thought of as that number, point zero, e.g. 500 = 500.0.
And by adding a decimal point at the end of the whole number you will have a decimal point to
move.

In each case you need to imagine lifting the decimal point off the paper and moving it.

Divide 250 by 1,000, pick up the decimal point and move it 3 places to drop it in front of the 2, e.g.

Such conversions are required in medication dosage calculations; therefore you must be confident
about them.

To change larger units (e.g. milligrams) to smaller units (e.g. micrograms) multiply the number by
1,000.

Or move the decimal point 3 places in this direction

To change smaller units (e.g. milligrams (mg)) to larger units (e.g. grams) divide the number by
1,000.

Or move the decimal point 3 places in this direction

For example:

1. To convert 5 grams (g) to milligrams (mg) multiply by 1,000 = 5,000 mg (because (g)
are bigger than (mg) and there are 1,000 milligrams in a gram).

2. To convert 6 litres (l) to millilitres (ml) multiply by 1,000 = 6,000 ml (because (l) are
bigger than (ml) and there are 1,000 millilitres in a litre).

3. To convert 16,000 micrograms (mcg) to milligrams (mg) divide by 1,000 = 16 mg

(because (mg) are bigger than micrograms (mcg) and there are 1,000 micrograms in a
milligram).

Medication forms and calculations

Tablets or capsules act as a vehicle for the active constituents, which are measured in grams (g),
milligrams (mg) or micrograms (mcg). By swallowing such tablets/capsules, the drugs can be
absorbed into the bloodstream, to have an effect.

Some drugs are prepared in liquid forms and in this case the drug is dissolved in or suspended in a
liquid such as water. Therefore the liquid is the vehicle for taking the drug into the body.

The drug will still be measured in grams (g), milligrams (mg) or micrograms (mcg) but because this
drug is in liquid, it has a concentration: that is, a number of g, mg or mcg per ml of liquid, e.g.
Furosemide 40 mg per 1 ml.

Use this formula for drug calculations

What you give = dose prescribed (what you want) ÷ dispensed dose (what you’ve got) × what it is
in. Consider these examples:

Example 1

Dose prescribed is 150 mg/dispensed dose is 50 mg/which is in 5 ml.

Therefore the sum is 150 ÷ 50 × 5 = what you give = 15 ml

Example 2

Dose prescribed is 300 mg/dispensed dose is 150 mg/which is in 1 capsule.

Therefore the sum is 300 ÷ 150 × 1 = what you give = 2 capsules

In the case of medication calculations that involve tablets or capsules, of course what it is in will
always be 1 (one), whereas with liquid medicines or injections it may not be.

A useful thing to know about is cancelling down. This helps with the sort of calculations shown.

The calculations could be laid out as

The rule for cancelling down is that if you apply a multiplication or division to the top of an
equation, such as these, and apply the same multiplication or division to the bottom of the equation,
then you will not change the answer.

This can help simplify the sum. In Example 3, both the top of the equation and the bottom of the
equation have been divided by 50. In Example 4, both the top of the equation and the bottom of the
equation have been divided by 150.

Example 3 (divided by 50)

Example 4 (divided by 150)

You may find it useful to know how to divide using a process called long division.

This is illustrated with this medication dosage problem in Example 5.

Example 5

Dose prescribed is 90 mg/dispensed dose is 75 mg/which is in 5 ml.

Therefore the sum is 90 ÷ 75 × 5. This would be easy if we knew what 90 ÷ 75 equals, but it is not
immediately clear what that is.

Figure 10.1 Example of long division

A long division approach would be set out like Fig. 10.1. Consider this and you’ll see that therefore
the answer to 90 ÷ 75 × 5 = 1.2 × 5 = 6 ml.

Incidently, this calculation could also have been approached by cancelling down. For this the steps
are:

Example 6

Step 1: what goes into 90 and into 75? 5 does. 90 ÷ 5 = 18; 75 ÷ 5 = 15

Step 2: what goes into 15 and into 5? 5 does. 15 ÷ 5 = 3; 5 ÷ 5 = 1

Step 3: what goes into 18 and into 3? 3 does. 18 ÷ 3 = 6; 3 ÷ 3 = 1

Practise your skills

Figure 10.2 provides ten practice calculations exercises using long division or cancelling down—
practise these and before checking your answers consider that some will involve conversion from
one SI unit to another. In each case, say what you would give if administering the 06:00 am dose.
Try doing them without a calculator. Check your answers with a calculator and then consult the
answers at the end of this chapter.

A few drugs (e.g. insulin and heparin) are measured in units. However, the approach is the same as
in Fig. 10.2.

The calculations exercises in Fig. 10.3 require you to choose from three heparin strengths—what
would you draw up and give? Try to undertake the calculation and then consult the answers at the
end of this chapter.

Prescriptions for IV fluids

Any prescription for IV fluids will state an amount to be given over a number of hours.

Stage 1, the first step, is to work out how many millilitres (ml) per hour, by dividing the amount of
fluid prescribed by the number of hours.

Example 7

Stage 1

1,000 ml over 12 hours = 1,000 ÷ 12 = 83.33 ml per hour

450 ml over 3 hours = 450 ÷ 3 = 150 ml per hour

 Figure 10.2 Practice calculations

Figure 10.3 Calculations exercises

This is as far as you need to go, if you are using a volumetric pump. Most acute settings use
volumetric pumps and this is all the calculation needed.
If, however, you need to calculate the rate for drops per minute, you need a second stage.

Stage 2 in the process is to divide the millilitres per hour by 60 to get the right number of millilitres
per minute and to multiply by how many drops there are in each millilitre, as specified on the giving
set packaging. This can be done as one cancelling down equation:

Example 8

Stage 2

For example, when prescription says 1,000 ml over 8 hours and the giving set has 20 drops per ml

The 20 and 60 can be used for cancelling down, leaving:

which is 28 drops per minute (to nearest whole drop).

If the infusion is to be administered in less than one hour, you need to adjust the method omitting
the converting to minutes step and so not dividing by 60 (see Example 9).

Example 9

A patient is to receive 150 ml of saline (0.9%) over 40 minutes. The IV set delivers 20 drops/ml. At
what rate (drops per minute) should the drip rate be set?

that is, after cancelling down to

, the answer is 75 drops per minute.

As you can see, rounding up/down to a whole number of drops makes sense (round up 0.5 and
above; round down 0.4 and below).

Practise your skills

Figure 10.4 has three IV infusion prescriptions. Consider the different calculations for each one and
check your answers at the end of the chapter.

Question 1: Calculate

a) the number of millilitres per hour

b) the number of drops per minute, with the indicated giving set
 Figure 10.4 Practice calculations

Online resource centre

You can find further advice and revision help for your OSCEs by going online now to see
www.oxfordtextbooks.co.uk/orc/caballero/.

References

Hutton, B.M. et al. (2010). Benchmark Assessment of Numeracy for Nursing: Medication
Dosage Calculation at Point of Registration. Edinburgh: NHS Education for Scotland.

Jukes, L. and Gilchrist, M. (2006). Concerns about numeracy skills of nursing students.
Nurse Education in Practice, 6(4): 192–198.

National Patient Safety Agency (2009). Safety in Doses: Improving the Use of Medicines in
the NHS. London: NPSA.

Nursing and Midwifery Council (2010). Standards for Pre-Registration Nursing Education.
London: Nursing and Midwifery Council.
 Sabin, M. (2001). Competence in Practice-Based Calculation: Issues for Nursing
Education. A Critical Review of the Literature. Loughborough: The Learning and Teaching
Support Network (LTSN).

Appendix: answers to calculation exercises

Practise your skills (Fig. 10.2)

1. 1 tablet, since 0.125 mg is equal to 125 mcg

2. 6 tablets

3. 6 ml, since 0.75 g is equal to 750 mg

4. 1.2 ml

5. 10 ml

6. 4 tablets

7. 15 ml

8. 1 tablet

9. 20 ml

10. 3.75 ml

Practise your skills (Fig. 10.3)

5 ml of heparin 1,000 units per 1 ml

Or 1 ml of heparin 5,000 units per 1 ml

Or 0.2 ml of heparin 25,000 units per 1 ml (best option, since smallest injection)

Practise your skills (Fig. 10.4)

1. a: 112.5 ml/hour

b: 28 drops/min

2. a: 125 ml/hour

b: 25 drops/min

3. 375 drops/min


Chapter 11
Administration of oral medication

Fiona Creed

Chapter aims

This chapter will enable you to:

• Understand why this important skill is assessed using OSCE,

• Revise key material in relation to this skill,

• Follow a step by step guide to the medication administration process,

• Understand how to prepare and revise for this OSCE,

• Highlight common problems at this station and identify how these may be avoided.

Introduction

Medication administration is a key skill and it is vital that you are able to demonstrate safety in all
aspects of the medication administration process in order to avoid harm or death to your patient.
The NMC (2004, 2010) reiterates this point, highlighting that the administration of medicines is an
important aspect of a nurse’s professional practice. They argue that it is not simply a mechanistic
task, but one that requires thought, exercise and professional judgement.

Studies suggest that medicine administration is one of the highest risk processes that a nurse will
undertake in clinical practice (NPSA 2007b; Elliot and Lui 2010). Medication administration errors
are one of the most common errors reported to the National Patient Safety Agency (NPSA). Indeed
in a 12-month period in 2007, 72,482 medication errors were reported with 100 of these causing
either death or severe harm to the patient (NPSA 2009). The frequency of these errors has led to a
number of changes in the medication administration process. Alongside these important
recommendations, most higher education establishments will want to ensure safety of medicine
administration and may test this vital skill using an OSCE to ensure that you are adequately
prepared for safe administration of medication in practice.

Key revision for your simulated examination

General principles of medication administration

There are a number of important laws and key documents that relate to the administration of
medication and it is important that you understand these as they all impact upon your practice
when administering medication to a patient. You may also be tested on your knowledge in relation
to these areas so it is important that you have read these. Important documents you will need to
know include:

• The laws that relate to medication in the UK,

• NMC Standards for Medicines Management (2010) (www.nmc-uk.org),

• Local policies related to hospital/Primary Care Trust (PCT) regulation of medication

(refer to local guidance).

Laws related to medication administration

There are a number of laws that influence the manufacturing, prescription, supply, storage and
administration of medication. Whilst you will not need to study the intricacies of these laws you will
need to understand the main issues each law covers. These are summarized in Table 11.1. You may
be expected to answer questions in relation to one or more of these laws in your OSCE.

Professional regulations

The NMC provides extensive guidance that relates to medicines management. This document has
increasingly expanded over the last decade as nurses take on a broader role in the prescription and
administration of medication. The NMC provides guidance related to:

• Supply and administration of medication,

• Dispensing of medication,

• Storage and transport of medicines,

• Standards for the practice of administration of medication,

• Delegation of responsibility related to medication administration,

• Disposal of medicinal products,

• Use of unlicensed products,

• Use of complementary and alternative therapies,

• Errors in the administration of medication,

• Controlled drugs.
 Note: Whilst this document is extremely large it is important that you understand this as it
provides important guidance for both the student and registered practitioner. You may be
expected to answer questions in relation to NMC guidance in your OSCE.

Local policies related to hospital/PCT regulation of medication

Alongside the laws and national and regulatory body guidance you will also have local policies that
will guide your practice. It is important that you familiarize yourself with local policies as these can
vary between NHS Trusts/PCTs and you will be expected to adhere to national and local guidance
when administering medication.

Systematic medication administration

In order to avoid medication errors it is important that you follow a systematic method when
administering medication as this will help to reduce the risk of medication error and promote
patient safety (Shawyer and Endacott 2009). It is widely accepted that most medication errors are
multifaceted and happen as a result of failures within the system that health care professionals
work in (Cohen and Shastay 2008; NPSA 2007b). However, it is important to recognize that nurses
are often the last person who can check for error prior to administration of medicine and have a
vital role in the prevention of error.

Table 11.1 Laws related to medication

 KEY POINT! Throughout this chapter the use of a systematic approach will be emphasized
utilizing the ‘5 rights’ approach to medication administration (Clayton 1987). This ensures
that medication by whichever route it is administered is:

• Given to the right patient,

• The right drug,

• The right route,

• The right dose,

• Given at the right time.

Prevention of administration errors

Common errors have been linked to personal factors and systems errors and it is important that you
have an awareness of this when administering medication.
A number of person centered factors have been identified (Jones 2009; Castledine 2009). These
include:

• Poor numeracy skills by nurses (see Chapter 10),

• Poor adherence to protocol, in particular not stringently following the ‘5 rights’ process,

• Not adequately checking patient (see section on right patient identification).

Equally a number of system factors have been identified that relate to the busyness of the ward
situation, time pressures and frequent interruptions (Jones 2009). To this end a large number of
NHS Trusts have implemented protected medication time to help reduce the number of errors.

Patient consent/education

As with all care in nursing, it is vital to gain patient consent prior to the administration of
medication. More recently studies have suggested that it is important to provide information about
the medication to the patient (Latter 2010). The purpose of this is twofold. Firstly it ensures that the
patient is providing informed consent. Secondly understanding of the role and importance of
medication increases patient compliance in self administering medication following discharge home
from hospital (Latter 2010).

Infection control

Several steps must be considered throughout the administration of medicines that relate to
infection control and it is important that the nurse follows correct infection control procedures.

Hands should be decontaminated using soap and water or alcohol rub (Dougherty and Lister 2008;
Hatchett 2009). It is not normally necessary to wear gloves unless you are preparing intravenous
medication, intramuscular injections or require gloves to protect yourself from body fluids, e.g
nasogastric or rectal administration of medicines. Remember if your patient scenario involves
administering medication to a patient with a transferable infection, e.g. MRSA, then personal
protective equipment should be used in accordance with local policy.

Any medication administered should not be directly touched by the nurse (Hatchett 2009) and this
will require you to practise a careful technique if the medication is stored in a bottle. You should
also ensure that any equipment used for the administration of medication is free from sources of
contamination, e.g. sterile syringes, sterile hypodermic needles and disposable medicine pots.
Where advanced routes of medication are being used, e.g. intravenous administration, nurses
should familiarize themselves with correct infection prevention technique.

Utilizing these approaches in your OSCE examination

In clinical practice there is a wide variety of methods used to administer medication to patients. It is
important to find out which method you are being assessed on in your OSCE and you are advised to
refer to your own university’s OSCE coordinators for this information.

The purpose of this chapter is to enable you to systematically administer oral medication. If your
OSCE relates to alternative routes of administration you can follow the same generic principles but
will need to refer to an appropriate clinical skills book for revision of different methods of
administration.
It is likely that you will be provided with a medication prescription chart and asked to administer
medication to one patient as though you were a registered nurse (i.e. single nurse administration).
It is most likely that you will be required to administer oral medication or perhaps a combination of
oral medication/injections.

Whichever the approach you will be expected to:

• Provide sufficient information that your patient may give informed consent,

• Maintain infection control throughout,

• Systematically administer medication,

• Make any appropriate checks to the patient (e.g. check BP prior to administering
antihypertensive medication),

• Document effectively,

• Discuss how you would monitor your patient post administration.

Remember you will be assessed on your:

• Professional attitude,

• Communication with the patient and other staff,

• Ability to administer medication systematically,

• Knowledge related to medication,

• Ability to maintain infection control,

• Documentation throughout the administration process.

Step by step

Systematic medication administration

Introduction and consent

It is vital that you introduce yourself to your patient and explain the need for the administration of
medication. During this stage it is vital that you gain the patient’s consent and provide information.
You will also be required to provide more information in relation to the medication as you progress
through the OSCE. It is essential to remember infection control and hands should be
decontaminated (washed with soap and water or alcohol gel) prior to commencing medication
administration. You will be expected to demonstrate a professional attitude to the patient
throughout the administration process. Having clearly introduced yourself (see Fig. 11.1a) and
maintained infection control you will then be required to systematically check and administer the
medication.

Figure 11.1a Introduce yourself

Right patient

It is essential to ensure you are administering medication to the correct patient and recent
directives reiterate the need to ensure that you have the correct patient (NPSA 2009; NMC 2010).
Remember 10% of errors in medication are caused by neglecting to ensure the correct medication
is given to the correct patient with 2,900 of these errors related to failure to check patient
wristbands (NPSA 2007a, 2007b).

Current recommendation is to check the patient’s identity using a patient wristband if the
medication is being provided in an acute care setting (Fig. 11.1b). The NPSA (2007a) has called for
standardization of information on patients’ name bands and suggests that it should include patient
name, date of birth and NHS number. If you are in mental health or a learning disability field of
nursing you should ensure that you follow established guidelines related to checking the identity of
the patient as it is unlikely that the patient/client will be wearing a patient identification bracelet. In
some instances photographs may be used to help identify patients.

You are cautioned against asking ‘Are you Mr Smith?’ as this may be an unsafe method of
confirming identity, especially in confused patients or where patients may have the same/similar
surnames (Elliot and Lui 2010). You should also double check the patient’s name on the drug chart.

Remember patients with allergies should have a red wristband that includes patient details in
black ink; there is no requirement to put other information, e.g. the name of the allergy, on the band
(NPSA 2007a). The presence of a red band should prompt you to take further action rather than
highlight the medication the patient is allergic to (Fig. 11.1c).

Figure 11.1b Check patient’s identity

Figure 11.1c Red patient wristband

Right drug
It is estimated that 1/3 of medication errors are related to the wrong medication being administered
(NPSA 2009). Therefore it is essential to ensure that you are administering the correct drug. You
will need to ensure that the medication has been clearly and legibly prescribed by the prescriber
(Fig. 11.1d). Recent evidence suggested that 14% of prescription charts had some form of error
with several that could have potentially led to incorrect medication being administered (Simons
2010). Remember if the prescription is unclear in any way you should withhold the medication and
speak to the prescriber and request that the prescription is rewritten in a legible manner (this will
help avoid further errors). When checking the chart you are also required to note any medication
allergies and ensure that the patient is not allergic to any medication prescribed (NMC 2010). It is
safe practice to always ask the patient about any allergies in addition to checking the medication
chart.

Figure 11.1d Check the prescription is legible

In addition to checking the legibility and potential risk of allergy you will also need to know what
the medication action is. It is vital to know this as it may be necessary to complete appropriate
checks or review results prior to the medication being administered. For example you may be
required to check blood pressure prior to administration of an antihypertensive medicine or need to
check the patient’s current potassium levels prior to the administration of oral potassium
supplements. Remember you are not required to rote learn medications but you must demonstrate
safe practice by checking the medication in action and required checks in a medication formulary,
e.g. the BNF (Fig. 11.1e).

Remember there may well be deliberate medication prescribing errors on the chart in your OSCE
to test your ability to act upon an incorrect prescription.

Alongside knowledge of medication action you may also be expected to demonstrate understanding
of its benefits, contraindications and side effects of the medication you are administering (Hatchett
2009). You may be required to explain these either to your patient or to the examiner. This
information can again be found in a medication formulary and you will not be expected to rote learn
it. It is likely that the medication formulary will be available to you throughout your OSCE.

Communication will be a vital part of this aspect of administration and you will also be expected to
explain the action of the medication and the benefits and potential side effects of taking the
medication to your patient (Fig. 11.1f). Studies suggest that a patient’s compliance with medication
at discharge is affected by their understanding of the need for the medication so the nurse is
expected to demonstrate appropriate patient education throughout the procedure and
communicate this effectively with the patient (Latter 2010).
 Figure 11.1e Medication formulary

Figure 11.1f Communication

Right route

Nurses are increasingly required to administer medication via several routes and it is important
that you are aware of and utilize the correct route for the medication. You should also be aware that
changes in route may alter the dosage of the medication (e.g. morphine if given intravenously is
given in a much smaller dose than if given intramuscularly). There have also been examples where
medication intended for oral use has been administered via the intravenous route causing harm to
the patient (Cohen 2006). Remember if you are administering any oral medication that requires
very accurate measurement in a syringe you must utilize a blue oral medication syringe to help
prevent any errors in inadvertent IV administration.

If your OSCE involves giving medication via different routes it is important to ensure that you
understand how to administer the medication via that route and any necessary interventions that
are required (e.g. left side lying for administration of rectal suppositories (Dougherty and Lister
2008)). You should discuss with your tutors which routes are likely to be utilized in your
examination and revise these using an appropriate skills book.

Right time

Medication will be prescribed to be given at a set time and it is essential in your OSCE that you
demonstrate your understanding of this important principle. The guiding principle is that
medication should be administered as close to the prescribed time as possible (Elliot and Lui 2010).
In clinical practice timing errors often relate to the incorrect timing of antibiotic therapy (Tang et
al. 2007). Many medication actions are affected by the time span between doses and in medication
such as antibiotics it is vital that they are given at specific times to ensure efficacy of serum
antibiotic concentration.
It is suggested that medication is administered within half an hour of the prescribed time and if this
is not possible, for whatever reason, a medication error should be reported and appropriate
electronic or paper forms completed. You will also be expected to demonstrate other factors relating
to timing of the medication, e.g. some medications such as steroids should ideally be taken with
food to prevent potential stomach ulceration whilst some antibiotics need to be administered before
food to facilitate absorption. Failure to demonstrate understanding of this in your OSCE will either
prevent a pass grade being awarded or substantially reduce the mark you are awarded.

You will also need to demonstrate your ability to explain this to the patient in your OSCE as
patients need to understand the need to take their medication at regular intervals, rather than at
convenient times. Again the nurse is expected to demonstrate appropriate patient education
throughout the procedure and communicate this effectively with the patient (Latter 2010).

Right dose

Administration of the correct dose of the medication is vital. However, studies suggest that the
majority of medication errors relate to incorrect dosage (NPSA 2007b; Jones 2009). Whilst it is still
generally medics who prescribe medication to acute patients (Jones 2009), nurses still have a
professional responsibility to ensure that the dose prescribed is correct and should check this
carefully with a medication formulary if they are unsure, before administering any medication (NMC
2010).

Nurses also have a responsibility to ensure that correct medication calculations are performed
accurately. Problems associated with the nurse’s ability to perform accurate medication calculation
are well documented (Wright 2006; NPSA 2007; Lee 2008). The need for accurate medication
calculations and improvement in nurse’s confidence with arithmetic is emphasized throughout the
literature (Wright 2006; Jones 2009). You are referred to Chapter 10 for additional detail on
medication calculations.

The NMC (2010) also highlights the need for complex calculations to be checked by two trained
nurses as the likelihood of error increases with the complexity of calculation. It highlights that
although nurses may use calculators for complex medication calculations they should not replace
accurate arithmetic knowledge and skill (NMC 2010).

Documentation

You will be expected to provide clear documentation in relation to medication administration and it
is important that it is clearly documented which medications have been administered. It is also vital
to correctly identify where medications have been withheld. The NMC highlights the need to
provide clear, accurate and immediate record of all medication administered, intentionally
withheld or refused by the patient. The documentation should be legible and clearly identify the
person/persons responsible for the administration of medication.

You are advised to document that medication has been taken immediately after the patient takes the
medication. Documentation prior to administration may cause problems if the patient refuses the
medication. More worryingly failure to document that medication has been administered may result
in the patient receiving the medication twice and result in potential harm to the patient (Elliot and
Lui 2010). Remember you are required to witness that the patient actually takes the medication
and medication should not be left with the patient to be taken later (Fig. 11.1g). Once taken,
complete the drug chart (Fig. 11.1h).

Where medication is withheld or refused it is vital that the rationale for the decision to withhold or
refusal is clearly documented on the patient’s medication chart. For example where digoxin is
withheld in a bradycardic patient the rationale related to low pulse should be clearly documented. It
may also be necessary to refer the patient to the medical team if digoxin levels need to be taken,
and again this should be clearly documented in the patient’s medical/nursing record.
 Figure 11.1g Witness patient taking medication

Figure 11.1h Complete drug chart

Any observations related to the administration of medication should also be clearly documented on
the patient’s observation chart so that it is apparent that appropriate checks have been made prior
to the administration of medicines.

Some medications may require you to complete additional paperwork, e.g. if you are required to
administer controlled medication you will be required to complete the necessary controlled
medication documentation (Misuse of Drugs Regulations 1973, 2001).

Aftercare of patient

Once medication has been administered the nurse has a continuing professional responsibility to
ensure that the patient receives appropriate aftercare (Elliot and Lui 2010). The nurse will need to
perform any necessary checks following administration of medication (examples of these are
included in Table 11.2).

Alongside appropriate observations the nurse should also observe the patient for any potential side
effects or allergic reaction. You may be asked to explain how you would monitor for side effects and
allergic reaction. It is useful to familiarize yourself with management of these situations and you are
referred to the Resuscitation Council’s (2008) guidance on the management of anaphylaxis, which
you should know if you are involved in administering any form of medication. Remember patients
may react to a new medication or one that they have taken before!

Safe storage of the medication

Following correct administration of medication you will be expected to ensure that medication is
stored appropriately and in accordance with the manufacturer’s recommendations (NMC 2010). The
type of storage will vary and may reflect storage at the local NHS Trust, e.g. patient pod systems or
more rarely medication trolleys. You will be expected to be able to state how medication should be
correctly stored and may be expected to discuss laws that relate to the safe storage of medicines.
With the exception of a few medications (e.g. cardiac arrest drugs and intravenous fluids) most
drugs should be locked securely in a cupboard when not in use (Duthie Report 1988). You should
therefore ensure that any medication used in the OSCE is returned to a secure cupboard (Fig.
11.1i).

Table 11.2 Aftercare following the administration of medication

Figure 11.1i Safe storage of medication

Putting it all together!

An overview of systematic medication administration can be seen in Box 11.1 which provides a
useful recap of all aspects of this skill.

Box 11.1 Putting it all together!

• Introduce yourself to the patient.

• Gain consent where able.

• Wash/gel your hands.

• Ensure you have all the equipment needed and the correct medication chart is available.

• Check the patient’s name band to ensure patient and medication chart are correct.

• Check for signs of allergy by asking patient and reviewing medication chart/name band.

• Read through the chart initially to see if any medication is due and review to see if any
tests, e.g. blood glucose, are required prior to administration of the medication.

• Check that you have the right drug that is prescribed on the chart. Remember the
examiner will expect you to be able to describe the actions of the medication.

• Check that you are giving the medication by the correct route.

• Check that you are giving the medication at the correct time.

• Calculate the dose and double check this to ensure you are confident that the dose is
correct.

• Ensure that a full explanation is given to the patient and that they understand why they
are receiving the medication and explain the action of the drug in terms the patient will
understand.

• Once you are confident that you have completed all the required checks, administer the
medication.

• When you have observed that the patient has taken the medication accurately document
this on the medication chart.

• Check that the patient is comfortable and check whether the patient requires any
 aftercare following administration of the medication and record this as required.

• Ensure the medication is returned to safe storage.

Examiners’ marking criteria

Various tools will be utilized to assess your competence at administration of medication. As stated in
earlier chapters it is advisable to review your own university’s marking criteria. An example of
marking criteria is included in Table 11.3.

Table 11.3 Example of examiners’ marking criteria

Examiners’ questions

Some universities may assess your knowledge in relation to administration of medication and it is
useful to prepare for that if that is a requirement. Box 11.2 outlines some typical questions.

Box 11.2 Example of examiners’ questions

1. Identify two reasons why it is important to administer drugs and not leave on patient’s
bedside.

2. Identify two different types of practitioners who can prescribe medication.

3. Identify two controlled drugs and state why these drugs are controlled.

4. Identify three symptoms of anaphylaxis.

5. Explain the limitation of the student nurse’s role in the administration of medication.

6. Identify three actions to take if patient suffers anaphylactic reaction.

7. Describe how controlled drugs should be stored in a hospital environment.

8. Describe how you would gain consent for medication.

9. Discuss how you would document a medication that has been withheld.

10. Discuss how you would monitor for reactions.

Answers are provided at the end of the chapter.

Common errors at this station

This may be a stressful station to undertake as students often have concerns over medication
administration and a number of errors occur; these include problems related to failure to:

• Introduce yourself and communicate with the patient,

• Maintain infection control measures,

 • Gain consent from the patient,

• Appropriately check the patient,

• Follow NPSA guidance to check patient’s identify,

• Check for any allergies,

• Demonstrate sufficient knowledge of medication,

• Check in a medication formulary if at all unsure,

• Deliver correct medication dosage,

• Utilize correct medication calculation,

• Observe patient taking medication,

• Record appropriate observations before administration of medicine,

• Record appropriate observations after administration of medicine,

• Document appropriately.

Alongside these, other common errors include:

• Making assumptions that the medication chart will correctly prescribe doses, times and
routes of medicines. Remember there may be deliberate errors,

• Panicking and becoming stressed,

• Rushing administration and making errors.

• Poor communication with the patient,

• Poor timing in the station/running out of time.

Top tips for passing this station

The key to passing this exam station is demonstrating the ability to:

• Follow a systematic approach when administering medication.

• Take time to ensure you have read and understood the medication chart and associated
medications.

• Use the BNF to check medications; you are not expected to know the mechanisms of
actions of all the medication you are asked to administer but MUST demonstrate safety in
checking when unsure.

• Remember to check the patient’s name band.

• Double check any calculations you may be required to perform.

• Communicate with your patient throughout, offering explanations at an appropriate

level.

• Perform any necessary safety checks/after checks as these will demonstrate your
understanding of the need for safety and mechanism of the drug action.

You may enhance your ability to pass this station by practising this skill and there are several things
that students have found helpful:

• Practising alongside your colleagues in clinical skills room,

• Attending university practice and theory sessions,

 • Using the skill in practice with your mentor and asking for constructive feedback,

• Attending study sessions that are run in practice (if the NHS Trust allows this),

• Practising sequence whilst being timed; this allows you to roughly calculate how much
time is needed for each part of the assessment,

• Checking with your university lecturers which routes of administration will be used in
the OSCE.

Online resource centre

You can find further advice and revision help for your OSCEs by going online now to see
www.oxfordtextbooks.co.uk/orc/caballero/.

References

Castledine, G. (2009) Blasé about drug administration. British Journal of Nursing, 18(19):
1219.

Clayton, M. (1987). The right way to prevent medicines errors. Registered Nurse, (50):
30–31.

Cohen, H. and Shastay, A. (2008). Getting to the root of medication errors. Nursing,
38(12): 39–47.

Cohen, M. (2006). Medication error: unfamiliar syringe, wrong route. Nursing, 36(3): 39–
47.

Dougherty, L. and Lister, S. (2008). The Royal Marsden Hospital Manual of Clinical
Nursing Procedures, Student Edn.

Chichester: Wiley Blackwell.

Duthie Report (1988). The Safe and Secure Handling of Medicine: A Team Approach.
Londan: Royal Pharmaceutical Society.

Elliot, M. and Lui, Y. (2010). The nine rights of drug administration: an overview. British
Journal of Nursing, 19(5): 300–305.

Hatchett, R. (2009). Administration of medication. Clinical skills.net.

Jones, S. W. (2009). Reducing medication administration errors in nursing practice.

Nursing Standard, 23(50): 40–46.

Latter, S. (2010). Evidence base for effective medicines management. Nursing Standard
24(43): 62–66.

National Patient Safety Agency (2007a). Standardizing Wristbands Improves Patient

Safety. London: NPSA.
 National Patient Safety Agency (2007b). Safety in Doses: Medication Safety Incidents in
the NHS: The Fourth Report from the Patient Safety Agency. London: NPSA.

National Patient Safety Agency (2009). Safety in Doses: Improving the Use of Medicines in
the NHS. London: NPSA.

Nursing and Midwifery Council (2004). Guidelines for the Administration of Medicines.
London: NMC.

Nursing and Midwifery Council (2010). Standards for Medicines Management. London:
NMC.

Resuscitation Council (UK) (2008). Emergency Treatment of Anaphylactic Reactions:

Guidelines for Healthcare Providers. London: Resuscitation Council.

Shawyer, V. and Endacott, R. (2009). Drug administration. In: Endacott, R., Jevon, P. and
Cooper, S. (2009) Clinical Nursing Skills, Core and Advanced. Oxford: Oxford University
Press.

Simons, J. (2010). Identifying medication errors in surgical prescription charts. Paediatric

Nursing, 22(5): 20–23.

Tang, F., Sheu, S., Wei, I. and Chen, C. (2007). Nurses relate the contributing factors
involved in medication errors. Journal of Clinical Nursing, 16(3): 447–557.

Wright, K. (2006). Barriers to accurate drug calculations. Nursing Standard, 20(28): 41–
45.

Appendix: answers to examiners’ questions

1. Identify two reasons why it is important to administer drugs and not leave on patient’s
bedside

• Patient may forget to take medication,

• Medication should be taken at prescribed time,

• Patient may knock drugs on floor,

• Risk to other patients, especially the confused patients,

• You are signing to say you have witnessed the patient swallow medication,

• Patient may store drugs,

• Risk of attempted suicide in depressed patients.

2. Identify practitioners who can prescribe drugs

• Doctors,

• Dentists,
• Nurses (limited),

• Pharmacists (limited),

• Midwives (limited).

3. Identify two controlled drugs and state why these are controlled for controlled drugs
see BNF Reasons include:

• Dangerous,

• Harmful,

• Potentially addictive or habit forming.

4. Identify three symptoms of anaphylaxis

• Extreme anxiety,

• Feeling of impending doom,

• Skin itching/flushing/urticaria,

• Tachycardia,

• Hypotension,

• Airway obstruction,

• Swelling,

• Wheezing/stridor/dyspnoea,

• Eventual cardiac and respiratory arrest.

5. Explain limitation of the student nurse’s role in administration of medication

• Can only dispense drugs in presence of registered nurse,

• Cannot be involved in single nurse drug administration,

• Must have drug administration countersigned by a registered practitioner,

• Must also follow NHS Trust guidelines.

6. Identify three actions to take if patient suffers anaphylactic reaction

• Seek urgent medical help,

• Prepare drugs: adrenalin, chlorpheniramine, hydrocortisone,

• Maintain airway,

• Administer oxygen,

• Check vital signs,

• Reassure patient,

• Prepare to use resuscitation equipment if needed.

7. Controlled drugs should be stored:

• Double locked cupboard,

• Separate key,

• Ward sister or deputy should hold keys,

• Ward sister or deputy accountable for keys.

8. Consent
 • Verbal consent should be gained from the patient,

• Where this is not possible in the case of an unconscious patient or where there are
mental capacity issues students should follow guidance from the Mental Capacity Act,

• Under no circumstances should students administer medication covertly.

9. Withheld drugs

Local policy should be followed, such as:

• Writing rationale in appropriate area on medication chart,

• Using code on medication chart to identify rationale,

• The nurse in charge and doctor responsible for the patient should be informed.

10. Reactions

• Observation of the patient required,

• Patient may require recording of physiological observations,

• The nurse should be conversant with potential side effects of particular medication and
discuss how these will be monitored,

• The nurse should be conversant with signs of allergic reaction and monitor for these.


Chapter 12
Recognition of acute deterioration

Fiona Creed

Chapter aims

This chapter will enable you to:

• Understand why this advanced skill is assessed using OSCE,

• Revise key material in relation to this skill,

• Follow a step by step guide to the patient assessment process,

• Understand how to prepare and revise for this OSCE,

• Highlight common problems at this station and identify how these may be avoided.

Introduction

Recognition and prompt treatment of the acutely ill patient is a significant issue in clinical practice
(NICE 2007). The need for all nurses to be able to recognize, assess and promptly escalate (ensure
timely and effective management) patients whose condition is deteriorating is stressed in the
literature (NCEPOD 2005; NPSA 2007). Therefore it is an important skill and your university will
want to ensure via OSCE that you are adequately prepared for any emergency that may arise in
practice.

It must be emphasized that this skill is a complex skill and most universities do not assess this skill
until the final year of your course. The key to succeeding in this OSCE is understanding the need
for systematic assessment, and timely intervention and escalation will be stressed throughout this
chapter. It is likely that you will be allowed approximately half an hour to demonstrate this skill and
answer related questions.

Revision of key material will enable you to understand why assessment is important and provide you
with a systematic framework to use in the OSCE and in clinical practice.

Key revision for your simulated examination

Problems with assessment

Concern over NHS staff’s management of the deteriorating patient has been highlighted in the
literature since the late 1990s. McQuillan et al. (1998) first discussed the concept of suboptimal
care suggesting that often deterioration in patients was ignored, misdiagnosed and/or poorly
managed in ward environments resulting in increased mortality and morbidity in ward patients.

Since McQuillan’s work several other studies have identified similar problems (McGloin et al. 1999;
NCEPOD 2005). More recently NICE (2007) has published guidance on recognition and
management of deterioration and the Department of Health (2009) has published competencies
related to recognition and management of deterioration that all acute staff should achieve.

Review of this literature highlights that several issues are clearly important in recognition of acute
deterioration and the need to utilize a systematic assessment tool linked to a robust track and
trigger scoring system is an important consideration in practice.

ALERT ®: a systematic assessment tool

Smith (2003) was instrumental in developing the ALERT® framework that has been adopted
internationally as a robust systematic assessment tool. The framework encourages practitioners to
utilize a systematic approach to assessment based on an alphabetical approach that is adapted from
the resuscitation framework (Creed et al. 2010).

This systematic tool focuses upon assessment of:

• Airway,

• Breathing,

• Circulation,

• Disability,

• Exposure/Everything else/Escalation.

The tool encourages practitioners to use a stepwise (systematic and logical framework) tool that
focuses upon recognition of potentially life threatening problems first using a ‘look, listen and feel’
approach (Jevon 2007). Practitioners are encouraged to recognize and treat any problem before
continuing with the assessment, e.g. if a problem is noted in breathing this should be addressed
before assessment of circulation continues. One example of this could be the addition of oxygen in a
patient with increasing respiratory rate and decreasing saturations. The application of oxygen
would be instigated before the practitioner continued with cardiovascular assessment.

Track and trigger scoring systems

Alongside the need for immediate systematic patient assessment most assessments will require you
to calculate a track and trigger score that facilitates identification of acute deterioration and
promotes rapid patient escalation. Most NHS Trusts have followed the NICE (2007) guidelines and
implemented track and trigger scoring systems. Many differing scoring systems are used but all
focus on attributing a score that increases as the patient’s condition worsens and their observations
fall outside of normal ranges. Track and trigger systems may be referred to locally as patient at risk
scores (PARS), early warning scores (EWS) or modified early warning scores (MEWS).

In 2007 NICE identified key components of all track and trigger scoring systems and emphasized
the need to include the following parameters:

• Heart rate,

• Respiratory rate,

• Systolic blood pressure,

• Level of consciousness,

• Oxygen saturations,

• Temperature.

See Box 12.1 for a reminder of normal parameters and examples of how to use a track and trigger
system.

Box 12.1 Reminders and examples of how to use a track and trigger system

1. Reminders of normal parameters

Normal parameters are generally accepted as:

• Heart rate 60–100 bpm,

• Respiratory rate 12–20 bpm,

• Systolic blood pressure 100–139 mmHg,

• Diastolic blood pressure 60–90 mmHg,

• Temperature 35.5–37.5,

• Oxygen saturations 94–98%.

Endacott et al. (2009);

British Thoracic Society (2008)

2. How to use a track and trigger scoring system

Track and trigger scoring systems will score 0 if parameters are normal but will record a point
value if there is variation from the normal
 Example 1—John Smith

Heart rate 78

Respiratory rate 14

Systolic blood pressure 110

Temperature 37.1

Oxygen saturations 94:

Would most likely score 0

Example 2—Jennifer Smith

Heart rate 103

Respiratory rate 20

Systolic blood pressure 110

Temperature 37.5

Oxygen saturations 94:

Would most likely score 2

Some scoring systems also utilize other parameters including:

• Pain assessment,

• Fluid balance,

• Urine output,

• Blood glucose level.

Escalation of concern

All track and trigger systems should be linked to an appropriate escalation policy that will facilitate
timely and effective management of the patient whose condition is deteriorating. The escalation
policy may prompt you to:

• Increase the frequency of observations,

• Call a medical practitioner (F1/F2/SPR),

• Call for an emergency response. Such examples include critical care outreach teams
(CCO), patient at risk teams (PART) and medical emergency team (MET).
Effective communication

The need to communicate effectively when escalating the patient is also important. Several tools
have been developed to improve communication between nurses and doctors as studies have
suggested that poor communication may prevent timely intervention and treatment (NCEPOD 2005;
NPSA 2007). One example of an effective communication strategy is the SBAR tool developed by the
NHS Institute for Innovation and Improvement (2008). This tool encourages nurses to state:

• Situation

Identify yourself and ward area,

State patient’s name and rationale for calling,

State concern.

• Background

Provide patient history,

Identify reason for admission,

Give a brief overview of treatment to date.

• Assessment

Provide assessment utilizing a systematic approach (ABCDE),

Identify track and trigger score,

Suggest any suspicions you may have about the patient.

• Recommendation

Explain what you would like the doctor to do,

Give a time frame for patient review,

Document who you have spoken to and their response.

Utilizing these approaches in your OSCE examination

Overview

It is likely that you will be asked to assess and effectively manage a deteriorating patient using a
simulation manikin in a pre-programmed scenario. Some universities may use ‘actors’ instead of
manikins. You are advised to check your university guidelines as some may assess this skill
formatively using groups of students whilst others may assess individual students using either a
summative or formative approach. Whichever the approach the commonalties are:

• You will receive a patient handover and then be expected to assess your patient,

• You will be required to use a systematic tool and initiate first line management,

• You will be required to calculate a track and trigger score,

• You will demonstrate an ability to follow escalation protocols,

• You will communicate effectively with the patient throughout,

• You will demonstrate an ability to communicate your concerns about the patient,

• You will document effectively throughout the scenario.

Remember you will be assessed on your:

• Professional attitude,

• Communication with the patient and other staff,

• Ability to assess the patient systematically,

• Knowledge related to assessment,

• Ability to maintain infection control,

• Documentation throughout the assessment.

Step by step systematic assessment

Once introduced to the patient, you will be expected to follow a systematic framework and should
demonstrate your ability to assess and initially manage the patient using a stepwise approach. It is
important that you remember infection control, even in a potential emergency. You should
decontaminate your hands prior to patient contact by either using alcohol hand gel or washing your
hands with soap and water.

Airway

If your patient is able to talk to you this normally indicates a clear airway; however, you should not
take this for granted and state that you will assess the airway. The patient’s airway should be
assessed for any signs of obstruction using a look, listen and feel approach (Fig. 12.1a). You will
need to observe for complete or partial obstruction of the airway. If the airway is completely
obstructed you will see no chest movement in the patient, no noise will be apparent (silent) and you
will not be able to feel movement of air. If the airway is partially obstructed you may notice
distressed breathing, e.g. paradoxical chest movement (see-saw breathing) and the workload of
breathing will be significantly increased. You should be able to feel some degree of air entry/exit
and there will be associated abnormal respiratory sounds, e.g. snoring, stridor, gurgling or
wheezing.

If there are any problems associated with the airway these should be rectified appropriately before
breathing is assessed. This may necessitate changing the patient’s position or use of an artificial
airway adjunct, e.g. insertion of a Guedel airway or nasopharyngeal airway (Jevon 2007). Selection
of airway adjunct may be dependent upon the patient’s consciousness levels as some patients may
not tolerate a Guedel airway and a nasopharyngeal airway may be more appropriate, providing
there is no history of skull fracture (Creed et al. 2010).

Figure 12.1a Assess for signs of obstruction using the look, listen and feel approach

Breathing

The patient’s breathing should be assessed using a look, listen and feel approach (see Fig. 12.1b).
The depth and inclusion of aspects of respiratory assessment may vary locally and care should be
taken to familiarize yourself with what is required.

All assessments will require you to count the patient’s respiratory rate for a whole minute (so
ensure that you do count the respirations for a whole minute!). During this time you should observe:

• Pattern of respiration,

• Use of accessory muscles,

• Depth of respiration,

• Workload of breathing,

• Symmetry of breathing,

• Bilateral chest movement.

Some of these elements, e.g. use of accessory muscles, cannot be assessed in a manikin but you
may be expected to ask the examiner about the presence of these. If any abnormalities are noted
you should assess for dyspnoea by asking the patient if their breathing feels difficult. You should
also note any obvious breathing noises, e.g. wheezing, stridor or persistent coughing.

Check

You should observe for signs of central cyanosis, bluish tinge to lips and mucous membranes around
the mouth, again this cannot be assessed in a manikin but you may be expected to ask the examiner
about the presence of cyanosis. You should ask the examiner about the colour of the patient’s
lips/mucous membranes.

Some universities may require you to perform more in-depth respiratory assessment which may
include chest auscultation (listening to the lung fields using a stethoscope) (see Fig. 12.1c) and
palpation (feeling for abnormalities such as tactile fremitus or the ability to feel secretions when the
patient breathes). Others may also include percussion of the chest (tapping the chest wall to note
resonance of air in the lung fields).

Figure 12.1b Assess breathing using a look, listen and feel approach

Note!: Adequate respiratory assessment is a vital aspect of patient assessment as this will
be the first observation to show signs of change during episodes of acute deterioration.
The respiratory system will provide an early physiological warning that the patient’s
condition is deteriorating as the rate will quickly increase if there are respiratory or
metabolic disturbances.
 KEY POINT! Studies have highlighted that changes in respiration are the most sensitive
indicator of deterioration (Cretikos et al. 2008). Worryingly they are the most frequently
omitted observation (NPSA 2007; Cretikos et al. 2008).

If the respiratory assessment identifies any difficulties the following measures may be considered:

• Emergency call if no or minimal respiratory effort,

• Change in patient’s position to facilitate breathing,

• Application of oxygen following the British Thoracic Society guidance (2008),

• Reassurance for the patient,

• Encouragement of deep breathing,

• Use of medication, e.g. nebulization of bronchodilators if there is an expiratory wheeze

on auscultation,

• Encouraging patient to cough if sputum retention evident on auscultation,

• Review of medication to see if patient has had any opiate based analgesia that may
suppress respiration (or recreational drugs if A&E patient).

Figure 12.1c Chest auscultation

Figure 12.2 Numerical recording

Document

You will also be required to record oxygen saturations and document respiratory rate and
saturations on your patient observation chart. Some charts will require you to provide a numerical
figure (see Fig. 12.2) whereas others may require a dot to be plotted in an appropriate area.

Circulation

The patient’s circulation should be assessed using a look, listen and feel approach.

Heart rate and rhythm

The patient’s radial pulse should be palpated and the heart rate for one full minute noted. During
this time the rhythm of the heart rate (regular verses irregular) and the strength of the heart rate
should be assessed.

Peripheral temperature

The nurse should also comment upon the patient’s peripheral temperature as if this is cold/clammy
it may indicate that the patient is compensating for some form of shock
(hypovolaemia/cardiogenic). If the patient is hot/sweaty it may indicate sepsis or another form of
distributive shock (anaphylaxis/neurogenic shock). It is also useful to assess capillary refill time
—normal refill time is less than 2 seconds and any increase in capillary refill time may indicate a
sluggish circulation.

Note: The assessment of capillary refill and peripheral temperature cannot be recorded
when using a simulation manikin. Some centres will supply this information verbally (but
only if you request this detail). You are reminded to ask the examiner for the capillary
refill time and also whether the patient is cool/clammy or hot and sweaty.

Blood pressure This should be recorded using either a manual or an electric blood pressure device
(see Fig. 12.1d). You should give consideration to the systolic pressure, diastolic pressure and
changes in pulse pressure (difference between systolic and diastolic pressure). Changes in these
recordings may help indicate what is happening with the patient. An example of this is that an
increasing diastolic pressure and narrowing pulse pressure could indicate the early stages of
hypovolaemia because of compensatory mechanisms.
Fluid balance

This will have a profound effect on cardiovascular status so you should consider the current fluid
balance of the patient (positive/neutral/negative) and report the findings and likely consequence of
the findings. Urine output should also be analysed and you should observe for increases or
decreases in urine output (see Fig. 12.1e). If urine output is decreased you should calculate the
expected output using the formula:

Output per hour = 0.5 ml per kg per hour

Reduced urine output may indicate that the kidneys are not being adequately perfused due to poor
cardiac output. If the patient is not catheterized bladder scanning to estimate output may be
advised or you may wish to consider urinary catheterization. Again this will not be feasible in
simulation but you may be expected to articulate potential solutions to estimation of urine output.

Figure 12.1d An electric blood pressure device

Temperature

This should be recorded. In some manikins the temperature will be displayed on the bedside
monitor. The patient should be observed for signs of infection (temperature above 38.5°C) or signs
of hypothermia (temperature below 35.5°C). The Surviving Sepsis Campaign (2007) highlights the
need for urgent attention in patients with temperature above 38.5°C.

Document

Having completed the circulation assessment you should document pulse, blood pressure,
temperature and fluid balance on the observation chart.

Check

You should observe for the Portsmouth sign (heart rate above systolic blood pressure) when
documenting the observations. This sign indicates that the patient’s condition is unstable and
urgent attention should be sought.

Having completed the circulation assessment you may wish to consider interventions. These may
include:

• Medical emergency team call/crash team call if no cardiac output detected.

If the patient has a cardiac output

• Change of position to improve blood pressure (lie patient flat),

• Administration of IV fluids/fluid challenge if prescribed,

 • Recording a 12 lead electrocardiogram (ECG),

• Adding additional monitoring (ECG, regular BP recordings, continuous saturation

monitoring),

• Informing medics and following local guidance in respect of the management of sepsis if
temperature is high.

Disability

The term disability is referring to the assessment of neurological status and consideration.
Generally in acute situations a crude gauge of neurological status is acceptable and in most
situations the AVPU tool will suffice. This is a very simplistic assessment that allows quick
evaluation of consciousness levels (Jevons 2007). It is not and should not replace a full neurological
examination if the patient’s condition requires this.

Figure 12.1e Observe for increase or decrease in urine output

AVPU stands for:

• Alert,

• Responds to Voice,

• Responds to Pain,

• Unconscious.

Resuscitation Council (2006)

Most situations will require you to conduct a formal neurological assessment if the patient responds
only to pain or is unconscious. In this group of patients consideration should be given to the
patient’s ability to maintain their own airway and emergency help may need to be sought.

You should consider factors that might affect the consciousness levels and if there are signs of
deteriorating neurological function (the score is V, P or U) you should:

• Record a blood glucose level to assess for hypoglycaemia,

• Review medication chart to note for any administration of medication that may affect
consciousness levels, e.g. opiate based analgesia.

It is also appropriate to assess for pain levels in the neurological assessment (see Fig. 12.1f) as
worsening pain may indicate deterioration, e.g. haemorrhage within the cranial cavity or raising
intracranial pressure (Creed et al. 2010).

Document

Having assessed the patient’s neurological function you should document the AVPU or Glosgow
Coma Score (GCS) if used on an observation chart.
 Figure 12.1f Assess for pain levels in neurological assessment

Consideration should be given to:

• Correction of hypoglycaemia if patient’s blood glucose is low,

• Maintenance of safety if conscious levels are affected (V or U score),

• Telephoning for an urgent medical review.

Exposure/Everything else/Escalation

Maintaining patient dignity you will be required to remove bed clothing and observe for any obvious
causes of the patient’s deterioration (Fig. 12.1g). This will include ruling out obvious forms of shock
as well as consideration of fluid overload and deep vein thrombosis/venous thromboembolism
(VTE).

• Hypovolaemia: you should check any wound drains/observe for pooling of blood in the
bed. If the patient has a wound consideration should be given to observing the wound site
for signs of bleeding/swelling that may indicate blood loss.

• Sepsis: you should observe for flushed appearance alongside decreasing diastolic blood
pressure and fast capillary refill time.

• Anaphylaxis: you should note any signs of redness/urticaria, again impossible to

simulate but some centres will supply this information verbally but only if you request this
detail. You may want to ask the examiner if there are signs of urticaria or redness that
may indicate anaphylaxis.

• Deep vein thrombosis/VTE: you should note any calf swelling, pain on inspiration or
expectoration of blood as these may indicate development of a pulmonary embolism, again
impossible to simulate but some centres will supply this information verbally but only if
you request this detail. You may want to ask the examiner if the calf appears
swollen/red/painful.

• Fluid overload: you should observe for any signs of dependent oedema. This may be
found on feet, ankles, hands, wrist or on the sacral area. Again impossible to simulate but
some centres will supply this information verbally but only if you request this detail. You
may want to ask if there are signs of dependent oedema.
 Figure 12.1g Exposure of patient

Document

Having completed exposure you should document changes and it may be helpful to review
documentation to explore:

• Trends from observation (fast or slow deterioration),

• Review of any tests, e.g. blood results, 12 lead ECG,

• Anything that may impact on the patient’s condition.

It is useful to allow some time to step back and consider changes and potential consequences of all
of the patient’s changes (see Fig. 12.1h).

Calculation of track and trigger score

The nurse should calculate the track and trigger score if this is being used. Once this is complete
the nurse should then ensure appropriate escalation. The track and trigger score will generally
indicate the degree of deterioration. If the score is low it may only necessitate increasing the
frequency of observations. If the score is high then urgent attention should be sought and escalation
policies followed.

It is probably advisable to follow the NICE (2007) guidance on escalation unless a local policy is
available and you may be expected to articulate who you would call and provide rationale for this.
The guidance suggests:

• Low score/concern. Patients scoring low scores should have the frequency of their
observations increased as a matter of course and the nurse in charge informed.

• Medium score/concern. Where patients score medium scores areas of concern should
be escalated to the primary medical team wherever possible. Outreach could also be
contacted if this service is available.

• High score/concern. Where the patient’s score is high there should be immediate
escalation of concern to an appropriate team. This may include medical emergency teams,
outreach calls, anaesthetists and cardiac arrest teams. The urgency of this escalation
should be articulated clearly and the need for an immediate response stressed (see Fig.
12.1i).
 Figure 12.1h Review observations and consider all changes

Figure 12.1i Escalation of concern

Communication

It is likely that you will be assessed on your ability to hand over your concerns to the nurse in
charge or the doctor. In some simulations you will have a telephone and be able to ring an examiner
acting as a ‘medic’.
 KEY POINT! It is likely that your ability to communicate your concerns succinctly and in a
logical manner will be assessed and this may, to an extent, be one of the most difficult
parts of the assessment. You are reminded to use a systematic tool such as the SBAR (see
earlier section on communication). A confident approach is useful in this area of
assessment.

To help you prepare for the OSCE please go to our website where you can listen to a nurse
communicating her concerns to a medic over the phone. Note how she does this succinctly
yet uses SBAR to provide all the necessary details.

Putting it all together!



As stated earlier this is clearly quite a complex skill to master and so Box 12.2 provides a useful
recap of all aspects of this skill.

Box 12.2 Putting it all together: systematic assessment of the acutely ill patient

1. Introduce yourself to the patient,

2. Gain consent where able,

3. Airway:

• Is patient talking to you?

• Any signs of obstruction?

• Any abnormal noises?

• Is there silence?

• Do you need airway adjuncts?

• Any laboured breathing/paradoxical breathing indicative of obstruction?

4. Breathing:

• Rate,

• Rhythm,

• Depth,

• Abnormal pattern,

• Symmetry,

• Effort,

• Use of accessory muscles,

• Presence of cyanosis.

5. Circulation

Heart rate:

• Strength,

• Speed,

• Rhythm,

• Regularity.

Blood pressure:

• Systolic pressure,

• Diastolic pressure,

• Pulse pressure.

6. Temperature:

• Hot/cold,

• Peripheral temperature: cool/clammy/delayed capillary refill.

7. Other factors

• How does patient feel? Patient tells you, e.g. ‘I don’t feel well’,
 • Chest pain.

8. Assessment of fluid status

• Fluid balance (needs to be up to date and accurate),

• Urine output,

• Any signs of fluid overload/dehydration.

9. Disability

Neurological factors

• AVPU,

• Blood glucose,

• Analgesia,

• Medication,

• Pain score.

10. Exposure/Everything else/Escalation

Exposure: Maintain dignity but expose patient (look under sheets/clothing)

• Any signs of bleeding?

• Any signs of fluid loss?

• Any oedema/where is this?

• Any signs of sepsis?

• Any signs of DVT/VTE?

• Any rashes?

Everything else:

• Recent blood results,

• Full history,

• Identify trends,

• Review ECG if appropriate,

• Step back and consider everything that may impact on patient through fresh eyes.

Escalation:

• Follow escalation policy on track and trigger chart,

• Call outreach/MET/Medic.

• Use SBAR tool:

Situation: where are you/who are you/why calling?

Background: PMH (past medical history), reason for admission, summary treatment to
date.

Assessment: use ABCDE framework, hand over findings systematically. State your
 concern. Articulate any suspicions.

Recommendation: what do you want doctor/outreach/team to do? Clarify an action plan

and document this clearly.

Examiners’ marking criteria

Various tools will be utilized to assess your competence at recognizing and responding to acute
deterioration. As stated in earlier chapters it is advisable to review your own university’s marking
criteria. An example of marking criteria is included in Table 12.1.

Table 12.1 Example of examiners’ marking criteria

Examiners’ questions

Some universities may assess your knowledge in relation to assessment of acute deterioration and it
is useful to prepare for that if that is a requirement. Some typical questions are included in Box
12.3.

Box 12.3 Example of examiners’ questions

1. Which groups of patients may be prone to deterioration?

2. Which groups of patients may have airway problems?

3. Which observation will alter first?

4. Why does respiration change if patient is deteriorating?

5. What else do you need to consider alongside oxygen saturations and why?

6. What is the significance of the systolic and diastolic blood pressure?

7. Why is it useful to examine the pulse pressure?

8. Why do patients develop tachycardia

9. Which groups of patients may become bradycardic?

10. What are the common causes of hypovolaemic shock?

11. How might the patient present in the compensatory stage of hypovolaemic shock?

12. How might the patient present in the progressive stage of shock?

13. How might sepsis present?

Answers are provided at the end of the chapter.

Common errors at this station

This is quite a stressful station to undertake and a number of errors occur; these include problems
related to failure to:

• Introduce yourself/communicate with the simulation manikin,

• Maintain infection control measures,

• Gain consent for patient assessment,

• Check patient’s airway or articulate that you are checking airway,

• Explain what you are checking and why,

• Assess the patient systematically,

• Include all elements of assessment,

• Respond appropriately to any changes you find,

• Complete all of assessment before escalating concern to the doctor (except in clear
emergency scenarios),

• Step back and appropriately review the situation,

• Understand the significance of your assessment findings,

• Demonstrate ability to seek appropriate help.

Alongside these, other common errors include:

• Panicking and becoming stressed,

• Rushing handover,

• Incoherent handover,

• Poor communication of concern,

• Poor timing in the station/running out of time.

Top tips for passing this station

Care should be taken at this station to avoid the common pitfalls. However, if you do make a
mistake you could consider the following:

• Returning to areas that you have missed as you will still be awarded points for this even
if it is out of sequence.

• Suggesting additional treatment/assessments at the end of the exam if you feel that you
have missed something.

• Providing explanation regarding your actions at the end of the exam if you forgot during
the exam itself.

The key to passing this exam station is demonstrating the ability to:

• Follow a systematic approach,

• Remain calm,
 • Conduct a thorough assessment,

• Summarize your findings,

• Ensure appropriate escalation,

• Communicate changes effectively.

You may enhance your ability to pass this station by practising this skill and there are several things
that students have found helpful:

• Practising alongside your colleagues in clinical skills room,

• Attending university practice and theory sessions,

• Using the skill in practice with your mentor and asking for constructive feedback,

• Working a day with a critical care outreach practitioner to observe experts using this
skill,

• Attending study sessions that are run in practice (if the NHS Trust allows this),

• Practising sequence whilst being timed; this allows you to roughly calculate how much
time is needed for each part of the assessment.

To help you practise this we have provided a fictional example of a deteriorating patient online for
you to use. Print this off and in a group of three:

• One can be the examiner and can walk through the sequence,

• One can read out instructions and respond when asked by the examinee,

• One can use the examiner’s marking sheet to give feedback.

Box 12.4 A student’s view

‘I found this station quite frightening at first because there was so much to remember.
Remembering the ABC format helped loads and I attended the practice sessions and tried, as best I
could to practise in my ward. I was glad it was a formative assessment but I learnt so much from the
assessment and I know this has built my confidence for handling emergencies in clinical practice
when I am qualified.’

Third year student nurse after a formative OSCE assessment

Online resource centre

To help you prepare for the OSCE please go to our website where you can listen to a nurse
communicating her concerns to a medic over the phone; note how she does this succinctly yet uses
SBAR to provide all the necessary details. Go to www.oxfordtextbooks.co.uk/orc/caballero/.
Demonstration of systematic assessment is also available online at
www.oxfordtextbooks.co.uk.orc/caballero/.
References

British Thoracic Society (2008). Guideline for Emergency Oxygen Use in Adult Patients.
London: BTS.

Creed, F., Dawson, J. and Looker, K. (2010). Assessment tools and track and trigger
scoring systems. In: Creed, F., and Spiers, C. (2010) Care of the Acutely Ill Adults: An
Essential Guide for Nurses. Oxford: Oxford University Press.

Cretikos, M., Bellamo, R., Hillman, K., Chen, J., Finfer, S. and Flabouris, A. (2008).
Respiratory rate as an indicator of acute illness. Medical Journal of Australia, 188(11):
657–659.

Department of Health (2009). Competencies for Recognising and Responding to Acutely Ill
Adults in Hospital. Draft Guidelines for Consultation. London: DOH, HMSO.

Endacott, R., Jevon, P. and Cooper, S. (2009). Clinical Nursing Skills: Core and Advanced.
Oxford: Oxford University Press.

Jevon, P. (2007). Treating the Critically Ill Patient. Oxford: Blackwell Publishing.

McGloin, H., Adam, S.K. and Singer, M. (1999). Unexpected deaths and referrals to
intensive care of patients on general wards: are some potentially avoidable? Journal of the
Royal College of Physicians, 33: 255–259.

McQuillan, P., Pilkington, S. and Allan, A. (1998). Confidential enquiry into quality of care
before admission to intensive care. British Medical Journal 316: 1853–8.

National Confidential Enquiry into Patient Outcome and Death (2005). An Acute Problem?
London: NCEPOD.

National Patient Safety Agency (2007). Safer Care for the Acutely Ill Patient: Learning
from Serious Incidents. London: NPSA.

NHS Institute for Innovation and Improvement (2008). No Delays Achiever, Service
Improvement Tools (SBAR). London: NHS.

NICE (2007). Acutely Ill Patients in Hospital: Recognition of and Response to Acute Illness
of Adults in Hospital. London: HMSO.

Resuscitation Council (2006). Advanced Life Support, 5th edn. London: Resuscitation
Council.

Smith, G. (2003). ALERT: Acute Life Threatening Events, Treatment and Recognition. 2nd
edn. Portsmouth: University of Portsmouth.

Surviving Sepsis Campaign (2007). www.survingsepsis.org.

Appendix: answers to examiners’ questions

1. Any patient’s condition may deteriorate at any time and the nurse should be vigilant for
change in all patients. Those patients who are at particular risk include:

• The elderly,

• The very young,

• Those with pre-existing condition,

• Malnourished patients,

• Cancer patients,

• Post operative patients.

2. Any patient but again those particularly at risk include:

• Post operative patients,

• Patients who are drowsy,

• Patients on large doses of opiate based analgesia,

• Patients admitted with acute neurological problems, e.g. head injury or stroke,

• Those patients with pre-existing neurological problems,

• Those patients with new or evolving neurological disease.

3. Respiration will change before any other sign.

4. The need for more oxygen is apparent in any situation of patient deterioration. The
respiratory drive will therefore automatically increase in an attempt to increase
oxygenation.

5. Saturation recordings need to be reviewed in line with oxygen requirements as this

gives an indication of how poor the patient’s oxygenation actually is. For example, if a
patient has saturations of 90% on air there is scope to improve oxygenation by adding
supplementary oxygen. However, if a patient has saturations of 90% on 15 litres of oxygen
via a non re-breathe mask there is no scope to add more oxygen and that patient is very
sick.

6. Systolic and diastolic pressures should be reviewed together as this will give the nurse
an idea if the patient is compensating for any form of shock. It would be expected that
diastolic changes would be seen before systolic pressure changes. In hypovolaemic and
cardiogenic shock, the diastolic pressure would rise; this signifies the release of
vasoactive substances that cause vasoconstriction in the compensatory stage of shock.
When compensation fails the systolic pressure will rapidly deteriorate. In the early stages
of distributive shock the diastolic pressure will fall and systolic pressure may remain
constant or fall. Exploration of these pressures may help the nurse to try to identify where
the problem is, e.g. bleeding verses sepsis.

7. The pulse pressure is an important indicator of shock and may help the nurse identify
whether compensation is occurring. Examination of the pulse pressure will help the nurse
to identify whether vasoconstriction or vasodilatation is occurring. In hypovolaemic and
cardiogenic shock the pulse pressure will narrow. In sepsis and other forms of distributive
shock the pulse pressure will widen as vasodilatation is occurring.

8. Patients develop tachycardia in response to the stimulation of the sympathetic nervous

system. In stress responses the parasympathetic nervous system is inhibited (this
prevents vagal stimulation to the sino-atrial node and increases the heart rate). At the
same time a release of adrenalin acts on the beta receptors in the heart. This increases
the heart rate and contractility of the cardiac muscle in an attempt to increase blood
pressure. Some patients who are deteriorating may also develop cardiac rhythm problems
that result in tachycardia, e.g. atrial fibrillation/supra ventricular tachycardia.

9. Patients with cardiac problems, e.g. right sided myocardial infarctions and patients
with heart block, may develop bradycardia. Additionally patients with hypothermia, raised
 intracranial pressure, neurogenic shock and hypothyroidism may become bradycardic.
Caution is advised in patients who are beta blocked as they may not exhibit raising heart
rate in response to shock conditions.

10. Common causes include:

• Excessive blood loss,

• Loss of body fluids,

• Movement of fluid into another space (third space),

• Dehydration,

• Excessive diuretics,

• Burns,

• Vomiting/diarrhoea.

11. In the compensatory stages of shock the patient will present with:

• Increased respiratory rate,

• Tachycardia,

• Normal or slightly raised systolic pressure,

• Increasing diastolic pressure,

• Narrowing pulse pressure,

• Increased capillary refill time,

• Cool peripheries.

12. In the progressive stage of shock the patient will present with:

• Hypotension,

• Tachycardia,

• Increased respirations,

• Pallor,

• Sweating,

• Decreased levels of consciousness,

13. Sepsis will usually present with:

• Increased temperature,

• Increased respiratory rate,

• Tachycardia,

• Warm peripheries,

• Quick capillary refill times (less than 2 seconds),

• Patient reporting feeling ‘fluey’,

• Increased white cell count,

• Increased C reactive protein,

• Increased blood lactate.

Patients with neutropenia may not present with typical pyrexia

Patients in late stages of sepsis may present with hypothermia.


Chapter 13
Basic life support (BLS)

Clare Cree

Chapter aims

This chapter will enable you to:

• Revise key material in relation to BLS,

• Follow a step by step guide to BLS,

• Understand how to prepare and revise for this OSCE,

• Highlight common problems at this station and identify how these may be avoided.

Introduction

This chapter will focus on preparing you to undertake an OSCE in the skill of basic life support
(BLS), in a cardiac arrest situation, following the Resuscitation Council (UK) Guidelines (2010).
Basic life support guidance is aimed especially at adults who in their professions have a duty to
respond to a cardiac arrest. Basic life support refers to maintaining the airway, breathing and
circulation without the use of any equipment, other than protective devices (Resuscitation Council
(UK) 2010). A number of studies (Ahmet and Sarac 2009; Berdowski et al. 2009; Oermann et al.
2011) recognize that effective implementation of guidance is likely to be enhanced by
comprehensive and timely education. Soar et al. (2010) suggest that survival from cardiac arrest is
dependent on a number of factors—particularly that respondents are well equipped and practiced in
the skill and that quality educational packages are readily available to those responders. This
chapter will endeavour to provide you with the relevant information to revise the components
required to complete an OSCE in the skill. Emphasis is placed on the importance of providing
effective, good quality chest compressions whilst minimizing any pauses and so maximizing blood
flow and oxygenation.

Key revision for your simulated examination

Note: The first aspect of the BLS skill you will be expected to carry out during your OSCE
is a full risk assessment of the situation including safety and infection control issues.

Safety

A respondent to any medical emergency should not put themselves or those around them at any
risk. If this is impossible, however, measures should be taken to minimize that risk whilst ensuring
no further harm comes to the casualty. In your OSCE, you will be expected to review the
surrounding area for hazards, e.g. deep water, electricity, oncoming vehicles, fire and smoke, falling
debris, biological threats, etc., to ensure your own and the patient’s safety.
 Note: This will depend on the way in which your OSCE station has been set up and if there
are no threats to yourself or the patient you will need to verbalize to the examiner that
you have checked the surrounding area and that it is safe for you to continue.

Only if the casualty or respondent is at risk of significant further injury should they be moved to a
safe place. Moving the casualty, however, should not propose any injury to the respondent.

Note: It is highly unlikely that you would be expected to move the patient during this
OSCE but still be prepared to if this will be required.
Particularly in the health care environment it is necessary to protect the casualty, respondent/s and
other patients or clients from infective hazards and for this reason personal protective equipment
(PPE) is available in the form of disposable gloves, aprons, goggles, masks and hand
decontamination either in gel form or washing facilities. Should your scenario be a hospital based
cardiac arrest you will be expected to decontaminate your hands and put on gloves and apron prior
to commencing BLS.

Note: All the necessary personal protective equipment will be made available to you at the
OSCE station.

Health care workers and patients are vulnerable to communicable diseases due to their highly
contagious nature and the close proximity of the population within the environment (Rothman et al.
2006). Studies following the severe acute respiratory syndrome (SARS) epidemic in 2003 (Chan-
Yeung 2004; Chen et al. 2004) showed that outbreaks of infection occur rapidly when health care
workers are overstretched. It is when situations are at their most stressful that health care workers
must follow the most basic of infection control principles during all patient contact to minimize the
spread of unknown pathogens into the general community.

KEY POINT! Once the safety of the casualty, you as the respondent and those around you
has been secured you can commence the basic life support algorithm (Fig. 13.1a).

The Resuscitation Council (UK) has developed an algorithm demonstrating the sequence in which
events should occur. This algorithm will now be gone through step by step to guide you through
your OSCE.
Responsiveness

In order to check for responsiveness you will be expected to gently shake the casualty’s shoulders
and ask loudly, ‘Are you alright?’ as demonstrated in Fig. 13.1b.

If the casualty makes a response you should try to find out what is wrong with them so that this can
be relayed to any help that is summoned. The casualty should be checked regularly for any signs of
deterioration.

Figure 13.1a Adult basic life support algorithm (Resuscitation Council (UK) 2010).

Figure 13.1b Check for responsiveness

If the casualty does not make any response to the ‘shake and shout’, help should be summoned
immediately. If you are alone with the casualty and there is no response to your call for help you
should open the airway and confirm absence of normal breathing before leaving your casualty to
summon help.

Note: As this is an OSCE to assess your competency in this skill the casualty will not
respond and you will be expected to put out an emergency call once you have established
an unresponsive casualty. This call could be a shout, 2222 call in a hospital or 999 call
 outside of a hospital. Some OSCE stations may have a telephone available for you to do
this or you may be required to ask someone else to put the call out. Please make sure you
understand what is expected of you in relation to this before commencing the OSCE. You
will be assessed for your ability to stay calm, act professionally and communicate clearly
throughout this station.

Calling for help

The method for calling for help will be dependent on the individual circumstances. Regardless of the
situation help should be sought ultimately from someone who is qualified and capable of providing
advanced life support.

In the health care environment this will generally involve pulling an emergency alarm and making a
telephone call, or asking someone else to do it, to summon the cardiac arrest or medical emergency
team. Each university will have slightly differing protocols for summoning emergency help and
therefore it is important that you know what will be expected of you for the OSCE.

Note: Whilst you are waiting for help to arrive you will be expected to open the casualty’s
airway.

Opening the airway

Basic life support follows the ‘ABC’ method of assessment and treatment advocated for all medical
emergencies (NICE 2007). ‘A’ is for airway and it is important to open this before moving on to any
further treatment or assessment. Without an intact airway it will be impossible for the casualty to
take in oxygen. The longer the organs and tissues, especially the brain, are without oxygen the less
likely the casualty is to recover without any long term damage.

There are two methods for ensuring the casualty’s airway is open. Firstly the preferred ‘head tilt
chin lift’ method and secondly the ‘jaw thrust’ are techniques that will minimize further damage
where spinal injury is suspected. The jaw thrust is not recommended for the untrained rescuer to
perform as it is difficult to learn and execute effectively (Resuscitation Council (UK) 2010).

Note: You will not be expected to demonstrate a ‘jaw thrust’ in your OSCE.

To do the ‘head tilt chin lift’ effectively, the casualty should be placed on their back. You will kneel
next to the casualty, placing one hand on the victim’s forehead, and gently tilt the head backwards.
Using two fingertips of the other hand, place them under the casualty’s chin and lift the chin to
open the airway (Fig. 13.1c). During the assessment of airway it is important to check that there are
no foreign bodies or sputum or vomit obstructing the airway. If these are present they should be
removed, using suction if required. Once the airway has been opened you must then check for signs
of normal breathing.

Signs of normal breathing

Looking for signs of normal breathing should be done for a time not exceeding 10 seconds with the
airway open. Therefore you must maintain the position described previously whilst checking
whether there is any chest movement, breath sounds or air coming from the casualty’s mouth. This
is best done when you remain in a kneeling position, placing your cheek just above the casualty’s
mouth and nose, and utilize a look, listen and feel approach to assess for breathing.

Small, infrequent and noisy gasps of breath may be evident from the casualty during a cardiac
arrest situation. In fact, Bobrow et al. (2008) describe these as ‘agonal gasps’ and suggest that they
are common in as many as 40% of cases. This, however, must not be confused with normal
breathing and should not delay commencement of the next step in the algorithm. If you are in any
doubt you should act as if there is no normal breathing (Ewy 2007) and begin chest compressions.
 Note: During the OSCE your casualty will not have any breathing sounds so you will need
to move onto the next step of the algorithm. If you have not already summoned help you
should call for help. This call could be a 2222 call in a hospital or 999 call outside of a
hospital.

Thirty chest compressions

Chest compressions should be started without delay and you will be expected to give 30 chest
compressions without interruption. Early chest compressions will improve the casualty’s potential
for survival and prognosis (Resuscitation Council (UK) 2010).

Figure 13.1c The ‘head tilt chin lift’ method

 Figure 13.1d Correct hand position for performing chest compression

Figure 13.1d demonstrates the correct hand position for performing chest compressions. You should
be kneeling beside the casualty with the heel of one hand in the centre of the casualty’s chest. The
heel of the other hand should be placed on top of the first hand and the fingers should be
interlocked to ensure pressure is not exerted over the ribs, abdomen or the end of the sternum
(breastbone). You should then position yourself vertically to the casualty’s chest with your arms
straight. A downward pressure should then be applied quickly and released. It should be aimed to
depress the casualty’s chest between 5 and 6 cm in depth at a rate of 100–120 compressions per
minute whilst allowing the chest to recoil completely after each compression (Resuscitation Council
(UK) 2010).

Note: Some manikins used during OSCEs will have a digital display unit which will be able
to provide you and the examiner with visual feedback on how effective your chest
compressions are and if your hands are in the correct position. Make sure you are familiar
with this technology if it is going to be used in your OSCE.

Compressions should be repeated 30 times consecutively without interruption. You will find it easier
to count each compression (you can do this out loud during the OSCE and this is positively
encouraged) in order to recognize the number performed and it should be recognized that
delivering chest compressions effectively can be exhausting. Zhan et al. (2009) studied the effects
of two different methods of counting on rescuer fatigue during cardiac arrest, ascertaining that
counting from 1–10 three times was less tiring, it taking longer for the respondents to reach peak
heart rate than when counting from 1–30 continuously. They suggest this is due to the polysyllabic
nature of the numbers counted in the continuous count.

KEY POINT! When 30 continuous chest compressions have been delivered you can then
progress to the final step on the resuscitation algorithm.

Two rescue breaths: Thirty compressions

Once 30 chest compressions have been delivered you will be expected to deliver two breaths via the
casualty’s mouth in an attempt to inflate the lungs so that further oxygen may be delivered to the
system during the next round of compressions. The casualty’s airway should be opened again in
order to deliver effective rescue breaths.

In a health care environment masks should be available with a one-way valve to assist in the
delivery of the rescue breaths (Fig. 13.1e). Larger ‘bag-mask’ devices that can also be connected to
a supplemental oxygen supply may also be available although this piece of equipment requires two
people to operate it effectively (Fig. 13.1f).

Figure 13.1e One-way valve environmental mask

 Figure 13.1f Larger bag-mask

Note: All relevant masks will be made available to you at the OSCE station.

You will now be expected to carry out rescue breaths utilizing the following process in order:

• The student opens the casualty’s airway.

 • The student closes the casualty’s nose by gently pinching the soft area of the casualty’s
nose with the index finger and thumb of one hand.

• The student allows the casualty’s mouth to open whilst still maintaining the ‘chin lift’
position.

• The student places their mouth over the casualty’s mouth ensuring there can be no
leakage of air between the contact.

• The student blows steadily into the casualty’s mouth whilst watching the casualty’s
chest rise.

• The student takes their mouth away from the casualty’s and watches the chest fall.

• The student repeats the process again.

You should make no more than two attempts at giving effective rescue breaths because further
attempts would increase the time in which the casualty has no circulating blood being delivered to
the tissues. These two breaths should not take longer than 5 seconds.

Once this process has been completed you will be expected to begin giving 30 chest compressions
in exactly the same manner as in the previous step on the algorithm. This part of the algorithm will
continue until either qualified help arrives or the victim begins to show signs of regaining
consciousness or the examiner asks you to stop. It is vital that there is no time delay in beginning
subsequent sets of chest compressions associated with the delivery of rescue breaths as in fact
chest compressions alone may be more beneficial than any unproductive pause. Soar et al. (2010)
actually suggest that in some circumstances it can be as effective to give continual chest
compressions without pausing to deliver rescue breaths at all. They do recommend, however, that
personnel with a ‘duty to care’ (which you are) should be trained to do chest compressions and
ventilations.

Delivery of chest compressions and rescue breaths at a ratio of 30:2 will continue until the examiner
asks you to stop.

Note: In a real clinical situation in order to reduce fatigue it may be necessary for others
to take over chest compressions at regular intervals although pauses should be kept to an
absolute minimum. If someone is to recover from a cardiac arrest the aim of the
respondent/s should be that the casualty will be of full mental capacity when they do
eventually regain consciousness or no worse than they were prior to the incident. To
achieve this a respondent must provide optimum artificial circulation and ventilation.
 Note: Some OSCEs on BLS might expect you to demonstrate your ability to put someone
into the recovery position at the end of the scenario; please follow the directions on how
to do this.

Recovery position

If the casualty is breathing normally they should be moved into the recovery position and their
breathing closely monitored until help arrives. The following sequence is recommended by the
Resuscitation Council (UK) to achieve the recovery position:

• Kneel by the casualty, making sure both their legs are straight.

• Place the nearest arm out at right angles from the casualty’s body with the elbow bent
up toward the head and palm of the hand facing up.

• Bring the furthest arm across the casualty’s chest, holding the back of their hand
against the near side cheek.

• Bend the far leg at the knee, keeping the foot on the ground.

• The far leg should then be used to lever the casualty onto their side.

• Once on their side, the casualty’s upper hip and knee should be manoeuvred so that they
are at right angles to each other.
 • Tilt the casualty’s head back so that the airway remains open.

The OSCE station

The OSCE is likely to be performed in a clinical skills laboratory at your university campus, and you
will generally have a time limit of between 10 and 15 minutes to complete the skill. The room will be
set up with a manikin either in a bed or on the floor and all relevant equipment will be made
available to you, e.g. PPE and masks.

You will be expected to communicate with the manikin and carry out the skill of basic life support
following these steps. Following the completion of the procedure you may be asked some questions
about basic life support so be prepared!

Examiners’ marking criteria

The criteria used to assess your basic life support skills will vary between universities and will
depend on the type of casualty you have. An example of simulated examination criteria are in Table
13.1.

Table 13.1 Example of examiners’ marking criteria

Examiners’ questions

Some universities may assess your knowledge in relation to resuscitation and it is useful to prepare
for that if that is a requirement. Some typical questions are included in Box 13.1.

Box 13.1 Example of examiners’ questions

1. Before commencing BLS what is the first thing you must do?
 2. What PPPE should you think of using?

3. Give three examples of the types of hazards you need to look out for when securing the
scene.

4. In what three ways can you call for help?

5. What does the ‘A’ stand for in the ABC assessment for BLS?

6. Which method of opening the patient’s airway is preferred?

7. How long do you take to look for normal signs of breathing once you have opened the
airway?

8. How many chest compressions do you do consecutively?

9. What is the ratio of breaths to chest compressions?

10. If your patient shows signs of improvement and starts to breathe on their own what
position can you put them in?

Answers can be found at the end of the chapter.

Common errors at this station

A number of errors occur at this station; these include failure to:

• Ensure that the scene is safe,

• Use appropriate PPE (gloves and aprons in hospital arrest situations),

• Put out an emergency call,

• Open the airway adequately,

• Administer 30 consecutive chest compressions in a timely fashion,

• Position hands correctly for effective chest compressions,

• Compress the chest effectively,

• Quickly provide adequete ventilations, thereby increasing the time away from chest
compressions,

• Carry out correct breath to chest compression ratios.

Top tips for passing this station

• Practise as much as you can prior to taking the OSCE utilizing all the practical sessions
put on by your university skills team.

• Learn the process off by heart so you do not have to spend valuable time thinking about
what to do next.

• Revise the underpinning knowledge in relation to basic life support as you may well be
asked questions at the end of the procedure. Please refer to the section on questions in
this chapter to guide your revision.

• If during the OSCE you realize that you have not done something or that you are doing it
incorrectly DO NOT PANIC—just stop, explain to the examiner what is wrong and start
again.
 • If you need to start again be aware that you may well be under a time constraint so
again DO NOT PANIC—carry out the procedure as best you can.

• If you run out of time you will be referred (i.e. not passed yet!) at this attempt but be
assured you will be given at least one more opportunity to pass.

• If you pass CONGRATULATIONS, you have mastered a life saving skill.

Online resource centre

You can find further advice and revision help for your OSCEs by going online now to see
www.oxfordtextbooks.co.uk/orc/caballero/.

References

Ahmet, O. and Sarac, L. (2009). The effects of different instructional methods on students’
acquisition and retention of cardiopulmonary resuscitation skills. Resuscitation, 81: 555–
561.

Berdowski, J. et al. (2009). Time needed for a regional emergency medical system to
implement resuscitation guidelines 2005—The Netherlands experience. Resuscitation, 80:
1336–1341.

Bobrow, B. et al. (2008). Gasping during cardiac arrest in humans is frequent and
associated with improved survival. Circulation, 118: 2550–2554.

Chan-Yeung, M. (2004). Severe acute respiratory syndrome (SARS) and healthcare

workers. International Journal of Occupational Environmental Health, 10: 421–427.

Chen, S.Y. et al. (2004). Facing an outbreak of highly transmissible disease: problems in
emergency department response. Annals of Emergency Medicine, 44: 93–95.

Ewy, G. (2007). New concepts of cardiopulmonary resuscitation for the lay public:
continuous chest compression CPR. Circulation, 116: 1907–1915.

National Institute for Health and Clinical Excellence (2007). NICE Clinical Guideline 50.
Acutely Ill Patients in Hospital: Recognition of and Response to Acute Illness in Adults in
Hospital. London: National Institute for Health and Clinical Excellence.

Oermann, M. et al. (2011). Effects of monthly practice on nursing students’ CPR

psychomotor skill performance. Resuscitation, 10: 1016–1022.

Resuscitation Council (UK) (2010). Resuscitation Council Guidelines 2010 (ed. J.P. Nolan).
London: Resuscitation Council (UK). www.resus.org.uk.

Rothman, R., Hsieh, Y. and Yang, S. (2006). Communicable respiratory threats in the ED:
tuberculosis, influenza, SARS and other aerosolized infections. Emergency Medicine
Clinics of North America, 24: 989–1017.

Soar, J. et al. (2010). European Resuscitation Council Guidelines for Resuscitation 2010,
 Section 9. Principles of education in resuscitation. Resuscitation, 81: 1434–1444.

Zhan, L., Qing, H. and Yang, M. (2009). The effects of two different counting methods on
the quality of CPR on a manikin—a randomized control trial. Resuscitation, 80: 685–688.

Appendix: answers to examiners’ questions

1. Before commencing BLS what is the first thing you must do?

• Secure the scene and make sure the environment is safe for both the casualty and
yourself.

2. What PPE should you think of using:

• Masks,

• Gloves,

• Aprons,

• Goggles,

• Aseptic gel.

• Secure the scene and make sure the environment is safe for both the casualty and
yourself.

3. Give three examples of the types of hazards you need to look out for when securing the
scene?

• Deep water,

• Electricity,

• Oncoming vehicles,

• Fire and smoke,

• Debris,

• Biological threats.

4. In what three ways can you call for help?

• Pull emergency call bell,

• Telephone hospital emergency number,

• Ask someone else to put the call out for you.

5. What does the ‘A’ stand for in the ABC assessment for BLS?
• Airway.

6. Which method of opening the patient’s airway is preferred?

• Head tilt chin lift.

7. How long do you take to look for normal signs of breathing once you have opened the
airway?

• 10 seconds.

8. How many chest compressions do you do consecutively?

• 30

9. What is the ratio of breaths to chest compressions?

• 2:30

10. If your patient shows signs of improvement and starts to breathe on their own what
position can you put them in?

• Recovery position.


PART III
Final preparation



Chapter 14
Reflecting upon your OSCE

Fiona Creed

Chapter aims

This chapter will explore learning from your OSCE experience through the reflective process. It will
explore:

• Definitions of reflection,

• Why reflection is important after an OSCE,

• Models available to aid your reflection,

• How you can use reflection to learn from the OSCE experience,

• Using feedback from your OSCE to develop practice,

• Moving forward after your OSCE.

Introduction

Once you have completed your OSCE assessment you will be informed of the outcome of the
assessment. This may be on the day, if it is a formative assessment, or sometime afterwards, if it is a
summative examination that has to be processed through an examination board. You should be
provided with detailed written feedback about your performance at the OSCE and it is useful to
review this alongside your recollections of the experience as this will help you to learn from the
experience.
Reflection is an important tool to use whether you have been successful or unsuccessful during your
OSCE. It is important in nursing that we are able to reflect and learn from both positive and
negative experiences.

Some universities may require you to reflect on your OSCE as part of the examination. Again this
may be on the day, immediately after your OSCE or a short period afterwards by reviewing a video
of your OSCE (the latter normally happening as part of a formative learning process).

What is reflection?

Reflection is not unique to nurses and is something that we do throughout our lives. In everyday
terms reflection may be described as an examination of our personal thoughts and actions
(Somerville and Keeling 2004).

In nursing you will be encouraged to develop reflective skills to facilitate your learning in the
university and in practice this is often referred to as reflective practice and is slightly different to
‘everyday reflection’. Indeed throughout your nursing career you will be encouraged to develop
reflective practice skills and become a reflective practitioner.

Reflection as a process was first discussed in 1933 by John Dewey who first identified the need to
evaluate our experiences and learn from them. In nursing as with most concepts there are a number
of definitions of reflection and this can at first appear to be confusing. Simplistically reflection can
be defined as a process of examining and exploring an issue that is related to an experience that
results in new learning. Therefore reflection refers to a series of steps that you may take to question
and explore an experience with the aim of learning from it (Hart 2010). Within health care many
models of reflection have been developed to facilitate the reflective process and you may be
required to utilize a model by your university (models of reflection will be discussed later in this
chapter). Most theorists agree that the reflective process can be used to reflect in two ways:

• Reflection on action,

• Reflection in action.

Schon (1983)

The main difference between these two processes is the time when reflection takes place (Hart
2010).

Reflection on action

This is perhaps the commonest form of reflection in nursing. During this process you are
encouraged to carefully rerun through events that have occurred in the past. The main aim of this
process is to evaluate your strengths and weaknesses and to develop new strategies for being more
effective in the future (Somerville and Keeling 2004). This type of reflection is often referred to as
retrospective as it occurs after the event you are reflecting on has taken place.

Most nurses will automatically use this sort of reflection after their OSCE to try to decide what their
strengths and areas for improvement were during the examination. Sometimes there is a tendency
for students to concentrate upon their mistakes and issues they think they have forgotten during the
exam and this is not always helpful.

Some universities may require you to reflect upon your actions (reflecting on action) and may use
this reflection to enhance your grade. For example if you forget to gain consent as the student in
Box 14.1 did you could identify this in your reflection and explain why consent is important. In some
universities an effective reflection on action, in which you discuss any potential errors, may make
the difference between a pass and fail grade.

Reflection in action

It is acknowledged that reflection in action generally only occurs with very experienced
practitioners and is a much more complex form of reflection (Tate and Sills 2004; Somerville and
Keeling 2004). Reflection in action involves exploring and reflecting upon a situation whilst you are
actually in the situation. A widely recognized nurse theorist, Benner (1984) suggests that this sort
of reflection involves experienced nurses using tacit knowledge (knowledge that is difficult to
articulate, such as ‘a feeling about something’) to help you make a decision about something whilst
you are in a situation. For example you are assessing a patient whose condition is deteriorating and
when you realize that something is ‘not quite right’ about that patient you alter the way you are
assessing the patient in order to find out what is wrong with the patient.

Box 14.1 Student reflection following an OSCE

‘When I reflected upon my OSCE I realized that I forgot to do things in the skills assessment that I
know I should have done. I made a few silly mistakes and felt really embarrassed. The worst
mistake was putting a thermometer in the patient’s ear without consent. I would never do this in a
real situation! I think reflecting upon it I was too anxious and had not really prepared for the
examination situation.’

It is unlikely that you will use reflection in action in your OSCE examination as most theorists link
this sort of reflection with experienced rather than student practitioners. Even with experience
reflection in action would be difficult in a stressful situation like an examination (Cottell 2007).

Why is reflection important in nursing?

There are a number of reasons why your university encourages you to develop reflective skills:

• Reflection can help you to focus upon the knowledge, skills and behaviour that you will
need to develop for effective clinical practice.

• Reflection will help you to identify your personal strengths and areas for improvement.
In identifying those areas that you feel require improvement you provide an opportunity
for future personal and professional development.

• Reflection will encourage you to become more self aware and encourage you to
understand your interactions with others.

Reflection will enable you to learn from your experiences and continually enhance your skills and
knowledge—an essential component of life long learning.

Using models to aid reflection

Many universities will encourage you to use a model for your reflection on your OSCE experience. A
reflective model provides structure and guidance to your reflection on your OSCE and may be used
to help you develop more effective reflective skills. The university may decide which model is useful
to guide your reflection and you will be required to use that model or you may choose a model that
you feel is most appropriate. There are many models of reflection available and it is beyond the
scope of this book to discuss all these. However, you are reminded to discuss reflective models with
the OSCE team and find out which models you should use and read around these. Models available
include:

• Gibbs’ reflective cycle,

• Johns’ model for structured reflection,

• Kolb’s learning cycle,

• Atkin and Murphy’s model of reflection,

• Rolfe’s framework for reflective practice.

The example that will be briefly described here is Gibbs (1988) as this is commonly used by nursing
students. However, regardless of which model you choose to reflect upon your OSCE there is a
common approach that is used in all processes that reflect on situations (Tate and Sill 2004).

The initial stage of reflection will be to return to the experience. During the reflection on your OSCE
you will need to return to the situation and remember what happened and explore this. It is
important that when you are reflecting you are kind to yourself and view the reflective cycle as
something to enhance learning rather than destroy your confidence. In most reflections nurses
often concentrate upon what they have not done or what they have done badly. Whilst this negative
approach is very common in nursing reflections and may help your professional development it does
sometimes prevent us from focusing upon what we have done well. (An example is included in Box
14.2.)

Box 14.2 Student reflection on an OSCE

‘In my BP assessment I found out the reason why I had failed and that was because I let the cuff
down too quickly and could not really hear the systolic and diastolic pressures properly.’

In this segment of the reflection it is clear the student is focusing upon the negative aspect of the
OSCE and not focusing upon the positive aspects of her care such as excellent infection control,
effective interpersonal skills and maintenance of patient dignity.

Remember when you return to your OSCE experience try not to focus on the negative elements
only.

Once you have recollected your experience, it may be of benefit to use a model to help focus your
reflection. Gibbs will be discussed as a tool for reflection upon your OSCE experience. Gibbs (1988)
developed his reflective cycle in 1988 and it is a useful and simplistic model that can be used to
guide reflection and is shown in Fig. 14.1.

The stages of Gibbs’ reflective cycle are described briefly here (it may be useful to refer to this work
in more detail if you are not already familiar with it).

Describe Event

This stage encourages returning to the experience and describing it. This stage is vital as it allows
you to recollect what happened. It is best to do this as soon after the event as possible so that the
memory is still fresh, although you may still forget some aspects of the experience.

Feelings

This stage encourages you to explore your feelings during the situation. It enables you to reflect
back upon what you were thinking about and any memories about the situation that you consider to
be important.

Figure 14.1 Reflective cycle of Gibbs (1988)

Evaluation

This stage encourages you to explore positive and negative aspects of the situation as well as
evaluating what happened during the situation.

Analysis

This stage encourages you to break down the situation into its component parts so that you can
explore each element separately. During this stage it is important to consider what factors impacted
upon the experience.

Conclusion
In this stage you are encouraged to explore the situation from different angles so that you can make
your judgement of the situation having explored all the issues that may have been involved in the
experience. It may be useful to explore here anything that you feel you handled well or could
improve upon.

Action Plan

In this stage you should reflect upon how you would act if you encountered the experience again.
You should consider whether you would act differently or whether you would act exactly the same if
this situation were repeated. This is an important stage in helping you to summarize learning from
the experience.

When reviewing your own OSCE experience you can use the questions in Box 14.3 to
guide your reflection. Do try to complete all of the questions.

Note you can also download copies of this to print out and write on from our online
resource centre: www.oxfordtextbooks.co.uk/orc/caballero/.

Box 14.3 Using Gibbs to reflect upon your OSCE

1. Describe Event: Describe what happened during your OSCE. Try to remember exactly
what happened during the OSCE situation and briefly write it down.

2. Feelings: What were you thinking and feeling at the time of your OSCE? Try to
remember how you were feeling. Were you very anxious? Were you calm?

3. Evaluation: List points that were GOOD and BAD about the experience. Try to focus
upon positive aspects first. What went well? Was there anything you were pleased about?
Once you have fully explored the positive aspects think about any areas you could have
improved upon. Try to focus on areas for improvement rather than negatively focus upon
‘things you forgot’ or ‘things that went wrong’ as this will help when you come to the
action plan stage!

4. Analysis: What sense can you make out of the situation? Break the OSCE situation down
into small components and focus on evaluating each of these small parts. Have a number
of influences affected your OSCE or was there only one issue?
 5. Conclusion: Focus upon answering the following: What went well (remember to
celebrate this!)? What could you have done in the OSCE? What perhaps would you not
have done in your OSCE?

6. Action Plan: If you had to retake your OSCE again, what would you do differently to
ensure you passed? If you have passed your OSCE consider what went well. How will you
learn from this experience and remember to repeat this in clinical practice?

Once you have completed this reflective account it is important that you acknowledge the positive
outcomes, explore how you can improve and develop an action plan following this experience.

Remember it may take some time getting used to using a structured model of reflection since it
encourages us to reflect in much more detail than we are used to in everyday life. Nevertheless it is
an important skill to develop as you will be expected to develop your reflective skills throughout
your time at university and as a registered nurse!

Making good use of feedback from your OSCE

The focus of discussion has so far emphasized the importance of the development of self reflection
during your OSCE and how this can be of benefit to you. However, you are also likely to be provided
with some written or verbal feedback from the examiner and it is important that you are able to
utilize this and develop the ability to reflect upon feedback from the examiner.

Understandably most students are keen to discover whether they have been successful or
unsuccessful with their OSCE and this is of course an important consideration. However, the
feedback that you receive, irrespective of your success, can help you to further develop and it is
vital that you read and reflect upon feedback as well.

Written or verbal feedback will provide you with an experienced lecturer’s opinion regarding your
achievement at OSCE and feedback from another perspective is central to the process of reflection
(Somerville and Keeling 2004). It is likely that feedback from a lecturer will provide you with an
objective opinion of your achievement in your OSCE. Recollect (Chapter 1) that one of the reasons
that OSCEs were developed was to provide an objective assessment that provides objective
feedback to the student. Your lecturer will highlight areas that you excelled in and areas where
there is scope for improvement. It is useful to use this feedback alongside your own personal
reflections to develop an action plan following your OSCE.

It may also be of benefit to arrange an appointment with one of your tutors to enable verbal
feedback. The tutor may well be able to help coach you with your reflection skills. This will enable
you to fully reflect upon the feedback and make an action plan for your own development. Often in
the early stages of developing reflective skills it is hard to reflect on feedback and personal
experience (Clark 2004). Some students’ views on the value of feedback are highlighted in Box 14.4.

Moving forward from your OSCE following success

Whilst achievement at your OSCE will seem like a huge milestone, especially in your first year, it is
important that you do not view your OSCE assessment as an end point as you will still have a lot to
learn. It is vital that you are able to harness learning from your OSCE and use this for your own
professional development. You can use the experience and feedback to develop an action plan for
your future development. You may wish to return to your reflective exercise and begin to highlight
your own particular strengths and weaknesses. It may be helpful to split the OSCE into distinct
learning areas, e.g. knowledge, skills and professional attributes. In doing this you will be able to
see if there are any areas where improvement in knowledge or skills is required. It may be useful to
complete the action plan in Table 14.1.

Box 14.4 Students’ views on the value of feedback

Successful student reflecting upon feedback

‘It was really nice to get the feedback in the OSCE…it really helped me develop my own practice.’

Unsuccessful student reflecting upon feedback

‘There were some skills that I had thought I had passed and when I got the feedback I knew the
reason why I had not. I can pick up from this feedback; I have learnt a lot from it.’

Note you can also download copies of this to print out and write on from our online
resource centre: www.oxfordtextbooks.co.uk/orc/caballero/.

What if you are unsuccessful?

Students may initially be unsuccessful at the OSCE. There are a number of reasons for this, some of
which have been highlighted throughout the chapters in this book. On some occasions it may be
because of failure to prepare; others are unsuccessful because they have become very anxious
about the examination and this affects their performance at OSCE. Anxiety is a common issue, as
the student’s reflection in Box 14.5 highlights.

Bloomfield et al. (2010) highlight the need to take time to absorb the information. It may be helpful
to view this as a minor setback rather than an endpoint. All universities will allow you at least one
more attempt for your OSCE.

Once you have taken time to assimilate the need to retake your OSCE it is important that you
prepare for the next attempt at your OSCE. Bloomfield et al. (2010) highlight the importance of
reflecting on your OSCE experience. It may be useful to focus upon:

• Personal aspects of the OSCE: Did you prepare well, were you excessively anxious, did
you forget everything you had learned because you began to panic?

• Knowledge aspects of the OSCE: Did you revise prior to the OSCE? Are there areas that
you need to revise in more detail?

Table 14.1 Action plan following OSCE

 Box 14.5 Student reflecting upon anxiety

‘I think the nerves got the better of me. In an exam situation I tend to freeze. I found trying to get
normal interaction with my patient in those circumstances really difficult.’

• Skill aspects of the OSCE: Had you practised the skill before? Did you understand how
you needed to perform the skill? Do you need to refine your performance of the skill?

• Professional aspect of the OSCE: Did you forget important professional aspects such as
consent because it was a simulated environment? Did you feel uncomfortable talking to
your ‘patient’? Were your interpersonal skills affected by anxiety?

An in-depth personal reflection may enable you to highlight problem areas that you need to address.
You may wish to return to your reflective exercise and begin to highlight your own particular
strengths and weaknesses. It may be helpful to split the OSCE into distinct learning areas, e.g.
knowledge, skills and professional attributes. In doing this you will be able to see if there are any
areas where improvement in knowledge or skills is required. It may be useful to complete the action
plan in Table 14.1.

When you have completed your reflection and action plan it would be useful to discuss this and
perhaps organize some practice sessions with one of the skills lecturers.
Online resource centre

You can find further advice and revision help for your OSCEs by going online now to see
www.oxfordtextbooks.co.uk/orc/caballero/.

Box 14.6 Some final reflections from two second year students

Student 1

‘I thought the OSCE assessment was good, although a little scary … it worked’ you could see what
you were doing…you did not just fly in and do it like you do in practice, you had to demonstrate
knowledge and skills.’

Student 2

‘I think that important skills should be examined using an OSCE, because I think if I were a patient
and the nurse did not know what she was doing or did not have the knowledge I would be terrified.’

References

Benner, P. (1984). From Novice to Expert, Excellence and Power in Clinical Nursing.
California: Addison Wesley.

Bloomfield, J., Pegram, A. and Jones, C. (2010). How to Pass Your OSCE: A Guide to
Success in Nursing and Midwifery. Harlow: Pearson.

Clark, A. (2004). Enabling learning through reflective tutorials in the nursing

practice setting. In: Tate, S. and Sills, M. (eds) The Development of Critical Refection in
Health Professionals Accessed from:
www.health.heacademy.ac.uk/publications/.../occasionalpaper04.pdf.

Cottell, P. (2007). A reflection on objective structured clinical examinations (OSCE).

Primary Health Care, 17(10): 22–23.

Dewey, J. (1933). How We Think. A Restatement of the Relation of Reflective Thinking to

the Educative Process. Boston: DC Health.

Gibbs, G. (1988). Learning by Doing: A Guide to Teaching and Learning Methods. Oxford:
Further Education Unit, Oxford Polytechnic.

Hart, S. (2010). Nursing: Study and Placement Learning Skills. Oxford: Oxford University
Press.

Schon, D. (1983). The Reflective Practitioner: How Professionals Think in Action. New
York: Basic Books.

Somerville, D. and Keeling, J. (2004). A practical approach to promote reflective practice

within nursing. Nursing Times, 100(12): 42–46.
Tate, S. and Sills, M. (2004). The development of critical refection in health professionals.
Accessed from: www.health.heacademy.ac.uk/publications/.../occasionalpaper04.pdf.


Glossary

Acute Refers to a sudden alteration in the patient’s condition, e.g. acute breathlessness, a
sudden onset of difficulty breathing.

Affective domain Relates to attitude and professional approach. You will be assessed on
this throughout your OSCE.

ALERT© Acute life threatening events, treatment and recognition. This is a well
established program used in practice to help identify and treat patients whose condition is
deteriorating.

Algorithm A list or set of instructions to solve a problem. In health care the resuscitation
algorithm is an important set of instructions that relate to resuscitation processes.

Anaphylaxis An extreme allergic reaction that causes potentially life threatening

symptoms in a patient.

Antecubital fossa This is the area on the anterior aspect of the elbow; it contains the
tendon of the biceps, the median nerve and the brachial artery. This is the location for
auscultation of brachial blood pressure.

Asepsis The absence of any infectious agents such as bacteria, viruses or fungi.

Aseptic technique A non-touch method that minimizes the possibility of cross

contamination that could lead to an infection.

Assessment criteria A list of assessment categories that examiners will use to assess you
either in clinical practice or in an OSCE.

AVPU A simplistic neurological assessment tool used to provide a quick assessment of

neurological status.

Basic life support (BLS) Resuscitation procedures utilized before more advanced life
support (utilizing resuscitation equipment) becomes available.

Blood pressure The pressure exerted by the circulating volume on the walls of the blood
vessels.

Brachial pulse The pulse from the brachial artery that is situated in the anterior aspect
of the elbow (antecubital fossa).

Bradycardia A slower than normal heart rate, usually below 60 beats per minute.

Capillary refill The amount of time for blood to reperfuse an area after blood supply has
been artificially reduced by compression. Commonly used to assess circulation by gentle
compression of the fingertip for 5 seconds and noting the time taken for blood supply to
return. It is usually less than 2 seconds.

Cardiac arrest Cessation of normal circulation of the blood because of failure of the
heart to pump effectively.

Carotid pulse The pulse from the carotid artery, situated in the patient’s neck.

Catheterization The insertion of a tube. In nursing this is usually into the urethra
(urethral catheterization).

Chronic A long term condition.

Cognitive domain Relates to knowledge and understanding. You will be assessed on this
throughout your OSCE.

Compensatory mechanism A physiological mechanism that occurs within the body in

order to maintain homeostasis. For example the blood vessels may constrict to allow flow
of blood to vital organs during episodes of bleeding; this is known as a compensatory
reaction.

Contraindication A factor that renders the giving of another medication inadvisable

because of the likelihood of reactions.

CPR A technique used to restore circulation and oxygen during periods of cardiac arrest.

Crash team The team who respond following an emergency cardiac arrest call. The team
is usually made up of specialist doctors, nurses and other health care professionals.

Deep vein thrombosis The formation of a blood clot in a deep vein. Commonly found in
the femoral or popliteal vein.

Diastolic pressure The pressure exerted by the circulating volume on the walls of the
blood vessels during relaxation of the ventricles (diastole).

Electrocardiogram (ECG) A graphic recoding of the electrical waveforms from the heart
muscle.

Escalation The process of ensuring appropriate referral to a doctor by an experienced

nurse during episodes of patient deterioration.

Exposure The final part of the assessment process whereby the patient is fully examined
to allow exploration of causes of patient deterioration.

Femoral pulse The pulse from the femoral artery which is located at the top of the leg.

Fluid balance This is normally recorded on a chart representing the total fluid input and
output from a patient for 24 hours. The balance refers to the subtraction of the output
from the patient’s input.

Formative examination An examination designed to provide constructive feedback to a

student. This examination does not normally contribute to your overall assessment grade
and you may not need to pass this examination.

Hand decontamination Refers to either washing the hands with soap and water or using
alcohol gel to prevent cross infection in hospital.

Health care acquired infection An infection acquired at least 72 hours after admission
to hospital. Also known as nosocomial infection.

Hypertension Higher than normal blood pressure. Blood pressure is normally considered
high if the systolic is 139 mmHg or higher and the diastolic is 90 mmHg or higher.

Hypotension Lower than normal blood pressure. Blood pressure is usually considered
hypotensive if the systolic is below 100 mmHg.

Hypothermia Lower than normal body temperature (usually lower than 35.5°C).

Hypovolaemia A low blood volume normally associated with bleeding, severe fluid loss
and dehydration.

Indications The reason why a medication is being prescribed.

Infection control The use of several techniques to prevent the spread of infection.

Intramuscular An injection administered into a muscle.

Intravenous An injection administered into a vein.

Korotkoff’s sounds The sounds heard via a stethoscope when auscultating blood
pressure.

Macroscopic analysis Examination by observation by the human eye.

Manikin A life-like representation of a human used for the purposes of simulation in

education, such as SimMan®.
MET team Medical emergency team. A team of doctors and nurses who will respond to
acute patient deterioration.

Microscopic analysis Examination by observation by utilizing a microscope, normally

performed in a hospital laboratory.

Neurogenic shock A type of shock caused by spinal cord injury which results in failure of
the autonomic nervous system to properly regulate sympathetic nervous responses.
Patients with this form of shock present with hypotension and bradycardia and are usually
warm to touch.

Nosocomial infection Another term for health care acquired infection.

OSCE An examination whereby students are assessed against objective criteria using
simulation.

Oxygen saturation The measurement of the amount of oxygen carried bound to the
haemoglobin molecule. It is sometimes referred to as SaO2.

Pathogen An organism that has the ability to cause an infection, e.g. bacteria, viruses,
fungi.

Personal protective equipment (PPE) Protective equipment designed to help reduce

the spread of infection. PPE includes gloves, aprons, visors, gowns, etc. Local policy
normally determines which PPE should be used in each circumstance.

Physiological measurements The recording of measurements that reflect the

physiological status of the patient. These normally include blood pressure, pulse,
respirations, temperature, oxygen saturations and neurological status.

Popliteal pulse A peripheral pulse located at the back of the patient’s knee.

Psychomotor domain Relates to performance of a skill. You will be assessed on this

throughout your OSCE.

Pulse Represents the tactile arterial palpation of an artery. It is important to assess the
strength of the pulse as it may indicate changes in the patient’s condition. For example, a
bounding pulse may suggest response to a severe infection whereas a thready weak pulse
may represent reduced circulating volume due to bleeding.

Pulse pressure A calculation representing the difference between the systolic and
diastolic pressures. A narrowing pulse pressure may indicate haemorrhage whereas a
widening pulse pressure may indicate sepsis.

Pyrexia A temperature that is higher than normal, usually above 37.5°C.

Radial pulse A peripheral pulse located in the wrist directly above the thumb.

Reagent strips Chemical strips used in practice to test for the presence of important
substances, e.g. urinalysis reagent strips.

Recovery position Refers to the lateral positioning of a patient who is unconscious but
has a pulse in order to maintain patient safety until the patient recovers.

Rescue breath An artificial breath used during CPR to maintain oxygenation. It may be
mouth to mouth or more commonly mouth to mask.

Respiratory arrest The cessation of spontaneous respiration. It may or may not be

accompanied by cardiac arrest.

Sepsis A systemic inflammatory response caused by severe infection.

Shock A failure of the circulatory system to maintain adequate organ perfusion. It may be
caused by loss of circulating volume (hypovolaemic shock), failure of the cardiac muscle
(cardiogenic shock) or failure of appropriate distribution of the blood supply (distributive
shock). Distributive shock includes anaphylaxis, sepsis and neutropenic shocks.

Side effects An adverse or undesirable effect of a medication, e.g. nausea. Common side
effects of medications are normally listed in a drugs formulary.
Sphygmomanometers A machine for recording blood pressure. This may be manual or
electronic/automated.

Suboptimal care Refers to care that has not reached expected standards. The term
suboptimal care is normally used where the patient’s deterioration has not been
recognized or treated appropriately.

Summative examination An examination that must be passed and which contributes to

the overall grade you are awarded.

Systolic pressure The pressure exerted by the circulating volume on the walls of the
blood vessels during contraction of the ventricles (systole).

Tachycardia A faster than normal heart beat, normally exceeding 100 beats per minute.

Track and trigger scoring systems A monitoring tool that alerts the user to any
abnormality in physiological parameters by firstly tracking the parameters as they are
recorded and then triggering a warning if they are outside of the expected range. They
are also referred to as early warning scores or modified early warning scores.

Urinalysis The analysis of urine using a chemical reagent strip.

Venous thromboembolism (VTE) A global term that refers to deep vein thrombosis and
pulmonary embolism.


Index

Page numbers in italic indicate answers to examiners’ questions

absorbent paper towels 57

academic journals 27

active listening 36–37

acute 209

administration of medicines, see medication administration

adult basic life support algorithm 186–192

affective domain 26, 28–29, 209

agonal gasps 189

airborne contamination 71, 83–84

airway assessment 167, 176

airway opening 188–189

alcohol hand rub 57

ALERT® 164, 209

algorithm 209

allergies 148, 150, 154

anaphylaxis 154, 161–162, 170, 173, 209

antecubital fossa 209

antibiotic therapy, timing 152

antiseptic hand washing 55–56

apneustic respiration 103

asepsis 70, 82, 209

aseptic non-touch technique (ANTT) 69–84

aims 70

common errors 80–81

definition 70

examiner’s questions 80

marking criteria 78–79

OSCE 77–78

personal protective clothing 74–75

principles 71–74
revision 69–77

risk assessment 74

time limit in OSCE 77

tips for passing 81

when it should be used 70–71

wound assessment, cleansing and dressing 75–77

aseptic technique 70, 82, 209

assessment criteria 18–19, 209

attitude 28–29

automated sphygmomanometers 107, 112–113

AVPU tool 171–172, 209

axilla temperature 90, 92

bacteria 54

bare below the elbow 56

bars of soap 55, 67

baseline measurements 86

basic life support (BLS) 185–196, 209

adult BLS algorithm 186–192

airway opening 188–189

calling for help 188

chest compressions 189–190, 192

common errors 194

examiner’s questions 194

marking criteria 193

OSCE station 193

recovery position 211

rescue breaths 211

responsiveness 186–188

revision 185–193

risk assessment 186

safety 185–186

signs of normal breathing 189

time limit in OSCE 193

tips for passing 194–195

bilirubin 121–122
blood in urine 121

blood pressure 107–118, 209

automated measurement 107, 112–113

common errors 115

deteriorating patient 170, 183

diastolic pressure 107–108, 183, 210

documentation 113

examiner’s questions 114–115

factors affecting 109

inaccuracies 109

Korotkoff’s sounds 108, 210

manual measurement 107, 110–111

marking criteria 114

normal values 108

OSCE 110–113

revision 107–109

systolic pressure 107–108, 183, 212

tips for passing 115–116

body fluids 55

body temperature 89–94, 104–105, 171, 177

brachial pulse 87, 209

bradycardia 88, 103, 183, 209

bradypnoea 94, 104

breathing

assessment in deteriorating patient 168–170, 176

looking for signs of normal breathing 189

cancelling down 134–135, 136, 139

capillary refill time 170, 209

capsules 134

cardiac arrest 185, 209

cardiogenic shock 170, 183

carotid pulse 87, 209

catheterization 209

chemical/heat reactive strips 90, 91, 92

chemical urinalysis 119, 120

chest compressions 189–190, 192

Cheyne-Stokes breathing 103

chlorhexidine gluconate 55

chronic 209

circulation 170–171, 176–177

clarifying 39–40

clinical mentor 28

Clostridium difficile (C. Diff) 53, 70

cloth towels 56

cognitive domain 26, 209

cold and clammy patient 170

combined marking approach 20

communication, see interpersonal communication

compensatory mechanism 209

complex single station OSCEs 14

computer based assessment 132

concentration of liquid medicines 134

conjugated bilirubin 122

consent 29, 98, 146, 147, 162

contamination, sources of 71

contraindications 209

controlled drugs 154, 161, 162

core body temperature 89

costs of health care related infections 58

CPR 210

crash team 210

cyanosis 168

deep vein thrombosis 173, 210

dependent oedema 173

dermatitis 57

deteriorating patient 85–86, 163–184

airway assessment 167, 176

ALERT® 164, 209

at risk patients 183

breathing assessment 168–170, 176

circulation 170–171, 176–177

common errors 180–181

disability 171–173, 177

documentation 170, 171, 172, 174

escalation 165–166, 174–176, 177, 210

everything else 174, 177

examiner’s questions 180

exposure 173–174, 177, 210

marking criteria 178–179

OSCE 166–177

revision 163–166

systematic assessment 167–177

tips for passing 181

track and trigger scoring systems 164–165, 174, 212

diastolic blood pressure 107–108, 183, 210

digital thermometer 90, 92

disability 171–173, 177

documentation

blood pressure measurement 113

body temperature 92–93

deteriorating patient 170, 171, 172, 174

medication administration 153–154

oxygen saturation 97

pulse rate 88

respiratory rate 95

dorsalis pedis pulse 87

dressing trolley, cleaning 71–73

dressing wounds 77

drug reactions 154, 162

drying hands 56–57

Duthie Report (1988) 145

early warning scores (EWS) 164

educating patients, medication administration 146, 147–148, 150, 152

electrocardiogram 210

empathy 37, 38, 39

environment, pathogen-free 71

escalation 165–166, 174–176, 177, 210

ethical issues 29

everyday reflection 200

examination regulations 21

examiner role 17–18

exhalation 94

expiry dates 74

exposure 173–174, 177, 210

feedback from OSCE 30, 204

femoral pulse 87, 210

filming 21

5 rights approach 146, 148–153

fluid balance 170, 177, 210

fluid overload 173

foot operated bins 57

formative examination 6, 210

gauze swabs 76–77

Gibbs reflective cycle 202–203

global mark 19

gloves 55, 58, 67

glucose, urine 121, 130

haemolysed blood 121

hand decontamination 53, 71, 210; see also hand hygiene

hand dryers 57

hand hygiene 53–67

alcohol hand rub 57

antiseptic hand washing 55–56

aseptic non-touch technique 71

common errors 66

drying hands 56–57

examiner’s questions 65–66

hand washing with soap and water 55, 56, 58–64

marking criteria 64–65

nails 56

OSCE 58–64

revision 54–58

rings 56

skin care 57

when it should be performed 54–55

hand lotions 57

hand washing with soap and water 55, 56, 58–64

head tilt, chin lift 188–189

Health Act (2006) 145

health care acquired infections (HAIs) 53, 58, 67, 69, 210

health care area 54

heart rate and rhythm 103, 170

high blood pressure 108, 117

hospital acquired infection 53

hot air dryers 57

hot and sweaty patient 170

hypertension 108, 117, 210

hyperthermia 105

hyperventilation 103

hypotension 109, 117, 210

hypothermia 90, 105, 210

hypovolaemia 170, 173, 210

indications 210

infection control 210

medication administration 146–147, 148

see also hand hygiene

information for patients, medication

administration 146, 147–148, 150, 152

inhalation 94

insulin 155

internet resources 27

interpersonal communication 35–51

common errors 50
effective 51

escalation of concern 165–166, 176

examiner’s questions 49

example of OSCE 42–46

marking criteria 48–49

medication administration 150, 152

revision 36–40

self-assessment 42

tips for passing 50

within a clinical skills OSCE 46–48

intramuscular 210

intravenous 210

irrigating wounds 76

IV fluids prescriptions 136, 139

jaw thrust 188

jewellery 56, 64

journals 27

ketones 122, 130

knowledge 7, 27

Korotkoff’s sounds 108, 210

Kussmaul’s respirations 103

laws, medication administration 144, 145

learning domains 26

learning style 25–26

leucocytes 122, 130

Likert scale 19

liquid medication 134

liquid soap 55

listening 36–37

local policies, medication administration 144

localized infection 75

lodophores 55–56

long division 135

low blood pressure 109, 117

macroscopic analysis 119, 120, 210

manikin 7, 210

manual blood pressure measurement 107, 110–111

marking criteria 19–20

measuring physical observations 85–105

common errors 101

consent 98

examiner’s questions 100–101

marking criteria 99–100

OSCE 98–99

revision 86–98

time limit in OSCE 98

tips for passing the station 101

medication administration 143–162

aftercare 154

allergies 148, 150

checking patient’s identity 148

common errors at the station 159–160

communication 150, 152

consent 146, 147, 162

controlled drugs 154, 161, 162

documentation 153–154

dosage 152–153

drug reactions 154, 162

educating patients 146, 147–148, 150, 152

examiner’s questions 158–159

5 rights approach 146, 148–153

infection control 146–147, 148

legal issues 144, 145

local policies 144

marking criteria 156–158

medication errors 143, 148, 149, 152

OSCE 147–156

preventing errors 146

professional attitude 148

professional regulations 144

refusal of medication 153

revision 143–147

route of administration 151–152

storage of medication 154–155

systematic method 144, 146, 147–153

timing 152

tips for passing 160

withholding medication 153, 162

medication calculation skills 131–141, 152–153

computer based assessment 132

converting units 133–134

formula for drug calculations 134

IV fluids 136, 139

medication forms 134

OSCE 132

practice based assessment 131–132

units 132–133

Medicines Act (1968) 145

MET team 210

methicillin resistant Staphylococcus aureus 53, 69–70

metric system 132

microbe 67

microgram (mcg) 132–133

microorganisms 54

microscopic analysis 119, 210

mid-stream specimen 120

milligram (mg) 132

millilitre 133

mirroring 38

Misuse of Drugs Act (1971) 145

Misuse of Drugs Regulations (1973/2001) 145

modified early warning scores (MEWS) 164

morphine 155

MRSA infection 53, 69–70

multiple short station OSCEs 13–14

nails 29, 56

name bands 148

neurogenic shock 170, 211

neurological assessment 171–173, 177

NICE guidance, escalation 174

nitrite 122

non-haemolysed blood 121

non-touch technique 74, 83

non-verbal communication 44

normal ranges

blood pressure 108

body temperature 90

oxygen saturation 97

pulse 88

respiration 94

urine pH 120

urine specific gravity 121

nosocomial infection 69, 83, 211

note taking 27

nurse–patient/client relationship 51

Nursing and Midwifery Council (NMC) 5, 144

objective assessment 5

Objective Structured Clinical Examination, see OSCE

oedema, dependent 173

online resources 27

open questions 39

opiate analgesia 155

oral temperature 90–91

OSCE (Objective Structured Clinical Examination) 211

assessment criteria 18–19, 209

check list 22

complex single stations 14

examination conditions 21
feedback 30, 204

filming 21

history of development 4

layout of stations 15

learning from 30

marking criteria 19–20

multiple short stations (short case) 13–14

organization 13–15

outcome 30

post-registration 14

preparation for 21–22, 25–31

reflecting upon 199–207

retaking 205–206

roles and responsibilities 16–18

timing 21

unmanned stations 14–15

unsuccessful outcome 205–206

oxygen saturation 96–98, 104, 211

pain 172

palpation 86

paper towels 57

paraphrasing 37, 38, 39

pass/fail 19

pathogen 211

patient at risk scores (PARS) 164

patient zone 54

patients

approach to 29

checking identity 148

role playing 16–17

safety 5

patting hands dry 57

performance of skill 6–7

peripheral temperature 170, 177

personal protective equipment 74–75, 83, 186, 211

pH, urine 120

physiological measurements 211; see also measuring physical observations

popliteal pulse 87, 211

Portsmouth sign 171

post-registration OSCEs 14

posterior tibial pulse 87

povidone iodine 55

practice sessions 21, 28

preparing for the OSCE 21–22, 25–31

prescribing drugs 161

prescription chart errors 149

Prescription Only Medicines Order (1997) 145

professional appearance 29

professional approach 28–29

professional attributes 7

professional development 204–205

professional regulations 5, 144

protein, urine 121

psychomotor domain 26, 211

psychomotor skills 7, 28

pulse 86–89, 98, 211

pulse oximeter 96

pulse pressure 183, 211

pyrexia 89, 90, 105, 211

questioning 39

radial pulse 86–87, 89, 211

reagent strips 211

reassuring 47

recovery position 192–193, 211

rectal temperature 90

red flags 19, 20

red wrist bands 148

redness 173

reflectio 199–207
definition 200

Gibbs reflective cycle 202–203

importance of 201

in action 200–201

interpersonal communication 37–39

models 201–204

on action 200

reflective practice 200

refusing medication 153

reliability of simulated examinations 8

rescue breaths 191–192, 211

resident bacteria 54

resources required for OSCEs 5

respiration 94–96, 103, 168–170

respiratory arrest 211

respiratory system 94

responding 38, 39

responsibilities 16–18

responsiveness 186–188

retaking OSCEs 205–206

revision 27

revision plan 30

rings 56

risk assessment

aseptic non-touch technique 74

basic life support 186

role playing patients 16–17

roles 16–18

safety issues

basic life support 186

patient safety 5

salbutamol 155

SBAR 166

sepsis 170, 173, 184, 211

shock 170, 184, 211

short case OSCE stations 13–14

SI units 132

side effects 154, 211

simple reflection 37–39

simulated examinations; see also OSCE

alternative names for 3

common features 4

defining 4

formative examination 6, 210

history of development 4

organization 13–15

reasons for development 5

resources required 5

skills assessed 6–8

standardization 6

summative examination 6, 211

validity and reliability 8

skill assessment 6–8

skin

care of 57

microorganisms on 54

social hand wash 55

specific gravity, urine 121

sphygmomanometers 107, 211

standardization of skills 6

station layout 15

sterile dressing pack 73

sterile field 71–73

sterilized equipment 74

steroid administration 152

storing medicines 154–155

suboptimal care 211

summarizing 39–40

summative examination 6, 211

surface temperature 89

swabs
infected wounds 75

wound cleansing 76–77

systemic infection 75

systolic blood pressure 107–108, 183, 212

tablets 134

tachycardia 88, 103, 183, 212

tachypnoea 94, 103–104

tacit knowledge 201

textbooks 27

therapeutic relationship 35–36

thermometers 89–92

tidal volume 103

timing

OSCE 21

revision 27

total mark awarded 19

towels, cloth vs paper 56, 57

track and trigger scoring systems 164–165, 174, 212

transient bacteria 54

tympanic temperature 90

tympanic thermometer 90, 93

uniforms 29, 56

units (drugs) 136

units (SI) 132–133

converting 133–134

unmanned stations 14–15

urinalysis 119–130, 212

bilirubin 121–122

chemical analysis 119, 120

cloudy urine 120

colour of urine 120

common errors 129

examiner’s questions 128

glucose 121, 130

haemolysed blood 121

ketones 122, 130

leucocytes 122

macroscopic analysis 119, 120, 210

marking criteria 127–128

microscopic analysis 119, 210

mid-stream specimen 120

nitrite 122

non-haemolysed blood 121

obtaining a urine sample 120

OSCE 122–127

pH 120

protein 121

revision 119–122

smell of urine 120

specific gravity 121

tips for passing 129

urobilinogen 122

urine output 170

urobilinogen 122

urticaria 173

validity of simulated examinations 8

ventilation 94

websites 27

white coat hypertension 109

withholding medication 153, 162

wound assessment 75

wound cleansing 75, 76–77

wound dressing 77

wound infection 75, 83

wound irrigation 76

wound swab 75

wrist watches 56
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