Unit of competency details

Descriptor 

This unit describes the skills and knowledge required to contribute to the nursing care of clients in a range of health environments

Application 

The knowledge and skills described in this competency unit are to be applied within jurisdictional nursing and midwifery regulatory authority legislative requirements

Enrolled/Division 2 nursing work is to be carried out in consultation/collaboration with registered nurses and under direct or indirect supervisory arrangements in line with jurisdictional regulatory requirements

Employability Skills 

This unit contains Employability Skills

Elements define the essential outcomes of a unit of competency.

The Performance Criteria specify the level of performance required to demonstrate achievement of the Element.

ELEMENT 

PERFORMANCE CRITERIA 

1. Establish and maintain therapeutic relationships  with clients

1.1 Provide appropriate introductions and explanations prior to all nursing interventions

1.2 Identify and use appropriate language and interpersonal skills to ensure that the diverse needs of clients and health care settings

1.3 Conduct the client advocate role within the Enrolled/Division 2 nurse's scope of practice

1.4 Work effectively with clients from a range of cultural, spiritual and religious backgrounds, taking action to address cultural factors that may impact on nursing practice

1.5 Demonstrate responsibility and accountability for implementing nursing care within the Enrolled/Division 2 Nurse scope of practice

2. Identify client needs relating to individualised nursing care

2.1 Identify actual and potential nursing care needs in consultation/collaboration with the client

2.2 Identify situations of risk or potential risk  and implement risk prevention/minimisation strategies and refer to registered nurse as appropriate

2.3 Identify client needs for health education and implement education within scope of nursing practice and in consultation/collaboration with registered nurse

2.4 Identify client nutritional needs in consultation/ collaboration with client and their significant others

3. Assist clients in activities of daily living

3.1 Explain to client the importance of hygiene and grooming to achieving health outcomes

3.2 Assist clients to address hygiene , dressing and grooming  needs

3.3 Describe conditions which affect the oral cavity and demonstrate effective oral hygiene to client

3.4 Assist clients with their diet and fluid intake and ensure client's nutritional needs are met in consultation/collaboration with registered nurse

3.5 Apply strategies to assist clients with diet and fluid intake

3.6 Recognise and manage emergency situations associated with diet and fluid intake

3.7 Assist clients with key aspects of elimination

3.8 Explain and demonstrate to clients key factors associated with fluid balance and bowel charts 

3.9 Assist with respiratory function especially deep breathing and coughing exercises

3.10 Use appropriate measures to promote comfort, rest and sleep

4. Assist with movement of clients

4.1 Apply the principles and techniques of safe manual handling  when assisting clients with movement

4.2 Actively encourage clients to contribute to their own mobility 

4.3 Implement the principles of 'no-lift' policy when assisting clients with movement

4.4 Assist clients to safely transfer using appropriate mobility procedures with reference to safety of self, client and others involved

4.5 Identify and describe to clients factors contributing to the formation of decubitus ulcers

4.6 Apply practices to avoid breakdown of pressure areas

4.7 Identify common pressure area sites with reference to the needs of each individual client

4.8 Use and explain appropriate strategies to prevent and manage decubitus ulcers 

5. Prepare clients for procedures

5.1 Provide each client with a full explanation regarding preparation for specific procedures

5.2 Incorporate health teaching into practice within role responsibility

5.3 Maintain privacy and dignity of client throughout

5.4 Complete documentation as per organisation policy and procedures

5.5 Observe validity of consent and report any concerns to the registered nurse, as appropriate

6. Contribute to nursing care in consultation/ collaboration with registered nurse

6.1 Participate in the implementation of a plan of nursing care in line with duty of care and Occupational Health and Safety policies and procedures

6.2 Identify and apply safe work place procedures as per OH&S policies and organisation policies and procedures

6.3 Identify and apply infection control principles in all work activities

6.4 Prioritise work activities to meet acuity of client needs in consultation/collaboration with a registered nurse

6.5 Work in a manner that maintains the client's privacy and dignity and demonstrates best practice based on a full range of relevant information including scientific rationale

6.6 Undertake nursing procedures as delegated within the nursing team and scope of practice in consultation/collaboration with a registered nurse

6.7 Apply strategies to promote comfort, rest and sleep

6.8 Assist with the implementation of appropriate nursing actions to prevent and manage decubitus ulcers in consultation/collaboration with a registered nurse

6.9 Implement appropriate action to address urgent needs in consultation/collaboration with a registered nurse and document and report as appropriate

6.10 Maintain documentation and reporting requirements as per organisation policies and procedures

7. Monitor and evaluate clients during care

7.1 Maintain ongoing observation and assessment during nursing care

7.2 Observe and document changes in client independence or pain tolerance within scope of Enrolled/Division 2 Nurse practice

7.3 Record and report changes in condition/baseline data/behaviour to the registered nurse, as appropriate

7.4 Document evidence of client outcomes in nursing care plan

7.5 Respond to and report situations of risk to registered nurse

7.6 Identify and respond appropriately to signs and symptoms of common emergency situations

7.7 Demonstrate respect for the client's attitudes and values in regard to resuscitation

7.8 Use emergency codes correctly

7.9 Initiate CPR according to organisation procedures

8. Evaluate own contribution to nursing care

8.1 Evaluate nursing care in consultation/collaboration with the client and the multidisciplinary team

8.2 Evaluate nursing care in light of client outcomes

8.3 Document and report all aspects of client care provided by self

REQUIRED SKILLS AND KNOWLEDGE 

This describes the essential skills and knowledge and their level required for this unit.

Essential knowledge :

The candidate must be able to demonstrate essential knowledge required to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role

This includes knowledge of:

• Discharge policy and planning requirements
• Documentation and reporting requirements
• Legislation relating to medication administration
• Lifespan approach to anatomy and physiology
• Microbiology and pathogenesis relating to nosocomial infection
• Opportunities to address issues of waste minimisation, environmental responsibility and sustainable practice
• Organisation policies and procedures
• Risk identification related to episodic care:

• age
• anaesthesia and surgery
• cognitive status
• deep vein thrombosis/pulmonary embolism
• immobility
• length of stay
• mental illness
• non-compliance
• nutritional status
• pain
• presence of morbidity

• Risk prevention strategies

• active/passive exercises
• asepsis/standard precautions
• falls assessment
• maintenance of skin integrity
• pressure area care

Essential skills :

It is critical that the candidate demonstrate the ability to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role

This includes the ability to:

• Apply Professional Standards of Practice:

• ANMC code of conduct
• ANMC code of ethics
• ANMC national Enrolled/Division 2 nurse competency standards
• state/territory Nurse Regulatory Nurses Act
• state/territory Nursing and Midwifery Regulatory Authority standards of practice
• scope of nursing practice decision making framework

• Handle challenging behaviour and refusal of treatment
• Meet nutritional needs
• Meet risk minimisation needs
• Promote comfort
• Undertake observation and assessment
• Use effective communication skills
• Undertake nursing interventions/procedures.

• mobility:

• manual handling/risk assessment
• assist with mobility
• positioning/active and passive exercises

• feeding a client
• specimens:

• collection of specimens
• urinalysis

• rest and sleep
• bed making
• bathing and showering
• pressure area care
• eye toilet
• nasal toilet
• perineal toilet
• oral hygiene
• dressing and undressing
• assistance with eating and drinking
• maintaining skin integrity
• nebulisers, puffers, peak flow assessment, oxygen administration and oximetry
• basic life support
• nasogastric and gastrostomy feeding
• ostomy care
• established tracheostomy care

EVIDENCE GUIDE 

The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria, Required Skills and Knowledge, the Range Statement and the Assessment Guidelines for this Training Package.

Critical aspects for assessment and evidence required to demonstrate this competency unit :

• The individual being assessed must provide evidence of specified essential knowledge as well as skills
• Observation of performance in a work context is essential for assessment of this unit
• Consistency of performance should be demonstrated over the required range of workplace situations and should occur on more than one occasion and be assessed by a registered nurse

Context of and specific resources for assessment :

• This unit is most appropriately assessed in the clinical workplace following assessment in simulation laboratory
• Where, for reasons of safety, access to equipment and resources and space, assessment takes place away from the workplace, simulations should be used to represent workplace conditions as closely as possible, prior to assessment in the workplace

Method of assessment 

• Observation in the work place of clinical performance
• Written assignments/projects
• Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice
• Questioning verbal and written
• Role play/simulation

Access and equity considerations :

• All workers in the health industry should be aware of access and equity issues in relation to their own area of work
• All workers should develop their ability to work in a culturally diverse environment
• In recognition of particular health issues facing Aboriginal and Torres Strait Islander communities, workers should be aware of cultural, historical and current issues impacting on health of Aboriginal and Torres Strait Islander people
• Assessors and trainers must take into account relevant access and equity issues, in particular relating to factors impacting on health of Aboriginal and/or Torres Strait Islander clients and communities

Related units :

This unit is recommended to be assessed in conjunction with units:

• HLTAP401B Confirm physical health status
• HLTEN402B Communicate effectively in a nursing role

RANGE STATEMENT 

The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance

Therapeutic relationships include :

• Nurse/client
• Nurse/significant other
• Client/client
• Nurse/nurse
• Nurse/multidisciplinary health care team

Actual and potential nursing care that clients may need assistance with :

• Hygiene and toileting
• Elimination/incontinence
• Physical comfort
• Sleep disturbances
• Health education
• Oral/dental care
• Immobility
• Respiration and circulation
• Fluid and nutritional deficits
• Pain
• Wounds - acute and chronic
• Stress
• Underlying medical condition
• Social emotional and financial issues
• Sensory deficits
• Cognitive deficits

Risks or potential risks due to hospitalisation /medical treatment may include :

• Adverse reactions
• Shock/haemorrhage
• Deep vein thrombosis/pulmonary embolism
• Nosocomial infection
• Skin tears/pressure ulcer formation
• Constipation
• Loss of muscle tone
• Slips and falls
• Social isolation
• Sleep deprivation
• Challenging behaviour
• Refusal of treatment
• Workplace harassment and aggression and violence

Risk prevention strategies :

• Recording of allergies
• Monitoring of client vital sign
• Other monitoring as required eg. fluid balance, blood sugar levels
• Pressure area care
• Anti-emboli stockings/DVT prophylaxis
• Aseptic technique/standard precautions
• Passive and active exercises
• Bed rails
• Assistance with transferring

The broad principles of manual handling may include :

• Body mechanics
• Organisation policy and procedures
• Risk minimisation and 'no-lift' policies
• Back care
• Ergonomics
• State/territory Occupational Health and Safety Act
• Safe operation of equipment

Manual handling techniques must include :

• Transferring a client from bed to chair and vice versa
• Assisting a client to ambulate
• Moving a client in the bed
• Client falls

Factors contributing to mobility may include :

• Client health status
• Active and passive exercises
• Equipment availability
• Culture
• Environment

Transfer /mobility devices /equipment may include :

• Hoist
• Wheelchairs
• Walking frames
• Slide sheets
• Walking aids

Purpose of hygiene and grooming may include :

• Cleanliness
• Assessment of skin
• Self esteem
• Social aspects

Hygiene may include :

• Showing and showering trolley
• Bed bath/sponge
• Bath

Grooming may include :

• Brushing hair
• Facial shavings
• Nail care
• Cleaning and applying glasses
• Cleaning and inserting hearing aid
• Application of make up and jewellery
• Application of prostheses and orthoses

Conditions of the oral cavity may include :

• Dry mouth, gums and tongue
• Halitosis
• Pale or bleeding mucosa and gums including tongue
• Candida albicans (thrush)
• Herpes Simplex/cold sores
• Ulcers of the mucosa, gums and tongue
• Ill fitting dentures
• Deviations of tongue alignment
• Stomatitis/Gingivitis
• Cleft palate/lip
• Dental caries

Oral hygiene may include :

• Brushing teeth
• Mouth wash/gargle
• Mouth toilet
• Application of lip emollient

Key aspects of assisting a client with diet and fluid intake may include :

• Comfort
• Hygiene and elimination needs are met
• Serviette provided/presentation of meal
• Meal size and food preference
• Placement of meal to facilitate appetite
• Suitable utensils and condiments offered
• Rate of eating and fluids offered
• Encourage independence
• Meal completion, hygiene and comfort needs are met
• Visual and hearing impairment considered
• Swallowing impairment
• Cognitive and physical impairment
• Fasting and restricted fluids

Strategies to assist may include :

• Position and environment

Key aspects of elimination may include :

• Bedpan/Urinal/Commode
• Enemas/Suppositories
• Perineal care
• Continence aids
• Privacy and dignity
• Positioning and hygiene
• Disposal of waste
• Odour control

Key factors associated with fluid balance and bowel charts may include :

• Intake and output measurements in millilitres, totalled with positive/negative balance calculated on fluid balance chart
• Diet intake chart
• Accurate and continuous documentation
• Description of stool on bowel chart
• Report variances as per environmental policies

Factors contributing to formation of decubitus ulcers may include :

• Intrinsic
• Extrinsic

Strategies for prevention and management of decubitus ulcers may include :

• Pressure risk assessment scales
• Use of pressure relieving devices
• Regular observation of skin condition\
• Repositioning

Rest may include :

• Power naps/meditation/relaxation techniques

Factors that promote and impede comfort , rest and sleep may include :

• Routine and position
• Environment/equipment
• Emotional state/pain physical state
• Medication
• Nursing interventions
• Visitors/other clients

Bed making may include :

• Occupied
• Unoccupied

Risk minimisation strategies for nurses may include :

• Hazard assessment/reporting/risk minimisation
• Implementation of 'No-Lift' policy
• Maintenance of regular contact with members of the care team/nurse supervisor
• Referral of self appropriately for debriefing/counselling
• Attention to own health and rest requirements
• Strategies for addressing workplace harassment/aggression and violence

Recording and reporting requirements includes :

• Admission and discharge documentation
• Client progress notes
• Fluid balance charts
• Conscious/neurological observations
• Specific charting as required
• Verbal handovers/case meetings
• Critical incident reporting to senior staff
• Incident reports
• Understanding of work roles of other health team members
• Occupational health and safety hazard reporting