Clinical Psychomotor Skills (5-Point)

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 CLINICAL
-PSYCHOMOTOR-
SKILLS
ASSESSMENT TOOLS
FOR NURSES
7TH EDITION

I
~
{
I

TOLLEFSON
HILLMAN
 CLINICAL
-PSYCHOMOTOR-
SKILLS
ASSESSMENT TOOLS
FOR NURSES
 CLINICAL
-PSYCHOMOTOR-
SKI LLS
ASSESSMENT TOOLS
FOR NURSES
7TH EDITION

TOLLEFSON
HILLMAN
.. '# CENGAGE
~
·- Clinical Psychomotor Skills: Assessment tools for nurses (5-point) ~ 2019 Cengage Learning Australia Pty Limited
7th Edition
Joanne Tollefson Copyright Notice
Elspeth Hillman This Work Is copyright. No part of this Work may be reproduced, stored in a
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Acknowledgements For permission to use material from this text or product, please email
Part opener Icons: Shunerstock.com/Nadiinko; Shutterstock.com/davooda; aust.permlssions@cengage.com
Shunerstock.com/DStarky; Shunerstock.com/Dstarky; Shunerstock.
com/davooda; Shunerstock.com/Keep Calm and Vector; Shunerstock. National Library of Australia Cataloguing-in-Publication Data
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Gather equipment: Shunerstock.com/Keep Calm and Vector Cengage Learning Australia
Appendix:~ Nursing and Midwifery Board of Australia, www. Level 7, 80 Dorcas Street
nursingmidwiferyboard.gov.au. South Melbourne, Victoria Australia 3205

Cengage Learning New 2ealand

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331 Rosedale Road, Albany, North Shore 0632. NZ

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Printed in China by China Translation & Printing Services.

12345672221201918
CONTENTS
Guide to the text vii
Guide to the onhne resources IX

New to this edition x

About the authors XI

Acknowledgements XI

PART 1 23. Blood glucose measurement 131

INTRODUCTION 1 24. Focused musculoskeletal health history

Psychomotor skills 2 and physical assessment and range of

1.
motion exercises 137
2. Clinical thinking 5
3. Person-centred practice 9
11
PART 4
4. Therapeutic communication
PROFESSIONAL COMMUNICATION 143
PART 2 25. Clinical handover 144
ASEPTIC NON TOUCH TECHNIQUE 13 26. Documentation 149
27. Healthcare teaching 154
5. Hand hygiene 14
6. Personal protective equipment 21
29
PART 5
7. Aseptic Non Touch Technique
35
ASSISTING WITH FLUID
8. Aseptic/ clinical hand hygiene
41
AND NUTRITIONAL STATUS 161
9. Surgical gowning and gloving
28. Assisting with meals 162
PART 3 29. Nasogastric tube insertion 167
ASSESSMENT 47 30. Administering enteral nutrition 174

Temperature, pulse and 31. Intravenous therapy -

10.
48 assisting with establishment 182
respiration measurement
32. Intravenous therapy - management 189
11. Blood pressure measurement 56
12. Monitoring pulse oximetry 63
PART 6
13. Pain assessment 69
ASSISTING WITH ELIMINATION 195
14. Physical assessment 74
15. Mental status assessment 81 33. Assisting with elimination needs 196
16. Focused cardiovascular health history 34. Administering an enema 203
and physical assessment 86 35. Suprapubic catheter care -
17. 12-lead electrocardiogram 93 catheter irrigation 211
18. Focused respiratory health history and 36. Urinary catheterisation 219
physical assessment 98
19. Focused neurological health history PART 7
and physical assessmen t 108 MEDICATION ADMINISTRATION 229
20. Neurovascular observations 116 37. Oral medication 230
21. Focused gastrointestinal health history 38. Enteral medication 239
and abdominal physical assessment 121 39 . Topical medication 246
22. Height. weight and waist 40. Optic medication 253
circumference measurements 126 41. Otic medication 260

v
 42. Vaginal medication 265 62. Tracheostomy care 425
43. Rectal medication 272 63. Chest drainage system assessment
44. Inhaled medication 280 and management 437
45. Parenteral medication 287
46. Intravenous medication administration: PART 12
volume-controlled infusion set 297 TRANSFUSION AND
47. Intravenous medication administration: BLOOD PRODUCTS 443
intravenous container 304 444
64. Blood transfusion
65. Venipuncture 451
PART 8
PAIN MANAGEMENT 309 PART 13
48. Non-pharmacological pain management WOUND MANAGEMENT 459
intervention - dry heat and cold therapy 31 0 66. Ory dressing technique 460
49. Patient-controlled analgesia or other 67. Complex wounds: drain and suture,
syringe-driven medication 315 staple or clip removal 466
50. Subcutaneous infusions 327 474
68. Complex wounds: wound irrigation
69. Complex wounds: packing a wound 481
PART 9
PERIOPERATIVE CARE 337 PART 14
51. Preoperative care 338 ADVANCED SKILLS [ALL ONLINE]
52. Post-anaesthesia handover and care 346 70. Caring for a person with a central
53. Postoperative care 355 venous access device
71. Assisting with stoma care
PART 10 72. Intravenous medication
ASSISTING WITH PERSONAL administration - bolus
HYGIENE AND SKIN INTEGRITY 365 73. Seclusion management
54. Bed bath or assisted shower 366 74. Electroconvulsive therapy care
55. Oral care, hair care, nail care 75. Non- pharmacological pain management
and shaving 373 interventions - therapeutic massage
56. Assisting a person to reposition 379 76. Non- pharmacological pain management
57. Assisting a person to mobilise 386 interventions - conventional
58. Pressure area care - transcutaneous electrical nerve
preventing pressure injuries 391 stimulation
77. Neonate - daily care
PART 11 78. Caring for a person who is unconscious
RESPIRATORY SKILLS 397 79. Continuous bladder irrigation
59. Oxygen therapy via nasal cannula or 80. Continuous abdominal peritoneal dialysis
various masks 398 Appendix: NMBA Registered Nurse Standards
60. Oropharyngeal and nasopharyngeal for Practice 2016 487
suctioning 408
61. Artificial airway suctioning 415 Index 495

VI CONTENTS
GUIDE TO THE TEXT
As you read this text you will find a number of features in every chapter to enhance your study of clinical s1cills and help
you understand how the theory is applied in the real world.

PART OPENING FEATURES

e If...Then boxes present a common challenge you may
face when performing a clinical skill and examining
how this can be overcome.
Chapter list outlines the chapters contained in each part
for easy reference. 11 tti. question• •no ,,,,on4 )'Ol.ll' ~ .,. Mff "'*"" llhtlll llNift"" Oft ,,..._., ~ 1111o1t.1l!ON tit •
Mn>Or nl.!Nt as f.OOl'l as"°'''"* 1t1I k..,. 9""" 1htM1swtn.,,.
~

Chapter linkages refer you back to important

foundational skills and highlight the connection
between similar tasks, procedures and s1cills.

Provide pain management information

l-.,_
Pain Is a ma;or fear of most ptc1ple lKint 1-W'Jtf)'· Ruuunl'lal lht , _ wiill M ~ e!f~ auats SOl!'le ro,i.
lo noltlt. Otti.rs niqwlre l•tJoite4 infwm.,,,.,, tkiut mel!uWM 1e;,. vs.t4, 1'9W!.ff. ll!M:I •""'~et 1t-. tn.M1•.su, T•xh
tc.e•
l.htm l\.ow to wse p.11" t1-1-eum•nt tools •J.
CllaiefJ AW I OIKVU lhe w. et Ptt!Ml ~ Ar~lfu1t IPCA.1 C•••
CH.aJefJ •1'W 4tl ac ep,ro,Ot1•. R••••wr~ t~ •1V1 . . . . _ .. ..,..,,.., Mft~~ • .-.., "'"""" fw ,eln AINI
""°"'"•"'
will tu•SI t!WM ptopl.4' to 1111Us• I.ti• !Mii" ~...,.,..,... "'*"" ~ ~ tMre Wfft ..,..,. lllCtifl-'•-'ltMit:t.
most of !tit .1ov•!Uilta Uttr•twrt rtll'i•wM r•..• • • ,.~11# ~ ~ ~M Mll..iytl'MI ,...,_..,..~ p.11"
..
ICtltliit t i .t,. 2014), C~rit c~c""" ••ow1 tfoltlr ,._.. t~ •a~"" ,....,.,..,...~, It t.-.No"c• q14ll'Y
pain n\lon•ttmtnl (~• &. 00or4on, 1015).

FEATURES WITHIN CHAPTERS ICONS

Indications sections identify the clinical reasons to
perform the skill outlined in the chapter.
o Safety icons indicate when you should
be aware of a particular safety issue
Safety when performing a clinical skill.
Indications
(:¥~ Pftt>arl!lf •
Stflit~ Thou ..t'IO Wt
Pfl"SOf'I . . . optAOOA ts • elftd:tfit
-9 Pfit?lftd.
...:iGtnta.'ld rn«t ~ l;tn Njlfy
°'
ftlMdlAb wUI ftM tl!M.
t. ut.tt-..eir ~ <11.1tt:tions
to~ in prt·~ tllt<OMJ inQ ttKfwl~
o Video icons direct you online where you
fit.ti"*' v. conb'..
ttrt<tiflg tlwil' att
tht ~ w UftS ~

upe6tnot ltss post-o;>~M ~-ft~

'°'
. . btttfr not.Mttd Ml'-<¥t
ttqiJift lt:SS tilnt 1111 ttlt ~
as
rttUp«ale more qud;tf.
Tht l:ypt ol SW9Wt ~ lht Ill~ Utt fM'\.
tlw tftt lrl Whfdl t. 40 l tifl4. ~.., . . . . Utt. hi
iNbn«,• j>ffMl!ft-6er,.., ... ~ , . ....... ........
ht1 b'flt for I NI IM4lc.:lf KMSlll>ff'll .....,.. ltllf ~
flHMt ., S)"l'fotM'I b ~ . . t6ff ~td Of
<Of'lb'Ollt4 Thty l!lq .uw. ,,......-.~ dlik. ~ ~
~ 9''9dm (Hlnn, M\ol'Ohy ' ir,n.ct\.10111
., be ftryS!Qlty p<e$¥t4 t..9-- ~9- st)! P'$¥~on>
ht' so-. ol thcit •rai~ to k al¥d pr.-~vtly.
tn o:nlnst,. n :wi .in~ (such aJ a r11plurtd 1p~dix)
tMlf It i.tttt ' •"Y f9PO't\1Nt1 t« P<t- Of>t<~vt art.with tht
UC~ fll ~< "'tty t~lt~. I it IS l dly Wtjlt ty,
0 Video
can find a suite of videos that take you
through each skill, step-by-step.
~ wid ..:lmibng the pen.on is don. on ltlt nmt d;,y,
~~in. ~t "'l4 llrn!119 of prt-.opmt..-. wt,
·~ flt pttSOl'I rot JllttttY -'So dtptflds on
h sw91Cilf procedwe. Prep.Vif\9 b• o pttSON, one ff» •
~Ind tht et!>« for 1n MHtorn!Nt rtffdiOI\ wll
~ •~b ., ,.~ wt intor~ 9!Ytl\ '""Plmb
~ ~..-. tttfCbts
,......dtftAnl
*Ml pflyt.laf ,....artbon fot ltltu tw.

o The coloured tabs on each page help

you to navigate quickly and seamlessly
Gather equipment table s list and explain each item of between different parts of the text.
equipment you will need to perform the clinical skill.

GATHER EQUIPM ENT

1""' .,.,.....~ .... 41-•" ......... ....._..,. lw "' -..ul\il IJll........... " .iu11n.a ll!M -,OU Ni...
............ ~.__ . . ,_._-,~ .,......,...,.,...__,.111cHuu.,.....1•ll·C1111Roi-o. Wk
pttl""""UM~ll........... CM,..,._.._~---._e..l...... Nrhldiool•l'le-to~llUIS.

.._ ........
- . - . . . ............... •.t.r:lreflli(_
~
Qnl. ftlflOl.,_ ilA ttMnlJ»oO.IOC

•.._
........
_ _ ...,,_.a-.w. ........, .. ,,,.,.._,.~_1..,...

'
___ ...._~ ...lil ...,..... _ w ........i . . . -

-...--~...---ui ....~,......._~.. llf•ttl•~

I- -•·-=:iw:--....
_...~.~,.,,..--

I• .,,...... _._... ,.,....,_,.~~lw""..........,.m"''"mtf!'·

_
n..-~,.,. ...,... ......... _ ;,......,...
...,...._...... ,,.,.........,,........_,.,""'
~
~11

................... _,.,....,._._ltfw.M...,,i,11
~-c.. .... ~--~....,~-k"'"'"'"
.. ~,_

............ ~..,-~ ............'llbi"'t.

ti ,_.... ........,..,_ _ _ ,..,... ........,......101.
~'-·••-1wMiroo--•IW ....... l,..._<I WO~fl'otll!
..'-'111......,•.,....,.,,.,,,. _..,.,...,.llt_, ...
Ul!l• • l!M "'"·

.._.........,._...... ........"",..'""'--'""
tlllilll_ . . ..,.....,,,... WIM . . -.~ .. atl'.Jll,ltlilM . .

t. ...:=-.
___..............
. . --..-··-11-•.ei.1.·-·.,....,..
~

_.,,...,...... ......YCl ..._ _ . . ..... ,....u.,....1011il,

................
. . . . . . "'" 1111oa.1---·
_.,_,.,_~""'

.._ _ _ _ _ -
_ _.. .. ,........ - .....
~-..\l!Mt.lfl~-"·''"'·
... -f;Ml,o
lfll ,<Ofl,o...,.
Ill-fl_.,....... ,,. •111•
(lllrOlllll

",....... _ _ _,,.._._.,._ ..._ , .. "ll'#J"ll!tftl•Wf!'I

·-.. .-·""'°""'- 11-·~- . . .

""",...........·-·-·" -•""'"+4
_...,,..... ,'""""..........
H•ftl...--.,.,""""lllo.
.,.__..._...., .......... .._11w..., .. .....it.._..._ . ,
_.......

VII
 END-OF-CHAPTER FEATURES
At the end of each chapter you 'll find a clinical skills competency table for you to review, prac tise and record your
growing competency for each clinical skill.

CLINICAL SKILLS COMPET£NCY

PRE·OPEIUl.TIVE CARE
Otmonstrates the ability •o tffeclivtly prepare a person for tht11trt
- Performance c.rfterla I 1 l 5
ltH1mb•n indic.at• NM9A Rtogitt•..-.d ~""'' $"t1danl$ tor
Pr~tic:~I
101;,.l'ldMld CM.art'"~ IA»i«Hl '
ISu,.rviutl) Cil'llkpel'IMl'ld

The key performance criteria for an entire I ldtntifi•$ indlc.ation 12.S. ,,2, ,,SI ~
11
skill are listed, not just a task or procedure, and
0 0 0
~ Evidtn« of IM~p•uik inter-action wM \ti• pcnon,

the relevant NMBA National Competency

e,9, givu .a i:le.ar ~laMtion oftM proadu~ (2. 1,
2.1. ' · u .11
0 0 0 0 D
Standards are included. . t (7.1. 7.3)
ptr$Ona.t protettiw equipment ltWa.n 9l0¥9S. ft'W"I

. or apr<inl
incontintl\Ct pad
•edpa n Of C<1mrr.odt it n"t.ssary
luth blanket or shttl
lubtleal'lt
0 0 0 0 D
tMma tolutlon at oNler.d
1'11!ctat h1b• al'ld lip
conla1tn•r Ir th• onema 11 not a com.m•rdat on•
gaur• t qual'lt
4. Otmcuutnttt cllnlc.11l rttJon1,., atiUUt.t, •um at
,.rsOfl ts.I,
prtpar'lf\9 tht t 1W!ron1T11nt, p.ot,llOft.11\f lM
S.2, S.l , 4, 1, 7. 1, 9.51
J 0 0 n
t
5 PttfOflTlt l!and hy•••n• (? 1, 9 5)
:::J ;"] 0 0 D
•• Oon1 personal proted.Nt 1~ul111nent (7.t , 9 ~l
D 0 0 D []
7. Lubtlca\ts the non.t t ot tht tnttna tw"tt<Ul tultt t7.I,
t.31 0 0 D 0 D
E:Xp1ls ••ctss a!.rf7.I. t .31
"
t . Stowtyfns• tts lite entf'IU nonle (7.1. t .31
D 0 0 0 D
D 0 0 0 D
10. Stowty lntroduus lite ftuld 17.1, t.l)
0 0 0 0 D
11. Slowly with draws tM nozzle or tulM t7.1, t.31
0 0 0 0 D
12. Dries the p1rineal tiss1o1e (7.1, t .3)
0 0 0 0 D
13, Asks th• poerson to "'tain tt.f enema (as a:ppro,riat1)
0 0 0 0 D
14, Assift$ U'le ptrlon to the toilQt. "1mmod1 or bHpan,
ares for th1 p.er$on fotlo~.nt the proced1.n 17.1. t.3) 0 0 0 0 D
IS. Oocument.J relevant information (1.1. 1.2, 1..3, 2.,,, t.2..
10.2) 0 0 0 0 D
14, Oemon$lr:alts th.I ability to tmk t.heoty to 1tra~ 13.2.,
4,1, 4.2• 0 0 0 0 D

StUdQnt:
SignatuJ'e section for students and clinical
facilitators to record assessment.
. .. Clinical faclli lalor: Date:

CtW'Tlll SI HJtlOf'(RATfVE CA•£

There is space for students and clinical facilit ators to record y our p erformance and p ro gre SS using the five-p oint
scale: Dependant (D) , Marginal (M), Assisted (A), Supervised (S) and independent (i).

VIII GUIDE TO THE TEXT

GUIDE TO THE ONLINE RESOURCES
FOR THE INSTRUCTOR
Cengage Learning is pleased to provide you with a selection of resources that will help you prepare your lectures
and assessments. These teaching tools are accessible via cengage.com.au/instructors for Australia or cengage.co.nz/
instructors for New Zealand.

INSTRUCTOR'S MANUAL CLINICAL SKILLS VIDEOS

The Instructor's Manual includes:
• Simple task oriented questions to test student
preparedness
• Higher level critical thinking questions for further
discussion
These videos provide relevant and engaging visual
teaching demonstrations allowing instructors to
illustrate in class the clinical skills covered in the
new 7th edition of Clinical Psychomotor Skills.
These visual resources are available to instructors

' p rescribing the text.

• I
0 I

WORD-BASED TEST BANK

This bank of questions has been developed in conjunction with the text for creating quizzes, tests and exams for your
students. Deliver these though your LMS and in your classroom .

ARTWORK FROM THE TEXT

Add the digital files of graphs, tables, pictures and flow charts into your course management system, use them in student
handouts, or copy them into your lecture presentations.

FOR THE STUDENT

New copies of this text come with an access code that
-~
# CourseMateExpress
gives you a 24-month subscription to the C ouneMate
Express website. VlSit http://login.c e ngagebrain.com
and log in using the access code card

COURSEMATE EXPRESS FOR

CLINICAL PSYCHOMOTOR SKILLS

On the Clinical Psychomotor Skills C ourse Mate Express

we b site you will find:
• Advanced skills chapters
• Clinical skills videos
• Revision quizzes
• Video quizzes
• Weblinks, and more

ix
 NEW TO THIS EDITION
The table of contents for this edition has been reorganised to improve the sequencing of skills, and each skill has been
significantly restructured to make content clearer and easier to navigate.
This edition includes five new skills that were requested by academics and clinicians:
• Topical medication administration
• Vaginal medication administration
• Rectal medication administration
• Continuous abdominal peritoneal dialysis (in advanced skills)
• Bladder irrigation (in advanced skills).
The Nursing and Midwifery Board of Australia's Registered Nurse Standards for Practice (2016) replaced the National
Competency Standards for the Registered Nurse (2006). This edition incorporated the changes necessary to reflect the
progression of thinking within the nursing profession.
People who are morbidly obese are becoming an ever growing part of nursing practice, and to acknowledge their
requirements, a brief discussion of 'Bariatric issues' has been added to relevant skills. We have also included a new
boxed feature for this edition, 'If ... Then' that highlights to students common challenges, scenarios or clinical questions
that might arise throughout their practice, and then provides practical solutions for how to deal with these challenges.
As always, nursing and associated literature was consulted to ensure that the information is as current as possible.
Available evidence-based information has been included in this edition. The information that forms the theory
underlying the skills in this book comes from a number of sources. Nursing fundamentals texts were used as a base, and
searches of various databases found recent, research-based material to make the information as current as possible. This
edition includes evidence-based material published between 2014 and the time this book went to print. The databases
searched were GIN.AHL, Medline, Cochrane Library, Joanna !Briggs Institute, Proquest 5000. Government, medical and
health-related websites were accessed for evidence-based information as well. This edition has incorporated information
from Joanna Briggs Institute (2013-15) evidence-based summaries and clinician information.
Adjustments to some of the skills were made using the recommendations of clinicians and clinical facilitators,
students and preceptors, who have kindly critiqued the skills and sent their comments to us.

x
ABOUT THE AUTHORS
Joanne Tollefson (RN, BGS, MSc, PhD) was Senior Lecturer in the School of Nursing Sciences at James Cook University.
She is a registered nurse with many years of clinical experience in several countries and extensive experience in
nursing education at both the hospital and tertiary levels. Her research interests include competency-based education
and clinical assessment, development of reflective practitioners for a changing work environment, chronic pain and
arbovirus disease in the tropics. She is a two-time recipient of the National Awards for Outstanding Contributions to
Student Learning (Carrick Award, 2007 and Australian Teaching and Learning Council Award, 2008). Since retirement,
she has maintained an interest in nursing through researching, writing and editing nursing text books.

Elspeth Hillm.an (RN, BN, MN) is a lecturer and Academic Lead: Professional Practice in nursing at James Cook
University, with an interest in nursing education research. She has extensive experience in several Australian states in a
range of clinical situations from rural to critical care nursing. Her experience includes facilitation of both undergraduate
nursing students in various clinical facilities, and of post-graduate nursing students in high dependency units.

ACKNOWLEDGEMENTS
The publisher would like to thank the following reviewers :for their incisive and helpful comments:
• Liz Price, The University of South Australia
• Jasmine Hutchison, The University of South Australia
• Sue Slater, Charles Sturt University
• Maria Chilvers, The University of South Australia
• Lynne Brown, Griffith University
• Gill Lewis, Australian Catholic University
• Mel Underwood, Charles Darwin University
• Jennifer Hosking, Deakin University
• Elicia L. Kunst, Southern Cross University
• Benjamin Hay, The University of Notre Dame
• Annette Saunders, The University of Tasmania.

XI
 Visit http:/ /login.cengagebrain.com and · Skills videos -~
~CourseMateExpress

use the access code that comes with this • Advanced skills
book for 24 months access to the resources procedures
and study tools for this chapter. The • Revision quiz
CourseMate Express website contains: • Web links

Note: These notes are summaries of the most important points in the assessments/procedures and are not exhaustive on the
su bject. References of the materials used to compile the information have been su pplied. The student is expected to have learnt
the material surrounding each skill as presented in the references. No single reference is complete on each subject.
 Psychomotor skills
Psychomotor skills are those that require an integra tion of motor dexterity, re lated knowledge, values, and in the case of
nursing, orientation toward and inclusion of the person in care. Psychomotor skills require practice to master and are
developed over time, initially with a concentrated effo rt on coordinating movement and reflexes along with incorporating
appropriate interpersonal skills. As you develop skills in nursing, you will be expected to meet the standards of care tha t
have been set by the Nursing and Midwifery Board of Au stralia - t he chief nursing body in Australia.

NURSING STANDARDS
In 1990, the nursing bodies in Australia developed the Austra lian Nursing and Midwifery Council (ANMC) National
Competency Standards for the Registered Nurse as the m inimum requ irements for registration as a nurse. The concept of
competency was later updated and defined as:

The combination of skills, knowledge, attitudes, values and abilities that underpin effective and/or superior performance
in a profession/occupational area.
ANMC 12006). p. 8

Since then, these competencies have been further revised and updated. The ANMC"s National Competency Standards for
the Registered Nurse (2006) were adopted by the Nursing and M idwifery Board of Australia (NMBA) at the inception of the
National Registration and Accreditation Scheme in 2010, and tthen in 2016 the Registered Nurse Standards for Practice
(NMBA. 2016) replaced them and remains the current standard (this document is available in Appendix 1 of this book). These
standards are instrumental in determining the model for tertiary nursing.
The Registered Nurse Standards for Practice outlines an entry-level standard across a global range of nursing activities to uphold,
including critical thinking and analysis, legal accountability, an individual's rights, excellent communication skills, patient safety and
trust. Two of the outcomes of utilising these standards include professional pride and the transferability of skills. However, because
much of the work done by nurses is interpersonal, competency is very difficult to determine and measure. The complexity in assessing
skill competency is addressed in the NMBA"s Framework for Assessing National Competency Standards (20151.
Clinical Psychomotor Skills outlines the practical aspects n ecessary for the skill assessment of entry-level registered
nurses (RNsl. The text is structured to enable theoretical kn owledge to be applied experientially. This assists you to
effectively master the practical applications of the theory you are learning. The tools in this book minimise the difficulties in
assessing your clinical skills and are already used extensively throughout Australian nursing schools.

PSYCHOMOTOR SKILLS ASSESSMENT

The actual ·motor skill' is only one aspect of the overall compe tency of an individual nurse. Other aspects include specialised
knowledge, cognitive skills, technical skills, interpersonal skills and personal traits, which are demonstrated when you
perform psychomotor skills. The observer or expert nurse assessor will reassess overall performance as new ·cues· are
added to the observation dataset. From this, over time, an idea about your abilities can be derived.
According to the NMBA (20161. assessmen t is con ducted using five principles:
• Accountability - the assessor is accountable to the public and the nursing profession to validly and reliably assess you in
a practice setting.
• Performance-based assessment - the assessmen t is undertaken in the context of a range of interactions between you
and the person receiving care to enable global assessment of your knowledge, skills, values and attitudes.
• Evidence-based assessment - you will be observed, interview ed and asked to reflect on your performance, your
documentation is examined, tests are given (e.g., medication calcula tions, questions about anatomy and physiology).
others are consulted for their views (peers, supervisors and individuals receiving carel and this information is analysed
using the assessor's professional judgement to form a conclusion about your competence.
• Validity and reliability- a knowledgeable and skilled nurse assessor gathers evidence from a variety of sources and with
reflection and judgement determines if the assessment meets the intended outcome (validity! and if the assessment
process is consistent and accurate (reliability).

2 PART 1: INTRODUCTION
• Participation and collaboration - the assessment process is based on participation and collaboration between you and
your nurse assessor. This involves high levels of communication. reflection on the process by both participants and
reinterpretation of the evidence.
As a beginning practitioner you will benefit from guidelines and direction. and having complex interactions simplified into
recognisable and achievable steps will enhance your learning, reduce stress and allow you to better concentrate on the
complexities of the situation.
Initially, skills are learnt in the safety of the laboratory through demonstrations and discussions with the laboratory
leader, who is a skilled current nursing practitioner. The ski lls and the linked theory can be read, digested, conceptualised
and discussed before you attempt a new skill in the clinical environment. This process increases confidence and fosters
clinical reasoning and judgement.

USING THIS ASSESSMENT TOOL

This book has been developed to guide you when learning a new skill. When you are on professional experience placements,
the book will need to be used in conjunction with the faci lity's relevant procedural guidelines.
The information provided here is generic and must be adapted to and integrated within the specific clinical context. The facility
type (e.g.. acute care, nursing home), geographical loca tion, sta ff availability, shift, time of day, day of the week, and the season
will influence how the procedural information is used. Individual differences between people, including age and developmental
stage, culture. gender. wellness level, stress levels, and their ability to communicate will alter the procedure as well.
This book contains many of the major psychomotor skills taught throughout the entire undergraduate nursing program
and is intended to be used both on professional experience placement and theory-building encounters throughout the entire
three years of study. Upon completion you will have a record of the clinical skills assessed and the results achieved during
undergraduate nursing education.
You can use this book in skills laboratories, or during demonstrations and discussions by the laboratory leader. We have
minimised the use of diagrams and lengthy explanations so the book can be easily carried into and used in clinical,
laboratory and assessment situations. Your facili tator or preceptor can also use it as a summative assessment tool to
provide a structured assessment process and assist in facil itating objective, comprehensive and constructive feedback on
your performance. They can assess the various aspects of your clinical skills performance as exemplars of your ability to
demonstrate domain criteria of the NMBA RN Standards of Practice (20161.
In this text we refer to each chapter as a 'Clinical Skill', and these will be cross-referenced in bold throughout the text
where relevant; for example, see Clinical Skill 53, is directing you to Chapter 53. Each Clinical Skill has two or three pages
that provide the required underpinning theoretical components. The information presented is not exhaustive in relation to the
subject, but it does provide you and the assessor with a mutual basic understanding of each procedure. Foundational nursing
texts and medical surgical texts must be used to supplemen t the material in the theoretical links to practice.
The Clinical Skills encompass entire skills, not just individual tasks or procedures. Nursing students with limited exposure
to clinical situations must still demonstrate a level of competence to demonstrate safe practice. The balance and integration of
the skills and knowledge you acquire determines your ability, n ot within just one skill, but in your overall readiness for nursing.
You are assessed on your ability to interact with the person you are caring for, to solve problems and to effectively manage the
time and resources at your disposal. You are also assessed on your ability to complete the procedure efficiently and safely, to
ensure the person is clean and comfortable, to document their care and to dispose of waste afterwards.
The evidence-based information tha t forms the theory underlying the skills in this book comes from a number of sources.
However, some fundamental nursing-care skills in this book still do not have a great deal of solid evidence or research-based
foundations. You are expected to read widely, attend professional experience workshops, and discuss issues with the laboratory
leader, clinical educator or RN, in order to broaden your knowledge prior to implementing a skill in the clinical setting.

PERFORMANCE CRITERIA
In the Clinical Skills Assessment table at the end of each Clinical Skill, each criterion is linked to one or more of the NMBA's
RN Standards for Practice (20161. Standards reference numbers are listed beside each criterion to facilitate linking your
performance with the relevant NMBA Standards criteria. The facilitator can gather many cues in relation to the specific
Standards criteria before giving you a formal judgement of your performance and verbal or written assessment feedback of
your progress for the relevant NMBA Standard.
Even though the performance criteria have been broken into arbitrary sections. the entire skill should be seamless. You should
not be assessed on your first attempt to complete a procedure; practice improves performance and fosters your confidence.

CHAPTER 1: PSYCHOMOTOR SKILLS 3

 The five-point Bondy rating scale is used in this edition. This scale considers three areas: professional standards,
competence and independence. There are five "Levels· of performance, as follows:
• Independent- you can complete the procedure or skill safely, accurately and efficiently, without any cues from the clinical
facilitator. You can discuss the theory as it relates to the person's clinical situation. You use appropriate vocabulary and
excellent communication and show appropriate affect. You use your time well and are confident in your actions. The clinical
facilitator would feel confident that you are able to perform this procedure, or one similar, independently.
• Supervised - you can complete the procedure, safely and accurately; however, you may require direction, prompting or
more time to complete the skill. You focus on the person in your care and your affect is appropriate. You can discuss the
theory behind the procedure in a general way. Conversely, you may be able to complete the psychomotor skill but not
discuss the rationale behind what you are doing. The clinical faci litator would not feel confident enough to allow you to
complete this or a similar procedure without some supervision.
• Assisted - you can accomplish the procedure safely and accurately; however, you may have difficulties with time
management, with focusing on the person rather than yourself or the skill, with your affect, with anxiety or with
communication, or your knowledge base may be lacking and you cannot provide a rationale for your actions. Your clinical
facilitator may have to provide directive cues as well as supportive cues to help you through the procedure and would
need to supervise this or a similar procedure in the future.
• Marginal - you cannot complete the procedure accurately, safely or without directive assistance from the assessor, and
you have difficulty in linking theory to the practice. You may be anxious and lack confidence, you take too much time to
finish and cannot focus on the person in care due to focusing on the procedure or on yourself. The clinical facilitator
would not allow you to complete this or a similar procedure without supervision.
• Dependant - you are unable to complete the procedure and your performance is unsafe and inaccurate. You are
uncoordinated, lack knowledge of the theory, do not focus on the person and require so much direction and assistance
that the assessor is essentially performing the procedure [Bondy, 1983).

NOTE TO THE CLINICAL EDUCATOR OR FACILITATOR

Several recent studies have demonstrated the importance of the clinical educator/facilitator"s role in fostering the learning
of nursing students, using strategies such as:
• role modelling
• creating a safe environment
• providing experiential learning opportunities
• setting realistic expectation
• providing feedback and stimulating learning (Karani et al., 20 14).
Using these teaching strategies will assist the student to develop the core professional characteristics of the RN: caring,
compassion, respect, confidentiality. reflection, competence, integrity, honesty, morality and ethical conduct (Cruess et al.,
2011). The se professional characteristics are enhanced by focus ing on the social. cultural and ethical dimensions of the
nurse-person interaction, in addition to the more easily taught and assessed technical and cognitive aspects of good care
(Langendyk, Mason & Wang, 2016). As a gatekeeper to our profession, you will need both confidence and courage as well as
the support of the university if/when it comes to failing a studen t for unsafe care (Hughes, Mitchell & Johnston, 2016). We
hope you will use your skills to help students to become grounded in a nursing culture of excellence.

References
Australian Nursing and Midwifery Council (ANMCI (20061. National competency standards for the registered nurse (4th ed.I. Dickson. ACT: Australian
Nursing and Midwifery Council.
Bondy. K. N. (19831. Criterion referenced definitions for rating scales in clinical. evaluation. Journal of Nursing Education. 22191. 376-82.
Cruess, R.L., Cruess, S.R.. Snell. L., Ginsburg. S.• Kearney. R.. Ruhe. V., Duchar me. S .. & Sternszus. R. (201 11. Teaching. learning and assessing
professionalism at the post-graduate level. Members of the Fu ture of Medical Education in Canada Consortium (Post-Graduate!. Montreal. Canada.
Hughes. l.. Mitchell. M. & Johnston, A. (20161. "Failure to fail" in nursing - a catch phrase or a real issue? A systematic integrative literature review.
Nurse Education in Practice. 20. 54-63. doi: 10.1 016/j.nepr.2016.06.009.
Karani. R.. Fromme. H.. Cayea. D.. Muller. D.. Schwartz, A.. & Harris, I. (20141. How medical students learn from residents in the workplace: A qualitative
study. Academic Medicine 89131. 490-6.
Langendyk, V.. Mason. G.. & Wang. S. (2016). How do medica l educators design a curriculum that facilitates student learning about professionalism?
International Journal of Medical Education. do1: 10.5116/ljme.5683.c2e0.
Nursing and Midwifery Board of Australia (NMBA) (20151. Framework for assessing national competency standards. Canberra: Nursing and Midwifery
Board of Australia .
Nursing and Midwifery Board of Australia (NMBAI (20161. Registered Nurse Standards for Practice. Dickson, ACT: Nursing and Midwifery Board of Australia.

4 PART 1: INTRODUCTION
Clinical thinking
Critical thinking is a process. It is a purposeful act that uses careful, deliberate thought, creativity, intuition, reflective
thinking, fair and open mindedness, logic, analysis and evaluation to arrive at a decision. In nursing, critical thinking forms
the basis for clinical decision-making. Thinking in a systematic and logical manner and openness to questioning and
reflecting on your reasoning process help to ensure sa fe nursing pract ice and quality care [Heaslip, 20081.
Clinical reasoning is a subset of critical thinking that focu ses on the care of a person within the healthcare system. Using
the critical thinking processes, clinical reasoning takes into consideration:
• medical and nursing knowledge about the person's diagnosis [e.g .. anatomy and physiology, pharmacology,
communications, clinical psychomotor skills)
• the legal. ethical and other professional standards
• safety
• evidence-based knowledge
• your knowledge of the person and their clinical situation
• your clinical experience to determine. prevent and manage care situations [i.e., to problem solve).
Clinical judgement is a complex process. It takes clinica l reasoning [i.e., the 'cues', such as data. signs and symptoms,
·normal' and 'abnormal' findings that you identified with the person) and applies pattern recognition and intuition to
determine if there is a nursing problem/something wrong with the person. And lastly the available alternatives to solve the
problem are sorted through and the best one is determined. Arriving at decisions with the person about their care using
clinical reasoning and clinical judgement is known as clinical decision making.
Sound clinical reasoning takes time to develop. It inv·olves incorporating theoretical knowledge from your nursing
courses, clinical knowledge from your clinical experiences, and practice and reflection on your clinical experience. Your
clinical facilitators or registered nurses IRNsl with whom you are working may assist you to develop your clinical reasoning
and judgement. For instance, they may ask you to analyse a care episode [see the example clinical scenario on pages 6-7) or
to talk through your reasoning and decision making fo llowing an interaction with someone in your care. Providing timely
feedback within a respectful environment is an essential part your clinical facilitator's efforts in assisting you to develop and
reinforce professional decision making [Koharchik et al., 2015). Cli nical reasoning is essential for promoting safety and good
outcomes for people in your care and for preserving professional nursing standards [Alfaro-LeFevre, 20171. It is also a skill
that many RNs find provides deep satisfaction throughou t their career.
According to Levett-Jones et al. (2010) the eight steps in clinical reasoning [as shown in Figure 2.1 ) are:
1. Looking - noticing signs, being aware of the person and looking for change during any interaction, and scanning the person
at each encounter.
2. Collecting - purposeful observation and assessment, data collection, review handover, charts, history, results of
investigations. recall related information [e.g., anatomy and physiology, pharmacology, therapeutics. culture) and context
of care.
3. Processing - cognition, including new relationships, cue clus ters, what is relevant, not relevant. normal versus
abnormal, nursing knowledge of past situations you have seen. deciding on significance of data in this person·s situation
and questioning what will happen if nothing is done.
4. Deciding - review and analysis, generating ideas and using theoretical and experiential knowledge to define the problem.
5. Planning - determining with the person which course of action is most appropriate to achieve the best clinical outcomes
for the person, stating a time frame and feeling confi dent that you have made the best choice.
6. Acting - carrying out the chosen course of action.
7. Evaluating - determining if the action was the best choice to improve the situation and why or why not.
8. Reflecting - thinking back, including questioning wha t coiuld have been done differently and asking yourself probing
questions about the entire process in order to learn from it; both in a clinical and a personal sense.
Ideally, all nurses, from novices to experts, use these steps. Expert nurses may not seem to use the steps, but they do -
just very quickly and using their experience to inform the processes. These steps can occur out of sequence, can overlap or
be blurred into each other; however. all are essential in nursing care. A ninth critical step, which precedes all the others is
anticipation. Know the person you are caring for. their diagnosis and their problems. and anticipate what could go wrong.
Your anticipation results in vigilance for signs of probable difficulties and helps you to recognise subtle indications early.

CHAPTER 2: CLINICAL THINKING 5


Contemplate what you
have learnt from this
process and what you
could have done
differently.
Evaluate
Evaluate the
effectiveness of and
actions outcomes. Ask:
"has the situation
improved nowr
Select a course of action
between different
alternatives available.
Review current information !e.g. handover
reports. patient history. patient charts.
results of investigations and
nursing/medical assessments previously
Describe or list facts. undertaken).
context. objects or Gather new information !e.g. undertake
people. patient assessment)
Recall knowledge !e.g. physiology.
Consider pathophysiology. pharmacology.
Reflect on the patient epidemiology. therapeutics. best practice
process and situation evidence. culture. context of care. ethics.
new learning
information
Clinical Process
information~---------------~
reasoning Interpret: analyse data to come to an
understanding of signs or symptoms.
cycle Compare normal Vs abnormal.
Discriminate: distinguish relevant
Identify from irrelevant information; recognise
problems/ inconsistencies. narrow down the
issues information to what is most important
Establish and recognise gaps in cues collected.
goal/s Relate: discover new relationships or
patterns; cluster cues together to
identify relationships between them.
Synthesise fa cts and Infer: make deductions or form
Describe what you want
inferences to opinions that follow logically by
to happen. a desired
make a defin itive interpreting subjective and objective
outcome. a time frame.
diagnosis of the cues; consider alternatives and
patient's problem. consequences.
Match current situation to past
situations or current patient to past patients
!usually an expert thought process).
Predict an outcome Iusually an expert
thought process).

Figure 2.1 The clinical reasoning process with descriptors

Reprinted from The 'five nghts' of clinical reasoning : An educationa l model to enhance nursing students' ability lo identify and manage clinically
·a1 risk' patients. Levell- Jones. T.. Hoffman. K .• Dempsey, J., Jeong, S.. Noble, O.. Norton. C.. Roche, J., & Hickey N, Nurse Education Today. Copyright
2010, with permission from Elsevier.

The following is a clinical scenario and analysis !see Table 2.1 I to illustrate the practical use of the eight steps in clinical reasoning:
You are working a night shift and it is 2345 hours. You have been asked to do the postoperative observations for
Mrs Gardiner, who returned from orthopaedic surgery [right foot) at 1700 hours. She is dozing when you enter her room but
wakens when you call her name. Her vital signs have been within acceptable limits, she states that her pain is minimal 13/101.
she is drinking and eating without experiencing any nausea and has been up to the toilet and voided a good amount of urine
twice since surgery. Mrs Gardiner has D5S infusing into her left cepha lic vein !forearm!. She states that the IV line keeps
pulling and waking her up and the lights and beeping of the pump are annoying and asks you to remove it. She also feels hot
and has tossed the blanket off.

Table 2.1 Analysis of example scenario using the clinical reasoning process

Clinical reasoning Description Clinical example

action

Looking Noticing signs and symptoms, being aware
and looking for change during any
interaction
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ....
Mrs Gardiner is alert Iawakes to voicel, her colour is
good lpinkl. and her skin is dry and well hydrated.
She is moving well in bed and she has drunk most of
the litre of water at her bedside. Her IV is infusing at
125 ml/hour. There is about 200 ml left to be infused.
Her blanket is bunched up on the side of her bed

6 PART 1: INTRODUCTION
 Purposeful observation and assessment,
data collection, review handover, charts,
history, results of investigations, recall
related information
Processing Cognition - new relationships, cue clusters,
what is relevant, not relevant, normal vs
not normal, nursing knowledge of past
situations you have seen, deciding on
significance of data in Mrs Gardiner's
clinical situation, what will happen i f
nothing is done?
Deciding Review and analysis, generating ideas,
using theoretical and experiential
knowledge to define the problem
Planning Determining with Mrs Gardiner which
course of action is appropriate to get the
best outcome for her, stating a time frame,
feeling confident that it is the best choice
Acting Carrying out the chosen course of action
Evaluating Determining if the action was the best
choice to improve the si tua tion and w hy or
why not
Her vital signs are: TPR: 36.9°C, 84/14; BP: 145/90 (on
admission it was 154/88). Pulse oximetry 96 per cent
on room air; states minimal pain (had a slow release
analgesic at 2200 hrs). Right leg and foot elevated.
Toes are warm, nails pink, can feel touch and wriggle
toes, dressing remains intact, unable to access foot
pulses due to bandaging. Moonboot on. IV infusing well
and IV site clean and dry
On the surgical chart, she had 2 L of fluid in theatre,
and has only the current litre remaining of the order.
She fasted from 0600 hrs. She is eating and drinking
well. She has been up to the toilet with assistance
twice since surgery, urinary output is approximately
350 mUvoid - urine clear and pale yellow
Mrs Gardiner is recovering from surgery without
incident. Her fluid intake is good (3.8 Lover the past
18 hours) and she has no nausea. There are no further
IV orders after the current litre. She had analgesia
about two hours ago which is effective
The IV line and pump are waking her up. If left in,
the IV line and pump will keep her awake periodically
throughout the night and she will need to be awakened
in an hour and a half to remove the IV line
She reports being hot. Temperature is 36.9° C.
Ambient temperature is 24°C. She had warmed
blankets on following theatre
If the IV is removed, there is no direct access to veins if
a need for rapid administration of medications or fluid
is needed [following surgery, this is not a good choice)
The hospital protocol allows the IV cannula to be
left in situ and capped for the night. Lowering the air
conditioning may increase her comfort
In this instance, capping the cannula now permits
Mrs Gardiner to sleep through until the next observation
period at 0400 hrs. taking advantage of the peak
analgesic period, although she will miss out on about
200 ml of fluid. Since her intake for the day is more
than adequate, this is a reasonable choice. Set the air
conditioning at 22°C
Cap the cannula and take away the line and volumetric
pump. Provide Mrs Gardiner with a fresh litre of water
and ask her to drink some now. Change the setting on
the air conditioner
Determine if Mrs Gardiner is sleeping during each
round throughout the night. Check if she still has a
blanket on
At 0600 hrs, when you come to take the
observations, ask Mrs Gardiner how she slept and
assess her pain levels
CHAPTER 2: CLINICAL THINKING 7
 Clinical reasoning Clinical example
action

Reflecting Thinking back asking yourself what you
could have done differently, and asking
yourself probing questions abou t th e entire
process in order to learn from it - both in a
clinical sense and a personal sense
I needed to look up the hospital protocol for leaving an
IV cannula capped. This is a common occurrence and
one I could have anticipated. I will have to be more
alert to common protocols in the future. I had read
about the surgery, and studied her chart before I went
to her room [anticipation). so I felt confident about
what observations to make
I checked with the RN about my clinical reasoning
and she agreed with my thinking and what I decided
I felt proud that I made the right clinical decisions

As you progress through your studies, you will encounter increasingly complex clinical situations; therefore, developing
clinical reasoning skills is an essential part of becoming a RN. It demands a deeper and more sophisticated understanding of
the knowledge underpinning practice and of the person in your care. The basis for developing effective clinical reasoning is a
sound core of the essential knowledge of the profession. Your clinical observation skills need to be nurtured and honed.
Beginning nurses often have difficulties differentiating between a situation that needs immediate attention and one that does
not, and also in processing large amounts of complex clinical data when under time pressure. In the beginning, deciding on a
course of action, then asking more experienced RNs tor their input and critique is a good strategy to develop your clinical
decision-making skills. There are also frameworks that look at physiological cues in acutely ill people !early warning
systems) to assist you in determining if the person's condition is stable or deteriorating.
Situational awareness is a process nurses use to avert poor outcomes in people with unstable conditions and that may
deteriorate quickly. This type of clinical reasoning begins with kn owing the person, their diagnosis, what is likely to go wrong
and what could go wrong. From here you notice their environm ent and apply:
• vigilance - look for indications of problems; for example, altered vital signs, reduced urine output, poor colour, swea ty
skin, saturated dressing, empty intravenous bag
• perception - notice the differences in the person from th e last time you saw t hem or from the handover you received; for
example, increased pain, confusion, less alert.
You can then use clinical reasoning to identify important elements, and decide what cues to look for, and from these cues
you can predict what might happen. At this point, you intervene if you can !e.g., apply oxygen, give pain relief as ordered) or
communicate your findings and prediction to a senior colleague who can address them !e.g., contact the medical team,
initiate a unit protocol for electrocardiograms).
Competent professional nursing care is never a superfi cial or habitual activity. Nursing practice requires a fully engaged
mind using critical, reflective thinking and the sound reasoning of an intelligent mind developed and dedicated to safe,
effective care. Nurses using well developed clinical reason ing skills positively impact on an individual's recovery and well-
being. Nurses with poorly developed clinical reasoning skills may be unable to determine when an individual is beginning to
deteriorate or to recognise the onset of a complication. They may also be unable to diagnose a problem or start appropriate
treatment for the problem or complication. They are not as effect ive in providing safe care as they could be.

References
Alfaro-Lefevre, R. (20171. Critical thinking, clinical reasoning and clinical judgement: A practical approach (6th ed.1. Philadelphia, PA: Elsevier.
Heaslip, P. 120081. Critical thinking and nursing. The Critical Thinking Community. Retrieved from http://www.cnt1calthinking.org/pages/critical·
thinking-to·thmk-like-a-nurse/834, accessed November 2016.
Koharchik, L., Caputi, L., Robb, M., & Culleiton. A. (2015). Fosteri ng clinical reasoning in nursing students. American Journal of Nursing, 7511), 58-61.
doi: 10.1097/01.NAJ.0000459638.68657.9b.
Levett-Jones, T., Hollman, K., Dempsey, J., Jeong, S., Noble, D., Norton. C., Roche, J., & Hickey N. (20101. The 'five rights' of clinical reasoning: An
educational model to enhance nursing students' ability to identify and manage clinically 'al risk' patients. Nurse Education Today, 30(6). 515-20.

8 PART 1: INTRODUCTION
Person-centred practice
Person-centred practice is a way of thinking about and doing things in a healthcare setting that reflects the person as an individual
with unique life stories, preferences, values and needs. It places the individual at the centre of the care being offered. Person-
centred practice is defined by the Nursing and Midwifery Board of Australia (NMBA) Registered Nurse Standards for Practice
[2016, p. 6) as a ·collaborative and respectful partnership built on mutual tru st and understanding through good communication·
and has been adopted for the NMBA's 2018 Code of Conduct for Nurses and Midwives. Registered nurses (RNs) use empathy and
compassion to provide holistic care to people in need [McCance & McCormack, 20161. We try to humanise health care by valuing
people as individuals, using their strengths and capabilities to fac ilitate active participation in their own care. Knowing the
person's values and beliefs enables RNs to make decisions with the individual and act on those decisions to meet the individual's
needs. Person-centred practice is responsive to a person· s needs and how we can meet them together (Moyle et al., 20151. Nurses
need to see an individual as expert about their own health and care. We need to 'do with the person', not 'do to the person'.
Draper and Tetley (2013) list the components of person-centred practice as:
• knowing the person as an individual
• being responsive
• providing care that is meaningful
• respecting the individual's values, preferences and needs
• fostering trusting caregiving relationships
• emphasising freedom of choice
• promoting physical and emotional comfort
• involving the person's family and friends, as appropriate.
Rathert et al. (2015) added to this: coordination and integration of care and services, providing information, education and
communication, continuity and transition from hospital to home and access to care and services. Understanding a person's
beliefs is also important in providing them with appro pr iate care.
On the healthcare system side, we need to consider the person's whole experience and promote continui ty and
coordination ensuring that the physical, cultural and psychosocial environment of health services supports person-centred
care. Healthcare professionals must be supportive, good communicators and strive to put people at the centre of their own
care. The term 'person centred' is as applicable to our interactions with our colleagues as to the people for whom we care.
Even though 'patient-centred care' is often used to mean the same as 'person-centred practice', the latter avoids the terms
'patient', 'consumer' or 'client' as politically and economically created terms which ignore the individuality of each person. Anyone
who comes into contact with the healthcare system is vulnerable because they seek help beyond their own knowledge and ability
to self-care. The word 'patient' places an individual in a position of increased vulnerability and powerlessness as the healthcare
system, including nurses, become the providers of and gateways to care. The use of the word 'patient' depersonalises an
interaction and places the focus on the nursing needs and medical diagnosis that take priority over personal needs of the care
receiver. 'Client' or 'consumer· are economically constructed terms that evoke the notion that the person receiving care is a
paying customer who must get what they want to have a satisfactory outcome. 'Person· or 'people' is used in the NMBA's
Registered Nurse Standards for Practice [2016, p. 6) to refer to 'individuals who have entered into a therapeu tic and/or
professional relationship with a registered nurse· and include families, carers, community groups, colleagues and students as
well as those requiring direct nursing care who come wi thin the scope and context of practice of the registered nurse.

HOW DOES PERSON-CENTRED PRACTICE

BENEFIT THE PERSON?
Person-centred practice:
• is informed by evidence
• incorporates the individual's needs, capabilities and goals
• is a collaboration between the person and the nurse
• includes family involvement
• takes into account the context
• is cost effective.

CHAPTER 3. PERSON-CENTRED PRACTICE 9

 Nursing interventions based on person-cen tred practice help individuals get the care they need when they need it, help
them to be more independent and active in their own health care. improve the quality of available healthcare services. and
reduce some health and social services pressures !Moyle et al., 2015). Putting people at the centre of their care has been
demonstrated to have a big impact on the quality of care [Olsson et al., 2013). It can improve the individual's experience of
care and their satisfaction with it. It can help people to lead healthier lifestyles; for example, by supporting them to make
healthier life choices such as exercising and eating healthily. It involves people in their care decisions so that the services
and support provided is what they need at the time and it can impact on their health outcomes (e.g., education and support
tailored to the individual assists in reducing blood pressure, stabilising blood glucose levels).
Person-centred practice benefits the healthcare system by reducing the frequency of the use of services which may then
reduce the overall cost of care. And it benefits nurses by improving the confidence nurses have in themselves and in the care
they provide. Person-centred care enhances the satisfaction nurses feel in their caregiving.
Tobiano et al. (2016) warn that there are barriers to providing person-centred care. These include the nurse·s task
orientation, risk minimisation (e.g., limiting necessary mobilisation to reduce falls in those deemed to be high-risk) and time
limitations, and nurses need to be aware of these to enable themselves to improve their person-centred practice. A great
deal of the success in implementing perso n-centred practice hinges on excellent communication skills.

References
Draper J .. & Tetley J . (20131. The importance of person-centred approaches to nursing care. Open University [Online). Retrieved from http://www.open.edu/
openlearn/body-mond/heatth/nurs1ng/the Importance person centred-approaches· nursing ·care, accessed 26 January 2017.
Mccance, T., & McCormack, 8. (20161. Person-centred practice framework. In T. Mccance & B. McCormack"s Person-centred practice in nursing and
health care. London, UK, John Wiley & Sons, p. 36.
Moyle, W., Rickard, C., Chambers, S. K., & Chaboyer, W. 120151 Partnering with patients model of nursing interventions: A first step to a practice theory.
Healthcare, 3121, 252-62: doi : 10.3390/healthcare3020252.
Nursing and Midwifery Board of Australia INM BAI (20161. Registered Nurse Standards for Practice. Dickson, ACT: Nursing and Midwifery Board of
Australia.
Olsson. L E.. Jakobsson. Ung. E.. Swedberg, K., & Ekman. I. (20131. Efficacy of person -centred care as an intervention in controlled trials - a systematic
review. Journal of Clinical Nursing. 2213-41. 456-65.
Rathert, C., Willia ms. E. S .. McCaughey, 0., & lshqaidef. G. (2015), Patient perceptions of patient-centred care: Empirical tes t of a theoretical model.
Health Expectations. 18, 199-209. doi: 10.1111/hex.12020.
Tobiano. G.. Marshall. A.. Bucknatt. T.. & Chaboyer. W. [20161. Activities patients and nurses undertake to promote patient participation. Journal of
Nursing Scholarship, 48(4). 362-70.

1Q PART 1: INTRODUCTION
Therapeutic communication
Therapeutic communication [or therapeutic interaction) is a specific type of verbal and non-verbal communication used by
health professionals to help the people for whom they are caring better understand what is happening to them. This assists
in reducing their apprehension, anxiety and fear to increase relaxa tion and foster trust in the healthcare personnel. It also
assists the person to provide information to participate in the ir care and influence the outcome of the health- based
interaction. Nurses use specific communication techniques t o gain information from a person about their unique life story,
preferences, values and needs, circumstances, health pro b lem and state of mind. It also helps to provide support and
information to assist a person to deal with and understand the ir situation and emotional reactions to it. This improves the
comfort and safety of the person, their trust in nurses and th e healthcare system, and ultimately their health and wellbeing.
The NMBA's 2018 Code of Conduct for Nurses and Midwives has adopted the term 'professional communication· [p.4) in
preference to therapeutic communication.
Professional communication is generally taught as part of a required subject in nursing courses, so this discussion is but
a brief introduction to this topic. Some specific communication techniques can be found in Table 4.1 .

Table 4.1 Techniques for professional communication

Technique name Explanation Example

Active listening A potent communication device fo undatio nal to Maintain appropriate eye contact; face the person
professional communication. It involves being at their level if possible and lean toward them,
attentive to the person - being 'with' the person, also use accessible language [no jargon]
calmly and actively

Give recognition Acknowledge the per son as an individual without Call the person by title or name, noting any changes
any value judgements such as they have applied makeup or shaved

Use open questions I Open questions require an explanati on and therefore
elicit more information. Ask only one question at a
time and explore that topic thoroug hly before moving
on to another
In contrast, closed questions requ ire only a brief
answer (e.g., yes or no] and are used if the situation
warrants (e.g., if the person is in severe pain or
respiratory distress)
Examples of open questions include: 'Tell me how
you are feeling' and 'What makes your pain worse?'
Examples of closed questions include: 'Do you feel
nauseated?' and 'What is the level of your pain on a
scale from zero to ten?'

Share observations Talk with the person about what you have seen or You haven't been out of bed much today'
heard, then remain silent to allow the person to respond

Use empathy Demonstrate an understanding of another 'It must be very frustrating to have to stay in bed
I person·s feelings and then wa it fo r a r esponse all day·
~~~~~~~~~--+-~~~~~~~~~~~~~~~~~~~

Acceptance Accept what the per son says without judgement to This could just be a nod, a smile or 'mmm·
acknowledge them

Touch Touch the person appropriately to offer co mfort Gentle touch, usually on their hand, arm or shoulder

Use humour Humour used appropriately promotes friendliness, This is situational. What may be humorous to one
sharing and relaxation person may be insulting or derogatory to another

Provide factual Information helps the individual to make Your surgery is scheduled for 11 this morning·
information decisions, feel safe. secure and to reduce anxiety 'Your IV can come out when this litre is completed'

Clarify Ensure an accurate understanding of what you Tm not sure I understood what you meant when
have heard (usually by restat ing] you said that you feel "down" just now·

CHAPTER 4: THERAPEUTIC COMMUNICATION 11

 Technique name Explanation Example

Explore Learn more about a situation !usually used if the 'Tell me more about ...' then ask further specific
person remains on a superficial Levell using broad, questions about the situation
then focused questions to delve into an exp erience
or situation

Focus on a single Explore a symptom or idea in greater depth 'You have pain in that ankle? Can you tell me your
idea level of pain on a scale of zero to ten?·
·can you point to where it hurts most?"
"What makes it feel worse? Better?·
·can you move the joint?·

Paraphrase Use different words to sum up the per son's
message. Paraphrases are usually shorter and
use different but similar words
The person tells you: "My foot is aching and the
arch feels like it has broken glass in it. I don't
want to get up and walk or do the exercises·
You could paraphrase with: "You are reluctant to
exercise your foot because it is so painful?'

Summarise Sum up the person's information so they know you "Since you had the Ibuprofen an hour ago. you have
understand the key parts of the interaction been able to take part in the physiotherapy for your
foot and partial weight bear without much pain·

Self-disclosure Telling someone about your own experiences, using
honesty and genuineness to demonstrate empathy
and focus the person on a diffic ult situation. This is
only used infrequently and i f the situation is both
true and relevant, and the nurse feels com fortable
disclosing the information about themselves
When looking after a person who is grieving - e.g., ·1
had a still birth between two normal pregnancies a
few years ago and I felt totally alone and bereft at
the time despite a really supportive family. I went to
see a grief counsellor, and it really did help. Do you
think it would help you to see a counsellor?·

Plan for action Helping the person to formulate a way to deal with Ask the person: 'The next time the doctor comes
a stressful situation and prevent anxiety from in, how are you going to express your concerns to
escalating her?' Perhaps suggest rehearsing or keeping a list
of questions

Terminating and setting boundaries on a professional relationship are also important techniques for you to learn early.
There are many more professional communication techn iques that you will learn and use throughout your nursing career.
Throughout this text, we suggest you use these communication technique s to:
• understand who the person is so you can incorporate their preferences within their care
• establish the person's understanding of a procedure, medication or outcome
• determine their readiness to learn a te chn ique or undergo a procedure which will help you incorporate the appropriate
health teaching required
• provide information, explanations and the reason for a procedure
• elicit any concerns the person has about a procedure or medication to be able to address these and increase safety and comfort
• make the person aware of the steps and sensa tions of a procedure to gain their cooperation, and thus reduce
apprehension and anxiety which will promote relaxa tion during a procedure
• gain a person's trust and confidence
• provide support.

We hope you find this book helpful in your clinica l skills development so that you can provide excellent nursing care.
Joanne Tollefson, RN, BGS, MSc, PhD
Elspeth Hillman, RN, BN. MN

References
Australian Nursing and Midwifery Council (ANMCI (20061. National competency standards for the registered nurse (4th ed.). Dickson. ACT: Australian
Nursing and Midwifery Council.
Nursing and Midwifery Board of Australia (NMBA) (2017). Codes of conduct for Nurses and Midwives. Dickson, ACT: Nursing and Midwifery Board of Australia .

12 PART 1: INTRODUCTION
 Visit http:/ /login.cengagebrain.com and • Skills videos *
-~CourseMateExpress
use the access code that comes with this • Advanced skills
book for 24 months access to the resources procedures
and study tools for this chapter. The • Revision quiz
CourseMate Express website contains: • Web links

Note: These notes are summaries of the most important points in the assessments/procedures and are not exhaustive on the
s ubj ect. References of the materials used to compile the inform at ion have been su pplied. The student is expected to have learnt
the material surrounding each skill as presented in the references. No si ngle reference is complete on each subject.
 Hand hygiene
• • • • •
• •
Indications • •
Conta minated hands of healthcare workers are a primary source transient microorganisms which include pathogens
• • of healthcare-associated infections (HCAI). Hand hygiene is carried on healthcare workers' hands and are responsible • • •
• • defined as 'the reduction of harmful infectious agents by the for most HCAls resulting from cross-infection. Transient • •
application of alcohol-based hand rubs (ABHR) without the organisms are easily removed by effective hand cleansing
• • • • •
addi tion of water, or by hand washing with plain or medicated/ technique.
• • • •
antimicrobial soap and water' (Larmer et al., 2008, p. 70). There The National Health and Medical Research Council
• • are three types of hand hygiene techniques: ( NHMRC, 2010, p. 42) emphasises that people have the right • • •
• • routine I social to question healthcare workers about their hand hygiene • •
aseptic/ clinical performance. Hand hygiene is the single most important
• • • • •
surgical (Grayson et al., 2013) strategy to reduce HCAls and applies to everyone - staff,
• • Grayson et al. (2013) describe two groups of microorganisms r ecipients of care and their visitors (Grayson et al., 2013). • •
• • found on skin: See Figure 5.1 for Hand Hygiene Australia's five moments • • •
resident microorganisms which rarely cause infection unless for hand hygiene.
• • • •
introduced into body tissue by trauma or in conjunction Washing hands wi th liquid soaps has minimal effect on
• • with foreign bodies, such as intravenous cathete rs antimicrobial activity and is suitable for routine/social hand
• • •

•
•

•
•
•

• , , .,, ------------- -, ~
•
•

•
•
•

•
•

• •
I
I '' • • •

•
•
•
• I
I
'
I
I •
•
•
•
•
• • • •
• • • • •
• • • •
• • I • • •
• • I • •
I I
• • I I
• • •
• • I I • •
•
•
•
•
'' I •
•
•
•
•

' ,_
•
•
•
•
~

-------- •
•
•
•
•

• • • • •
• • • •
Figure 5.1 Five moments for hand hygiene
• • • • •
• • Source: Reprinted from ·My 5 moments for hand hygeine·. World Hea lth Or ganisation, Copyright 2009. http://www.who.int/gpsc/Smay/ • •
background/Smoments/en/.
• • • • •

14 PART 2: ASEPTIC NON TOUCH TECHNIQUE

• • •
• • BEFORE TOUCHING When: Clean yoor hands before touching a patient and their lnmedate surroondlngs •
• • • 1 A PATIENT Why : To protect the patient against acqulrtng harmful goons from the hands of the HCW. • •
• • • •
• • •
2 BEFORE
A PROCEDURE
When: Clean yoor hands lmmedlalely before a procedure.
Why : To protect the patient from harmful germs (Including thetr own) from enteting ti- body <iJ:1ng a procedure.
• •
AFTER A PROCEDURE When: Clean your hands immediately after a procedure or body fluid exposure risk.
• •
• •
•
•
3 OR BODY FLUID
EXPOSURE RISK
Why : To protect the HCW and the healthcare surroundings from harmful patient germs.
•
•
•
AFTER TOUCHING When: Clean your hands after touching a patient and their immediate surroundings.

•
•
•
•
•
4 A PATIENT Why : To protect the HCW and the healthcare surroundings from harmlul patient germs.
•
•
•
•
• • 5 AFTER TOUCHING
APATIENrs
SURROUNDINGS
When: Clean yol.lf hands alter touchng any objects in a patient ·s surroundngs When the patient has rot been touched.
Why : To protect the HCW and the healthcare surroundings from harmful patieflt germs.
• •
• • • • •
• • Figure 5.1 Continued. • •
• • • • •
washing (Grayson et al., 2013; NHMRC, 2010). ABHR is th e gold organisms or non-enveloped viruses, or after using the
• • • •
standard of care for all Standard Aseptic Non Touch Technique bathroom (Grayson et al., 2013; Le, 2016; Mann, 2016). (See
• • • (ANTT) procedures in healthcare settings, whereas hand Clinical Skill 7 for ANTT and surgical procedures.) Periodic • •
• • washing is reserved for situations when hands are visibly dirty hand washing with soap and water should supplement use of • •
• • • or contaminated with protein-based material, soiled with blood alcohol-based hand rub during a shift due to loss of • •
or other body fluids. or exposed to potential spore-forming effectiveness over 10 uses (Chu, 2017; Mann. 2016).
• • • •

HAND PREPARATION
Limit the amount of jewellery (e.g., rings, bracelets and wrist watches) worn to work. Be aware of the healthcare facility's
hand hygiene, jewellery and dress code policy. Many health facilities have a 'bare below the elbows· policy as jewellery
harbours microorganisms in its nooks and crannies and between the jewellery and the skin. Limiting jewellery provides
better soap or ABHR solution access and friction to underlying skin. A plain wedding band may be worn but must be moved
about on the finger during hand hygiene enabling the solution and friction to be applied to the metal and the underlying skin
to dislodge dirt and microorganisms. Simple bands should be removed in high-risk settings (NHMRC, 201 OJ.
Hand Hygiene Australia does not recommend acrylic nails for those working in clinical areas. Long or artificial nails and
nails with chipped or old nail polish harbour four times the microorganisms than unpolished or freshly polished nails
[Grayson et al., 20131. Therefore. your nails should be clipped short and nail polish removed.
Inspecting your hands for any lesions allows you to select an appropriate hand hygiene method and dictates further
precautions; for example, covering lesions with an occlusive/waterproof dressing.
If personal protective equipment is required, apply these prior to commencing hand hygiene to avoid contaminating clean
hands by touching your hair or clothing.

GATHER EQUIPMENT
The following equipmen t is requ ired to wash hands:

Explanation

Warm running water • Less damaging to your skin than hot water, which opens pores, removes
protective oils and causes irritation !Mann, 2016)
• Cold water is less effective at removing microorganisms and can be
uncomfortable

CHAPTER 5: HAND HYGIENE 15

N
l-
a::
~ Equipment Explanation

• The sink should be a co nvenient height and large enough to minimise

splashing, because damp clothing encourages the multiplication and
transmission of microorganisms, and wet floors increase the risk of
slipping

Soap or an antimicrobial solution
• Used to cleanse your hands. The choice is dictated by the person's
condition
• Effective hand washing with plain soap removes dirt, soil, various
org anic subst.ances and loosely adherent transient microorganisms,
rendering your hands socially clean and suitable for social contact and
most non-invasive clinical care activities [Chu, 2017; Grayson et al.,
2013; Mann, 2016)
• Aseptic/clinical hand hygiene is required for any care activity involving
direct or indirect contact with a mucous membrane, non-intact skin or
an invasive procedure [Grayson et al., 2013; Le, 2016; NHMRC, 2010)

A convenient dispenser (preferably Increases hand hygiene compliance

non-hand-operated)

Disposable paper towels • Preferr ed for drying hands because they prevent the transfer of
microorganisms
• Ensure you do not contaminate the remaining paper towels, which can
lead to cross-in fection [Dougherty, Lister & West-Oram, 2015)

HAND WASHING
Turn on the wa ter flow
Using the available mechanism (hand, elbow, knee, foot or sensor control), establish a flow of warm
Video water to rinse dirt and microorganisms from your skin and flush these into the sink.

Thoroughly wet hands and apply soap

When wetting hands do not touch the inside or outside of the sink, which is contaminated; touching it transfers
m icroorganisms onto your hands. As you wash your hands take care not to contaminate the taps, sink or soap dispenser
nozzle with dirt or organic material washed off your hands (Dougherty, Lister & West-Oram. 20151. Wet hands to above the
wrists; keeping hands lower than elbows prevents water from flowing onto your arms and later contaminating your clean
hands. Add 5 m l (or the effective amount recommended by the manufacturer) of liquid soap or an antimicrobial cleanser -
less does not effectively remove microbes. and more than that wa stes resourc es. If only bar soap is available, lather and
r inse the bar to remove microbes before starting to wash your hands, and do not put the bar down until there is sufficient
lather for the duration of the wash. Lather hands to above the wrists.

Clean under the fingernails

Under the nails is a highly soiled area with high concen tra tions of transient microbes. Clean debris from under your nails by
using the nails of the opposite hand. Cleaning this area under flowing water is most effective for removing debris.

Wash hands with soap or antiseptic solution

Effective hand washing technique takes 40 to 60 seconds and involve s three stages: preparation, washing and rinsing, and
drying (Grayson et al.. 2013). Friction, caused by vigorously rubbin g one hand with the other, is effective in dislodging dirt and
transient microorganisms. Dirt and microorganisms lodg e in ski n creases, so pay particular attention to your palms, backs
of hands, knuckles. and webs of fingers. Lather and scrub up over wris ts and onto your lower forearms to remove dirt and
m icroorganisms from this area. Wrists and forearms are considered less contaminated than hands; scrubbing these after
your hands prevents microorganism transmission to a less contaminated area (see Figure 5.2).

16 PART 2: ASEPTIC NON TOUCH TECHNIQUE

 ~ Duration of the entire procedure: 40- 60 seconds

Iii II

Wet hands with water Apply enough soap to cover all hand Rub hands palm to palm
sur faces

II

Right palm over Lett dorsum with Palm to palm with fingers interlaced Backs of fingers to opposing palms
interlaced fingers and vice versa with fingers interlocked

II II II

Rotational rubbing of left thumb Rotati onal rubb ing. backwards and Rinse hands with water
clasped in right palm and vice versa fo rwards wi th clasped fingers of ri ght
hand in left palm and vice versa

II m
(

Dry hands thoroughly with a single Use towel to turn off tap Your hands are now safe
use towel

Figure 5.2 How to hand wash

Source: Reprinted from 'How to handwash?', World Health Organisation, Copyright 2009, http://www.who.int/gpsc/Smay/How_To_ HandWash_Poster.
pdf?ua=l, accessed 21/02/18.

Rinse hands
Rinse your forearms, hands and fingers, in this order [Laws & Hillman, 2015) under running water to wash transient
microorganisms and dirt from the least con taminated area , over a more contaminated area and off into the sink. Rinse well
to prevent residual soap from irritating your skin [see Figure 5.21.
Note: this sequence differs from aseptic/clinical and sur gical scrub requirements for ANTI and surgical procedures.

Dry hands
Using paper towels, pat your fingers, hands and forearms to dry your skin well [see Figure 5.21. Damp hands are a source of
microbial growth and transmission, and contribute to chapping and hand lesions developing.

CHAPTER 5 HAND HYGIENE 17

N
.....
IX

ct. Turn off taps

To turn off hand-manipulated taps use dry paper towe l s, tak ing care not to contaminate hands on the sink or taps lsee
Figure 5.21. Carefully discard paper towels so that your hands are not contaminated.
Turn off other types of taps with a foot. knee or elbow as appropriate.

ALCOHOL-BASED HAND RUB

Hand hygiene using a waterless alcohol-based hand rub IABHR) is more effective against most bacteria and many viruses
than liquid or antimicrobial soap. However, if your hands are visibly soil ed they must be washed with soap and water
!Grayson et al., 2013; Le, 2016; NHMRC, 20101. ABHR ar e not effective against Clostridium difficile and non-enveloped
viruses such as norovirus, will not remove dirt and some organic ma terial, and are not effective in some outbreak situations
I Grayson et al., 2013; Le, 20161.

[C.] Duration of the entire procedure: 20-30 seconds

m m II

Apply a palmful of the product in a cupped hand. covering all surfaces Rub hands palm to palm

II El

Right palm over left dorsum with Palm to palm with fingers interlaced Backs of fingers to opposing palms with
interlaced fingers and vice versa fingers interlocked

II II II
(

Rotational rubbing of left thumb clasped Rotational rubbing, backwards and Once dry, your hands are safe
in right palm and vice versa forwards with clasped fi ngers of right
hand in left palm and vice versa

Figure 5.3 How to hand rub

Source: Reprinted from "How to handrub7, World Health Organisation. Copyright 2009. http://www.who.int/gpsc/5may/How To..HandRub .Poster.pdf?ua=1.
accessed 21/02/18.

18 PART 2: ASEPTIC NON TOUCH TECHNIQUE

 Messina et al. (2008) state cutaneous adverse reaction rate is 0.47 per cent, much less than the 20 per cent claimed for
hand washing with soap or antiseptic solution. Alcohol-based solutions containing emollients cause less skin irritation and
dryness, and are quicker than washing hands with soap or other disinfectants (Nguyen, 2016).
Although ABHR is more expensive than soap or antiseptic hand-washing solutions, it has been demonstrated to save
time. increase compliance and reduce infections [N guyen, 2016). Alcohol-based hand rubs should be routinely used for hand
hygiene. in combination with washing with soap/antiseptic agents and water [Le, 2016; Nguyen, 2016)
Apply the solution to dry, visibly clean hands and rub vigorously over all hand and finger surfaces for 20 to 30 seconds,
until your hands are thoroughly dry. Pay attention to palms, back of the hands, finger webs, knuckles and wrists as you
would while hand washing (see Figure 5.3).

MAINTAINING HAND HEALTH

Part of hand hygiene is maintaining healthy and intact skin. Moisturising your hands contributes to healthy skin (Mann, 2016;
NHMRC, 2010, p. 41) by restoring moisture and oils re moved by repeated use of soap or ABHR solutions. Applying emollients
compatible with the facility"s ABHR or antiseptic soap ensures no reduction in their effectiveness. You should apply
moisturiser a minimum of three times per shift to reduce chapping and drying. Applying the lotion prior to tea and meal
breaks and when going off-duty is a good routine.
Remember that many people in healthcare facilit ies are bed bound and unable to perform hand hygiene. Offering ABHR
or soap with a water basin and a towel to people unable to independently attend to hand hygiene before meals, vi siting hours,
or before settling for the night or after they use a bed pan/urinal allows the person to maintain their hand hygiene and
reduces their infection risk.

References
Chu. W. (2017). Hand hygiene in community settings. Adelaide , SA: Joanna Briggs Institute.
Dougherty, l., Lister, S., & West-Oram, A. (Eds) (20151. The Royal Marsden manual of clinical nursing procedures (9th ed.). Oxford, UK: Wiley-
Blackwell.
Grayson, l., Russo, P., Ryan, K., Havers, S., & Hea rd, K. (Eds). (2013). Hand Hygiene Australia manual. Australian Commission for Safety and Quality in
Health Care a nd World Health Organization. Retrieved from http://www.hha.org .au/UserFiles/file/ManuaVHHAManual 2010-11-23.pdl.
Larmer P. J .. Tillson T. M., Scown F. M., Grant P. M., & Exton J. (2008). Evidence -based recommendations for hand hygiene for health care workers in
New Zealand. New Zealand Medical Journal, 121(12721, 69- 81. Retri eved from https://www.nzma.org.nz/data/assets/pdf file/0005/17816/Vol-121-
No-1272-18-Aprol-2008.pdf.
Laws, T.. & Hillman, E. 12015). Infection prevention and control. In A. Berman, S. Snyder, T. Levett-Jones. T. Dwyer. M. Hales, N. Harvey, ... D. Stanley
(Eds.I. Kozier & Erb's fundamentals of nursing (3rd Australian ed. I. Vo l. 2. pp. 739- 92. Frenchs Forest. NSW: Pearson.
Le. L. K. D. (20161. Perioperat1ve settings: Surgical hand hygiene. Ade la ide , SA: Joanna Briggs Institute.
Mann, E. (2016). Hand hygiene. Adelaide, SA: Joanna Briggs Institute.
Messina. M., Lindsey, A., Brodell, 8. A., Brodell. R. M., & Mos tow. E. N. (20081. Hand hygi ene in the dermatologist's office: To wash or to rub? Journal of
the American Academy of Dermatologists, 5916), 1043-9. doi: 10.1016/j.jaad.2008.07.033.
National Health and Medical Research Council (NHM RC). (201OJ. Australia n guidelines for the prevention and control of infection in healthcare.
Commonwealth of Australia. Retrieved from http://www.nhmrc.gov.au/ files nhmrc/publicallons/attachments/cd33 complete.pdl.
Nguyen, P. (2016). Hand Hygiene: Alcohol- based solutions. Adelaide, SA: J oanna Brigg s Institute.

CHAPTER 5: HAND HYGIENE 19

 • • • • • • • • • • • • • • • • • • • •
• • • • • • • • • • • • • • • • • • • •
• • • • • • • • • • • • • • • • • • • •

N
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~
C LINICAL SKILLS ASSESSMENT

HAND HYGIENE
Demonstrates the ability to effectively reduce the risk of infection by performing social hand wash
or hand rub.

Performance criteria 1 2 3 4 5
[Numbers indicate NMBA Registered Nurse Standards for Practice) !Dependant) [Marginal) !Assisted) !Supervised) !Independent)

1. Identifies the indication 11.1, 1.4. 3.S)

D D D D D
2. Identifies Hand Hygiene Australia"s five moments for hand
hyg iene 11.1, 6.2) D D D D D
3. Undertakes hand preparation 11.1, 6.21. e.g., skin in tact, no
rashes, cuts or abrasions; no acrylic/a rtificial nai ls; na tural
nails are clean and manicured
D D D D D
--
4. Gathers equipment 11.1, 6.2):
• warm running water
• soap or an antimicrobial solution
• a convenient dispenser !preferably D D D D D
non-hand-operated)
• disposable paper towels
.
I

Sa. Turns on and adjusts water flow 11.1, 6.2)

D D D D D
Sb. Wets hands, applies enough appro priate soap to cover all
surfaces of hands 11.1, 6.2) D D D D D
Sc. Cleans under fingernails (1.1 . 6.2)
D D D D D
Sd. Thoroughly washes hands by rub bing hands together
vigorously, distributing solution over palms, back of hands,
between fingers and wrists 11.1, 6.2)
D D D D D
D I. D
Se. Rinses hands thoroughly under running water, allowing water to
drip from fingertips 11.1, 6.2) D D D
--
Sf. Dries fingers. hands and forearms (1.1, 6.2)

--
D D D D D
Sg. Turns off the water without contaminating hands 11.1, 6.2)

--
D D D D . D
6a. Applies appropriate amount of solution into cupped hands
ensuring all hand surfaces covered 11.1, 6.2) D D D D I D
6b. Rolls hands distributing solution over palms, back of hands, between
fingers and wrists (1.1, 6.2) D D D D D
7. Rubs hands together until all surfaces are dry 11.1, 6.1)
D D D D D
8. Demonstrates ability to incorporate theory in to clinical
practice (1.1, 1.2, 6.2) D D D D D

Student:

Clinical facilitator: Date:

20 PART 2: ASEPTIC NON TOUCH TECHNIQUE

 Personal protective equipment
• • • • •
• •
Indications • •
Personal protective equipment (PPE) is anything used or worn effectively managing these infections using evidence-based
• • • to minimise health or safety risks including face masks, strategies (ACSQHC, 2018). • •
• • goggles, gloves and aprons. PPE is worn to prevent Using PPE singly or in combination interrupts • •
• • • microorganism transmission from a reservoir to a susceptible transmission of contaminated material, contamination of • •
host, such as from healthcare workers to recipien ts of care or steril e materials (e.g., when preparing medications,
• • • •
family and friends, and vice versa. PPE also prevents spray or intravenous fluids) and exposure of mucous membranes,
• • • splash injuries from chemicals and hazardous medica tions. eyes, broken skin, or clothing to another person's bodily • •
• • PPE is an integral component of standard and transmission- secretions, blood, excretions or hazardous substances. You • •
based precautions in healthcare facilities . Preven table need a sound understanding of the modes of microorganism
• • • • •
healthcare-associated infections (HCAI) increase a person's transmission for effective infection prevention and control
• • pain; may result in life-long disabilities or death; extend measures. Additionally, you need to be aware of the • •
• • • length of stays, reducing available bed access; and increase occupa tional requirements for safe handling of hazardous • •
health systems' economic burden (Australian Commission on medica tions and chemicals. Your decision to use PPE should
• • • •
Safety and Quality in Health Care [ACSQHC) 201 8; NHMRC, be based on an assessment of risks associated with the
• • • 2010). Preventing and controlling HCAI is Standard 3 of the person and the care activity you are undertaking, or the
• •
• • National Safety and Quality Health Service Standards aiming potential for contamination from microorganisms or • •
• • • to stop people from acquiring preven table HCAI and hazardous chemicals. • •

EVIDENCE OF THERAPEUTIC INTERACTION

Incorporating a person-centred approach to care and enabli ng people to actively participate in their care process is more
than just explaining treatment risks - it requires considering and incorporating the person's needs at every level
[McCormack & Mccance, 20161. Before putting on PPE, explain to the person that these are routine aspects of infection
prevention and control strategies used for everyone· s safe ty IN HMRC, 201 OJ. Wearing PPE could indicate to the person that
they are 'dirty' and are being treated differently to others. People should be familiarised with the facility's infection
prevention and control strategies and informed of their specific requirements. The person and visitors should be encouraged
to minimise infection risks by following hand and respiratory hygiene practices, and be provided with necessary information
and instructions to be able to adhere to these. People must be informed of their right to ask healthcare professionals if hand
hygiene was performed and whether PPE should be used.

GATHER EQUIPMENT
Gather the equipment before you initiate the care activity. PPE used as part of standard precautions
includes aprons, gowns, gloves. surgical masks, protective eyewear and face shields (NHMRC. 2010, Slade,
20161. PPE selection is based on risk assessment of:
• transmission of infectious microorganisms
• contamination of your clothing or skin or that of other people by blood, body substances, secretions or
excretions
• the facility's policies and current health and safe ty legislation [NHMRC, 2010, p. 461.

Gowns and aprons

Gowns or aprons are recommended PPE for procedures or care activities when close contact with the person,
materials or equipment leads to contamination of your skin, uniform or other clothing with infectious agents or

CHAPTER 6: PERSONAL PROTECTIVE EQUIPMENT 21

 hazardous medications or chemicals (NHMRC, 2010; Sla de, 20 16). The apr on or gown type required depends on
the risk. the anticipated contact w ith infectious mate ri al and th e potential for blood, body substances or
hazar dous materials to penetrate through to your clo th es or skin. Appr opriate gowns or aprons need to be worn
for a single procedure or care episode and r emoved wh ere the car e episode took place. The following 1s a
summary of apron and gown types, characteris tics, and c on sider ations fo r appropriate selection:

Equipment Explanation

Plastic apron • Single-use

• Plastic
• Impervious to liquids
• Disposable
• Protects your uniform from contamination by droplets or sprayed
substances
• Worn when ther e is a low ri sk that clothing or your arms will be exposed
to blood or body substances [generally environmental] during low-risk
procedures
• Worn during contact precautions when contact with the person or their
environment is like ly

Gowns • Single-use
• Disposable
• Worn to protect your skin and clothing from blood, body substances
(except swea t!. secretions or excretions during procedures or care
activities associ ated with splashing or sprays of blood or body substances
• Worn wh en ther e is close contact with the person, when equipment or
materials may contaminate your skin or uniform, or to protect the
person from the micr obes you carry

Lon g-sleeved gown (full body gown] • Single-u se

• Fluid-resistant
• Long -sleeved, closed - fronted and elastic/ kn it-closed cuffs (under which
gloves are tucked ]; worn:
• during procedures or care activities during which there will be
contact between your skin and a person's broken skin
• during extensive skin-to-skin contact [e.g .. repositioning a person
with extensive burns]
• during contact with or splashing from uncontained blood or body
substances [vomiting, uncontrolled diarrhoea)
• when ther e is a ri sk of exposure to large amounts of body
substances during an operative procedure
• when handling cytotoxic agents

Sterile gown • Steri le prepacka ged gowns

• Worn fo r procedures re quiring aseptic fields

Source: NHMRC (20101. Austr alian guidelines for the preven tion and control of infection in healthcare. Commonwealth of
Australia; Slade, S. (20161. Aprons, gowns, face masks and eye protection. Adelaide, SA: Joanna Briggs Institute.

Face and eye protection

Face and eye protection includes gog gles or safety glasses [with side protection ). surgical masks or full- face
shields. These are required wh en ther e is a r isk of air borne, dr oplet or spr ay contamination of your mucous
membranes (eyes, nose and mouth] or non-intact skin surfaces, w hich are entry portals for microorganisms.
Face and eye protection is required to pr event splashes, spr ay or dust from cytotoxic medications or hazardous
chemicals (Slade, 20161. The ties, ear pieces and headbands securing face and eye protection are considered
'clean'. These are safe to touch w ith bare hands (NHMRC, 20101.
Masks are worn once and discarded promptly wh en dam p or soiled, or when the procedure is completed. Do
not leave your mask dangling around your neck .

22 PART 2: ASEPTIC NON TOUCH TECHNIQUE

 Face and eye protec tion is su m ma rised in th e followin g:
Equipment
Goggles and safety • Rigid plastic
glasses • Usually reus able
Surgical masks • Loos e-fitting items protecti ng your
mouth and nose
• Pleated face
• Two to three polypropylene layers
• Filtration via mechanical impaction
• Fluid- resistant
• Ties a t crown a nd bottom of head
Face shields • Exte nd from the c hin to the c rown
• Provide better protection of you r face
and eyes from splashes and s prays
than wrap-a ro und style, as th e s id es
reduce s plas hes a round the s hi eld"s
edges [NHMRC, 20101
P2 respirators [N9SI • Raised dome or du ckbill
• Four to five layers [po ly propylene
ou te r, charge d polypropylene centre l
• Sturdi e r tha n a nd fi t be tter than
s urgical m as ks [NHMRC, 20101
• Offering greate r protection against
a irborne and drople t in fection as well
as from contact from splashes a nd
sprays
• Filtration via mecha nical impaction
and electrostatic captu re
• Ties a t c rown a nd bottom of head,
pliable meta l nose bridge
• Fi t testing and fit checking requi re d
Source: Adapted from NHMRC [20101. Australian guide lines for the prevention and control of infection in healthcare.
Commonwealth of Australia, p. 50.
Face and eye protec tion usage requi rements a re s um marised in the following :
Procedure or care
activities
Routine care • Assessing vital s ig ns
• Physica l a ssessme nt
Procedures ge nera ting • Emptying wou nd or ur inary drainage
sp lashes or sprays bag, bed pans or urinals
• Ad mi niste ring int ravenous cytotoxic
medications
Procedures involving • Intuba tion
respiratory tract and • Nasopharyngeal suction ing
mouth
Source: NHMRC [2010). Australian guideli nes for the preve ntion and control of infection in healthcare. Commonwealth of
Australia; Slade. S. [2016). Aprons. gowns, face masks and eye protection. Adelaide. SA: Joanna Briggs Institute.
• Procedures involving the respiratory
tract or those generating splashes and
s prays (NH MRC, 2010, p. 491
• Pro cedures requiring surgical ANTT to
protect the person from exposure to
in fectious microorganism s carried in
you r nose or mouth
• Routi ne ca re of people requirin g
droplet preca utions (NHMRC, 201 OI
• Procedures generating splashes or
s prays of large blood droplets, body
substances, secretions, excretions, or
hazardous medications or chem icals
• Routine care of people requiring
airborne precautions
• Bronchoscopy or other high-risk
procedures in a person of unknown
in fectious status
• Procedures involving particle
a erosolis ation containing specific
pathogens
• Not required unless caring for a
person on droplet precautions
[su rgical maskl or airborne
precautions (P2 respi rator!
• Surgical mask
• Protective eyewear/full- length fa ce
sh ie ld
• Protective eyewear
• Surgical mask or if required P2
respirator
CHAPTER 6 . PERSONAL PROTECTIVE EQUIPMENT 23
N
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~ Gloves
Glove use plays a key role in reducing microorganism transmission between the person and you, and vice versa.
Gloves also assist in preventing your skin from being exposed to chemicals and hazardous medications [Yan,
20131. As with all PPE, which gloves are used is determined by risk assessment of the procedure or care activity,
contamination type, whether an aseptic or clean technique is required, and if you or the person has a latex
allergy [Slade, 20171. Gloves should also be fit for purpose and avoid interference with your dexterity, and not
cause friction, excessive sweating, or finger and hand muscle fatigue (NHMRC, 2010 p. 531.
Non-sterile gloves should remain in their original box until needed to maintain their integrity (Mann, 20161.
Keeping gloves in your pocket contaminates the gloves from your hands or pocket debris. Put gloves on
immediately before undertaking a procedure and remove them immediately after completing it. Discard gloves
into a contaminated waste bin. Gloves are changed after each care episode and between individuals. Ensure you
perform effective hand hygiene [HH] before putting on gloves and immediately after you remove your gloves [Yan,
20131. Remember: wearing gloves is no substitute for effective hand hygiene [Grayson et al., 2013; Mann, 2016;
NHMRC, 2010).
The following table provides a summary of glove types and clinical examples of their use.

Required for Clinical examples

Non-sterile gloves • Potential exposure to blood, body • Emptying urinary drainage bags
substances, secretions or excretions • Nasogastric aspiration
• Contact with non-intact skin or • Vaginal examinations
mucous membranes • Management of minor cuts or abrasions

Sterile gloves • Potential exposure to blood, body
substances, secretions or excretions
• Contact with susceptible sites or
clinical devices requiring that sterile
conditions be maintained
• Surgical Aseptic Non Touch Technique
complex dressings
• Dressing changes for central venous
line insertion sites
• Clinical care of acute surgical wounds
and drainage sites

Synthetic gloves. e.g.. Procedures involving a high ris k of Preparing or administering cytotoxic
nitrite or polyvinyl exposure to blood -born e viruses or where medications
chloride !PVC) high barrier protection is required

Sources: Grayson et al. !Eds). 12013). Hand Hygiene Australia manual. ACSQHC and WHO; NHMRC 1201 O). Australian
guidelines for the prevention and control of infection in healthcare. Commonwealth of Australia; Rahman 12013).
Chemotherapy: personal protective equipment (PPEJ [Evidernce summary]. Adelaide, SA: JBI.

Sharps containers
Sharps containers are important in reducing r isks from sharp devices. There are a number of devices available
designed to eliminate sharps injuries [e.g., needleless and retractab le safety devices!; however, many procedures
require sharp instruments. When sharps are used, handling must be minimised - instruments rather than fingers
are used to grasp sharps when possible; use of neutral zones such as basins for scalpel transfer; disposable
needles should not be bent, broken or recapped after use. The person using a disposable sharp instrument is
responsible for its safe management and immediate disposal after use [NHMRC, 20101. All used disposable sharps
[e.g., blades, needles, catheter stylets and glass vials] must be placed into clearly labelled, puncture-proof,
leak-proof and untippable point-of-use containers to minimise sharps injury or contamination [Chu, 20161.

PUT ON AND REMOVE PERSONAL PROTECTIVE EQUIPMENT

To minimise the risk of transm itting microorganisms, the NHMRC [2010, pp. 55-6] recommends
the following sequence for safely and effectively putting on PPE [see Table 6.4] and removing PPE (see
Table 6.5).
Video

Hand hygiene
Hand hygiene must be performed before putting on PPE and aft er removing PPE (Grayson et al., 2013; NHMRC, 201 DI.
Perform appropriate hand hygiene [see Clinical Skill S].

24 PART 2: ASEPTIC NON TOUCH TECHNIQUE

Put on personal protective equipment
Table 6.4 Putting on PPE

Aprons
• Place over your head and fasten the ties behind you r
back
Gowns
• Pick up and hold out by the neckline in front of you and
allow to unfold (without being contaminated by body or
substances)
• Slide your arms and hands into the sleeves
• Fully cover your body from neck to knees, ar ms to end
of wrists, and wrap around the back
• Fasten at the back of your neck and waist

Masks or face shields

• Hold upper ties, and place over your nose and mouth.
Upper ties are tied at the back of your head or strung
over your ears and tied under your chin
• Lower ties are tied at the nape of your neck or the top
of your head to secure a firm fit over your face. Smooth
aluminium strip over your nose
• If you wear glasses, fit your mask under your glasses
to reduce clouding from exhalation

Protective eyewear {goggles or safety glasses, face shields)

• Place over your eyes and face, and adjust to fi t you r
face (and over glasses) comfortably

Gloves (clean)
• If wearing a gown, pull the gloves up over the cuffs
• If no gown, extend gloves to protect your wrists. (see
Clinical Skill 9 for putting on sterile gloves)

Sources: Grayson et al. IEdsl. 120131. Hand Hygiene Australia manual. ACSOHC and WHO: NHMRC 120101. Australian guidelines for the prevention and
control of infection in healthcare. Commonwealth of Australia.

Remove personal protective equipment

PPE is designed to be used once and must be removed when a specific procedure or care activity is completed. This prevents
other sites, people or the environment being contaminated.

CHAPTER 6: PERSONAL PROTECTIVE EQUIPMENT 25

N
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Cf. Table 6.5 Removing PPE

Gloves
• Outside of gloves is contaminated
• Grasp outside of glove with opposite gloved hand;
peel glove off this hand
• Keep removed glove in gloved hand
• Slide fingers of your ungloved hand under the wrist
of remaini ng glove; peel it off over you r first glove
• Discard glove bundle into contaminated waste bin
• Perform hand hygiene

Protective eyewear or face shield

• Outside of eye protection or face shield is
contaminated
• Remove eye protection by touching only headband
or earpieces
• Discard single-use items into the contam inated
waste bin
• Place reusable items into cleansing container
• Perform hand hygiene

Apron or gown
• Apron front or gown front and sleeves are
contaminated
• Unfasten ties
• Pull gown away from your neck and shoulders. only
touching the inside of apron or gown
• Turn apron or gown inside out
• Fold or roll into bundle
•
·~
;-.. .•
.
• i

• Discard apron or single-use gown into contaminated ; ; o;;;; i ;

waste bin ..... ·;

• Place cloth gowns into appropriate linen skip
• Perform hand hygiene

Surgical masks
• Front of mask is contaminated
• Grasp bottom of mask, then top ties or elastic and
remove
• Discard mask into contaminated waste bin
P2 respirator
• Perform hand hygiene
• Step outside room or into anteroom before
removing and discarding mask into closed container
• Perform hand hygiene again

Sources: Grayson et al. IEdsl. (2013). Hand Hygiene Australia manual. Australian Commission for Safety and Quality in Health Care and World Health
Orga nization; NHMRC (20101. Australian guidelines for the prevention and cont.rot of infection in healthcare. Commonwealth of Australia; Slade, S.
(2016). Aprons, gowns, face masks and eye protection. Adelaide, SA: Joanna Br iggs Institute.

CLEAN , REPLACE AND DISPOSE OF EQUIPMENT

Dispose of single-use safety equipment in the contam inated -waste r ecepta cle in the dirty utility room. Non-disposable items
such as goggles or face shields will require clean ing according to the manufacturer"s instructions and the facility"s policy.
The front of face shields and goggles is considered con taminated and shoul d not be touched with bare hands. Generally,
cleansing with a mild detergent and warm water, and drying well prior to r eplacing the equipment is sufficient. If there is
gross contamination or contaminating material is infectious, disinfection using an instrument-grade disinfectant is required
(NHMRC. 2010, p. 51). Hand hygiene is performed as the final infection prevention and control measure when cleaning is
completed.

26 PART 2: ASEPTIC NON TOUCH TECHNIQUE

References
Australian Commission on Safety and Quality in Health Care IACSQ HCI 120 18). Safety and Quality Improvement Guide Standard 3: Preventing and
Controlling Healthcare Associated Infections. Sydney, NSW: Austra lian Commission on Safety and Quality in Health Care. Retrieved from http://
www safetyandquality.gov.au/wpcontent/uploads/20 12/10/Sta ndard3 Oct 2012_ WEB.pdf.
Chu. W.H. 120161. Sharps/needlestick injury: Prevention. Adelaide, SA: Joa n na Briggs Institu te.
Grayson. L.. Russo. P .. Ryan. K.. Havers, s .. & Heard. K. IEdsl. 120131. Hand Hygiene Australia manual. Australian Commission for Safety and Quality in
Health Care and World Health Organization. Retrieved from http://www. hha.org .au/UserFiles/file/ManuaUHHAManual 2010 11 23.pdf.
Mann. E. 120161. Gloves. Adelaide, SA: Joanna Briggs Institute.
McCormack. B.. & Mccance. T. [20161. Person-centred practice in nursing and health care: Theory and practice. [2nd ed.I. Oxford. UK: Wiley-Blackwell.
National Health and Medical Research Council [N HMRCI [20101. Australian guidelines for the prevention and control of infection in healthcare.
Commonwealth of Australia. Retrieved from http://www.nhmrc.gov.a u .
Ra hma n. M.A. [20131. Chemotherapy: personal protective equipment (PPE} [Evidence summ a ry). Adelaide, SA: Joanna Briggs Institute.
Slade, S. [2016). Aprons. gowns, face masks and eye protection. Ad elaide, :SA: Joanna Briggs Institute.
Slade, S. [2017). Surgical site infection: Surgical hand scrubs and gloving. Adela ide, SA: Joanna Briggs Institute.
Yan, K. P. [2013). Gloves [Evidence summary). Adela ide, SA: Joanna Briggs Institute.

CHAPTER 6. PERSONAL PROTECTIVE EQUIPMENT 27

~ ~

• • • • • • • • • • • • • • • • • • • •
• • • • • • • • • • • • • • • • • • • •
• • • • • • • • • • • • • • • • • • • •

N
I-
a::
~
C LINICAL SKILLS ASSESSMENT

PERSONAL PROTECTIVE EQUIPMENT

Demonstrates the ability to assess and selec t a ppro pr iate personal protective equipment (PPE] for
r isks associated with the procedure or care act ivity a nd utilises PPE to prevent transmission
of microorganisms transmitted by contact, drop let o r a irborn e modes, or to prevent injury
from hazardous medications or chemicals.
Performance criteria 1 2 3 4 5
(Numbers indicate NMBA Registered Nurse Standards for Practice) !Dep endant) (Marginal) (Assisted) (Supervised) !Independent)

1. Identifies the indication (1.1, 1.4, 3.5)

D D D D D
2. Evidence of therapeutic interaction with the person, carers or
visitors (1.2, 2.1, 2.2, 2.9, 6.1) D D D D D
3. Demonstrates clinical reasoning abilities, such as risk
I
assessment and obtaining PPE prior to performing hand
hygiene [1 .1, 1.4)
D D D D D
--
4. Identifies and gathers appropriate PPE (1.1, 1.2, 1.4):
• plastic apron
• gowns
• long-sleeved gown (full body gown)
• sterile gown
• goggles and safety glasses
•
•
surgical masks
face shield
D D D D D
• P2 respirator (N95)
• non-sterile gloves
• ster ile gloves
• synthetic gloves. e.g., nitrite or polyvinyl chloride [PVC)
• sharps conta iner

5. Performs hand hygiene (1.1, 6.1)

D D D D D
6. Safely and effectively puts on, uses and removes PPE (6. 1)
D t--
D D
,____
D I D ~

7. Cleans, replaces and disposes of equipment appropriately

(1.1, 3.6, 6.1) D D D D D
-- ..... t-- ~

8. Demonstrates the ability to link theory to practice (1.1, 3.3,

3.4, 3.5) D D D D D

Student:

Clinical facilitator: Date:

28 PART 2: ASEPTIC NON TOUCH TECHNIQUE

 Aseptic Non Touch Technique
• • • • •
• •
Indications • •
Surgical ANTI or Standard ANTI is used when pre paring for conversation should be minimised to reduce the spread of
• • • and undertaking any invasive procedure penetrating the droplets
• •
• • body's natural defence of intact skin and mucous membrane. sterile objects opened for one person can only be used for • •
• • • ANTI principles incorporate the following: tha t person • •
sterile objects remain sterile only when touched by unused sterile supplies are discarded or resterilised if
• • another sterile object these are to be used for another person (Australian
• •
• • • only sterile objects may be placed in an aseptic fie ld College of Operating Room Nurses Standards, 2013; Chu • •
• • sterile objects or aseptic fields become contaminated by 2016; Peters, 2017). • •
prolonged exposure to air These principles are similar and compatible with standard and
• • • • •
sterile objects or aseptic fields should be kept in view transmission-based precautions recommended by the NHMRC
• • a sterile surface coming in contact with a wet (2010). Conscientiousness. alertness and honesty are essential • •
• • • contaminated surface becomes contaminated by capillary qualities in maintaining asepsis. Unless these principles and • •
• • action guidelines are strictly followed, safety is compromised and infection • •
fluid flows in the direction of gravity or by capi llary action may occur. You must assess people for whom you are caring for
• • • the edges of an aseptic field are considered contaminated risks associated with the procedure and use the appropriate ANTI
• •
• • skin cannot be made sterile; however, washing reduces and protective barriers (Peters, 2017; Slade, 2017). • •
• • • the number of microorganisms on it The following is a general guideline for Surgical ANTI • •
sterile gloves are used to further prevent transfer of (e.g., dressing change or catheterisation) conducted in a non-
• • • •
microorganisms operating theatre environment.
• • • • •

BACKGROUND TO ASEPTIC NON TOUCH TECHNIQUE

Aseptic Non Touch Technique (ANTT"'l is a specific type of aseptic technique with a unique theory and practice framework
[NI CE, 20121. ANTT protects individuals during invasive clinical procedures by utilising infection-prevention measures to
minimise the introduction of sufficient quantities of microorganisms to cause an infection by hands into susceptible sites,
surfaces or equipment (National Health and Medical Research Council [NHMRC]. 2010; Peters. 2017). ANTT is the
recommended standardised aseptic technique adopted with in Australian healthcare facilities (NHMRC. 201 Ol. It uses a
concept called key-part and key-site protection to achieve asepsis by identifying and then protecting procedure key-parts and
key-sites from contamination. This is achieved by:
1. appropriate and effective hand hygiene
2. maintaining Non Touch Technique [NTTl
3. using new sterilised equipment
4. disinfecting existing key-parts to a standard rendering these aseptic before use (NHMRC, 20101.
Although based on the same principles, in practice the type of ANTT is determined according to risk assessment of the
procedure (NHMRC, 2010; Peters, 2017; Rowley et al., 20 101.
Aseptic fields provide a vital controlled aseptic working space necessary to maintain asepsis during clinical procedures.
In ANTT, the types of aseptic fields utilised depend on whe ther Standard or Surgical ANTI is being used. Larger, sterile
drape-type aseptic fields are termed critica l aseptic fields and are used in surgical ANTI when key-parts and/or key-sites
[usually due to their size or number) cannot be easily protected w ith individual covers or caps, or be handled at all times by
NTT. These include insertion of PICC lines, complex wound care or in operating theatres. This approach demands more
sterilised equipment, sterile gloves and other barriers such as gowns are required (Chu, 20161. Critical micro aseptic fields
involve covering or protecting key-parts with syringe caps. sheaths. covers or packaging. The cap and covers inside are
sterile, providing optimal aseptic fields for key-parts. Used along with NTT. these provide an aseptic field for key-parts and
contribute to a general aseptic field, promoting asepsis.

CHAPTER 7: ASEPTIC NON TOUCH TECHNIQUE 29

N
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f!t. The core infection-control components of ANTT are summarised below:
• Key-part and key-site identification and protection - determine the key-part (e.g., the equipment part, dressing or
cleansing material) that comes into contact with the susceptible key-site (the person·s vulnerable site, such as incisions
or open wounds!. Key-part protection means tha t only th ese areas come into contact with other key-parts or the key-site.
A vital aspect of maintaining asepsis is the use of NTT on the key-part. For example, where the key-site is an incision, it
is only touched by an aseptically clean key-part: steri lised gauze squares dampened with sterile normal saline using
sterilised forceps.
• Non Touch Technique (NTTJ - not touching key-parts directly by using sterile instruments, dressings or solutions.
• Hand hygiene - an essential ANTI component (see Clinical Skills 5 and Sl.
• Sterile gloves - used if it is necessary to direc tly touch any key-parts or key-sites. If not, non-sterile gloves are usually
used. Your ri sk assessment determ ines wh ether you can perform the procedure and maintain asepsis without touching
ei ther the key-part or the key-site and contam inating it. Complex procedures are usually more difficult, and inexperience
often dictates the need for sterile gloves ra ther than non-sterile gloves, or t he use of additional barrier precautions.
Rowley et al. (201 Ol originated two types of ANTT as fo llows:
1. Standard ANTT procedures generally re quire less than 20 minutes and are technically simple clinical procedures
involving relatively few and small key-sites and key-parts (see Figure 7.11. These require a main general aseptic field
and non-sterile gloves, using critical micro aseptic fields and NTT to protect key-parts and key-sites. Examples
include IV therapy, simple wound dressing, and fo r exp eri ence d health professionals, urinary catheterisation or IV
cannulation. Less-experienced healthcare workers. however, may require a critical aseptic field (NHMRC. 20101.
2. Surgical ANTT procedures are technically complex, re quir e more than 20 m inutes to complete. and involve large
open key-sites, or large or numerous key-parts. Surgical ANTT procedures require critical aseptic fields, sterile
gloves and full-barrier precautions (see Figure 7.1l. Surgical ANTT procedures continue to utilise critical micro
aseptic fields and NTI when practical to do so (NHMRC. 20 1Ol. Examples include complex dressings, CVC insertion
and surgery.

Figure 7.1 Use of Standard and Surgical ANTI

Source:© Aseptic Non Touch Technique [ANTI!

EVIDENCE OF THERAPEUTIC INTERACTION

Introduce yourself and advise the person of your designation. Confirm the person·s identity. Inform the person abou t the
procedure and obtain their verbal consent to proc eed. Clarify tlheir imm ediate concerns regarding the procedure. Discuss
with the person the most comfortable position fo r them during the proce dure and their expectations of the procedure. By
explaining how t he person can assist you, you enable them to ac tively participate in their care and reduce the risk they will
touch or contaminate sterile items, and will also reduce the need to talk during the procedure.

30 PART 2: ASEPTIC NON TOUCH TECHNIQUE

DEMONSTRATES CLINICAL REASONING
Environment control
Before conducting an aseptic procedure. you need to ensure that there are no avoidable risk factors. such as bed making or
people using commodes (NHMRC, 20101.

Position the person

Consider the person's position in relation to the duration of the pro cedure, and the location of the treatment site. Positioning
the person comfortably reduces or eliminates movement dur ing the procedure, reduces their discomfort and avoids
unnecessary contamination of items. Ensure tha t you administer the required analgesia approximately 30 minutes before the
procedure. Anticipate toileting requirements and atten d to these before you position the person or set up the critical aseptic
fie ld. Maintain privacy to enhance the person's comfort and dignity.

GATHER EQUIPMENT
The equipment required depends on the procedure and the facility's procedural guidelines. Planning the
procedure and having all equipment ready for use beforehand are part of an effective time-management
strategy and reduce the time that the critical aseptic field will be exposed to the air. A critical aseptic field left
unattended is considered to be contaminated.

Equipment ' .
A trolley • Collect and clean with th e facility's recommended solution to establish a
clean [not sterile) work surface
• Removing much of the microbial load from the trolley surfaces helps to
prevent cross-contamination

Dressing equipment • Gath er dr essing equipment while the trolley dries, to save time and
eliminate microorganism transfer via moisture
• Place the dressing pack on the top shelf and all other unopened plastic-,
paper- and cloth-wrapped items and required personal protective
equipment on the trolley's bottom shelf, leaving the top surface as clean
as possibl e for the aseptic procedure [Peters, 2017)

A plastic bag • A plastic bag large enough to collect used materials is taped or clipped
to the side of the trolley closest to the person. which avoids
con taminated material being brought over the critical aseptic field
• Open the mouth of the bag wide enough so that material can easily be
dropped into the bag, preventing contamination of forceps or gloves

PERFORM ASEPTIC NON TOUCH TECHNIQUE

Hand hygiene
This should be performed using an alcohol- based rub or another surgical hand wash prior to performing
Video ANTT as your hands were contaminatedl by touching the packaging while adding sterile items to the
critical aseptic field (Pe ters. 20 17). Depending on the facility's policy or your risk assessment, you may
need sterile gloves and other personal protective equipment (Chu, 2016) (see Clinical Skills 6 and 91.

Confirm the sterility of the packages and solution

Inspect items to confirm thal they remain sterile - the co lour-change sterility indicator should indicate that package is
sterile. the item should be within its use-by date and the pac kaging must be dry and intact. with no water damage or stains,
and bottles must be unopened. Tears and punctures create a pathway for microorganisms to access the interior of the

CHAPTER 7: ASEPTIC NON TOUCH TECHNIQUE 31

N
l-
a::
Cf. packaging. Stains, dampness and water damage indicate tha t the wrapping has been wet, allowing microorganisms to enter
the package by capillary action. A broken seal on a bottle indicates that the contents have been exposed to the air and have
possibly been contaminated.
Perform hand hygiene. Take the trolley and all items required for the procedure to the person·s bedside.

Prepare the critical aseptic field

Initially, remove the outer plastic wrap (in prepackaged supplies) and drop the inner, sterile, still-wrapped tray package (e.g.,
dressing tray or catheter tray) on the trolley's top surface. With the initial fo lded flap facing you, touch only the wrapper's
outside surface to maintain the sterility of the inner surface. Using your thumb and forefinger, grasp the flap and fold out,
away from you, which eliminates reaching over the exposed sterile contents and contaminating these.
To avoid reaching over sterile content, carefully using your r ight hand for the right-side flap and your left hand for the
left-side flap, fold out the sides. Finally, the last flap is folded towards you to form a critical aseptic field. Adjustments of the
critical aseptic field's position are made from underneath the outside surface of the wrapper. The main critical aseptic field
for sterile items (dressing tray, catheter tray, dressings) is fo rmed 5 cm inside the border edges.

Add sterile supplies

Stand back from the established critical aseptic field while opening all packages to avoid contaminants from the outside of
the packaging material falling onto the field. Ensure that only sterile items come into contact with your critical aseptic field.

Open sterile packages

Grasp the opposite edges of the two sides of the wrapper and carefully peel down to fully expose the item (gauze squares,
instruments, IV catheters). Without reaching across the critical aseptic field or touching non-sterile wrappings on the critical
aseptic field, drop the item from the wrapper onto the cri ti cal as,eptic fie ld, avoiding the 5 cm border edges. Dropping sterile
items from about 15 cm avoids packaging material or your hand touching the critical aseptic field. Alternatively, after you
open the package and fold back the packaging sides, hold the package in one hand. Carefully pick up the top forceps by the
handle with your other hand, using the forceps to position the sterile item wit hin your critical aseptic field. Remember that
the forceps tips and body remain sterile; this section is placed within the critical aseptic field, ensuring the forceps handle
section you touched is within the 5 cm non-sterile edge of your critical aseptic field.

Unwrap hospital-wrapped items

Hold the item in your non-dominant hand and open the top flap away from you. Remove the sterilisation tape and, using your
dominant hand, open the flap away from you, folding the corners well back from the item. Take care not to touch the
wrapper's contents as you carefully and fully expose the item by folding the side and front flaps away from the contents.
Grasp the wrapper's loose corner material and secure it at your wrist with your dominant hand (to keep the unsterile
wrapping material from inadvertently contaminating the critical aseptic field) before carefully dropping the item onto the
critical aseptic field.

Open the solution bottles

Generally, there is a container within the basic dressing pack available for solutions. Read the label three times - before you
place the bottle on the trolley, before you pour the solution int o the container, and before you replace it on the trolley's
bottom shelf - to ensure that the correct solution is used. Break the bottle's seal and remove the cap. Either keep the cap in
one hand or place the cap on a clean surface, inside up. Check the label and then cover it with your palm to prevent
inadvertent splashes or dribbles obscuring the wri ting. Hold the bottle approximately 5 cm directly above the container to
prevent accidentally touching the critical aseptic field and pour slowly to prevent splashes contaminating the field by
facilitating microorganism movement through the drape. Some facilities consider previously opened bottles to remain sterile
for 24 to 48 hours, after which the contents must be discarded. If this is the case, recap the bottle immediately without
touching the inside of the lid to maintain sterility. Write a time and date clearly on the label and initial it. To reuse, cleanse
the bottle's lip by pouring a small amount of the contents into a sink or plastic bin prior to pouring the solution into the
sterile container on the critical aseptic field.

32 PART 2: ASEPTIC NON TOUCH TECHNIQUE

Another random document with
no related content on Scribd:
epäinhimillistä, raakalaismaista, melkein ylittää kaiken sen, mitä
hirmuvaltiaat ovat koskaan tehneet.»

Noiden ankarien, vaaleiden silmien valo sai komean Baziretin

vapisemaan ruumiissaan ja sielussaan.

»Mitäpä minä voin, kansalainen edusmies? Joka päivä lähettävät

viranomaiset minulle näitä potilaita liian täyteen sullotuista
vankiloista, joissa he eivät voi olla sairastumatta. Entä minun
apuneuvoni sitten! Ne ovat ihan riittämättömät. Käytettävissäni oleva
tila täällä ei ole suurempi kuin sen näette olevan. Minä en voi
rakennuttaa uusia sivurakennuksia Archevêchéhen.»

»Mutta te voitte pitää siistinä sen tilan, joka teillä on… ja voitte
välttää olemasta nenäkäs minua kohtaan, jos suvaitsette. Minä
vihaan nenäkkyyttä. Se on merkki alhaisesta mielenlaadusta.»

»Nenäkäs? Minäkö?» Lääkäri vaipui yhä syvemmälle kauhun

kuiluun. »Oi, mutta, kansalainen edusmies, minä vakuutan teille…»

»Riittää!» Hänen käskevä sävynsä oli peloittava. »Minä vihaan

myöskin matelevaisuutta. Se kävi varsin hyvin päinsä Capetin
päivinä. Mutta se ei kelpaa Järjen kunniakkaalla aikakaudella, nyt
kun kaikki ovat vapaita, kaikki yhdenvertaisia, kaikki veljiä ja sisaria.
Nyt ei ole herroja. Ymmärrättekö?»

»Ihan täydellisesti, kansalainen edusmies.»

»Siitä teitä onnittelen. Astukaamme edelleen.» Sulttaanin sävy

huonekuntansa orjaa kohtaan ei koskaan ole ollut halveksivampi.
»Mitä on teillä tuolla ylhäällä?»
 »Ylhäällä? Ylhäälläkö?» Tohtori oli hartaasti kuvitellut, että
tarkastus jo oli lopussa. »Oh, ei mitään, minkä vuoksi teidän
kannattaisi vaivautua.»

»Kaikkien asioiden vuoksi kannattaa kansan innokkaan palvelijan

vaivautua. Painakaa se mieleenne, kansalainen lääkäri. Se voi
kannustaa teidän omaa intoanne.»

Näpsäyksen saanut lääketieteen harjoittaja kumarsi kunnioittavasti

äänettömässä kauhussaan.

Vapauden ja veljeyden apostoli jatkoi:

»Opastakaa minua, olkaa hyvä.» Ja hän viittasi kädellään

ylöspäin. »Täällä tapaamastani asiaintilasta laaditaan selostus, jonka
tänä iltana esitän konventille. Tämä häpeällinen meno on
lopetettava.»

Tohtori, jonka käsi oli porrasten käsipuulla ja sirosolkiseen

kenkään puettu jalka ensimmäisellä askelmalla, pysähtyi ja kääntyi.
Hänen kasvonsa olivat harmaat.

»Te ette tosiaan, kansalainen edusmies, voi panna tätä… tätä

häpeällistä menoa minun tililleni. Minä…»

»Te kulutatte minun aikaani, ja minun aikani kuuluu Ranskalle.

Teille tarvitsee muistuttaa ihan päivänselviä asioita. Voitte luottaa,
kansalainen lääkäri, mitä ehdottomimpaan oikeuteen. Vääryyden
valtakausi loppui despoottien inhoittavan hallituskauden mukana.
Minä selostan mitä näen.» Hän hellitti hiukan ankaruudestaan.
»Tähän asti en ole teissä mieskohtaisesti mitään syytä havainnut. Te
olette ollut vilpitön. Ette ole mitään salannut. Ette ole millään tavoin
yrittänyt tarkastustani vaikeuttaa. Se kaikki puhuu teidän
puolestanne. Jatkakaa samalla tavalla, niin teidän ei tarvitse minun
selostustani pelätä. Mitä teillä tuolla yläkerrassa on kätkettynä?»

Lääkäri hengitti vihdoinkin vapaasti. Rohkenipa hän hiukan

naurahtaakin vastatessaan: »Kätkettynä? Kätkettynäkö, kansalainen
edusmies? Mitäpä minä kätkisin?»

»Sitä minä teiltä juuri kysyin.»

»Oh, ei mitään, ei yhtään mitään! Kaikki on teidän

tarkastettavissanne.» He alkoivat nousta leveitä portaita. »Täällä
ylhäällä on muutamia henkilöitä, jotka on täytynyt eristää, muutamia
onnettomia, jotka on todistettu mielenvikaisiksi.»

»Mielenvikaisia!» Chauvinière näytti kummastuneelta. »Siis

laitokseen, jossa ei enää ole tilaa sairaillekaan, lähetetään niitäkin,
joiden pitäisi olla hulluinhuoneessa! Mikä häpeällisyys!»

Baziret myönsi, niinkuin hän myönsi kaikki, mitä ylväs edusmies

olisi sanonut. Jos nuo ylemmät suojat voitaisiin tyhjentää
asukkaistaan, voisi hän järjestää sinne toisen osaston ja siten
vähentää tungosta alhaalla. »Mielipuolet», valitti hän, »ottavat niin
paljon tilaa».

»Olen sen huomannut», vastasi Chauvinière. »Ne täyttävät koko

maailman.»

Ryhdyttiin sitten tarkastamaan yläkertaa. Baziret avasi oven

toisensa jälkeen noihin yksinäisiin vankikammioihin, joissa nähtiin
milloin vanha mies, milloin vanhanpuoleinen ylimysnainen, ja
jokaisessa kammiossa samanlainen vaatimaton puutuoli ja
lautapöytä ja huoneen nurkassa patja ja huopapeitteitä.

Vihdoin, lopettaen kärsimättömyyden, jonka Chauvinière oli

täydellisesti salannut, Baziret avasi oven sen henkilön huoneeseen,
joka oli syynä kaikkeen tähän innokkuuteen edusmiehen puolelta —
sen henkilön, jonka tähden tai jota koskevien omien tarkoitustensa
vuoksi hän nyt penkoi kaikkia näitä asioita ja edelleenkin penkoisi. Ja
niin kätkettyä ja taitavaa myyräntyötä hänen penkomisensa oli, että
pinnalla ei näkynyt mitään, mikä hänen työnsä tarkoituksen
paljastaisi.

Mademoiselle de Montsorbier istui huoneen ainoalla tuolilla, jonka

hän oli sijoittanut ristikkoikkunan viereen Hän käänsi päätänsä, kun
ovi avattiin, ja säpsähti hiukan nähdessään Chauvinièren, joka
katseli häntä arvostelevasti, osoittamatta mitään tuntemisen merkkiä.
Tyttö näytti hänestä tavallista kalpeammalta, silmät olivat hiukan
jännittyneet, piirteet hieman vääntyneet. Mutta yleensä hän oli ehkä
muuttunut vähemmän, kuin mitä edusmies oli odottanut, viikon
jälkeen, joka oli kulunut hänen äitinsä teloituksesta ja siitä, kun hänet
itse Conciergeriesta siirrettiin tänne; ja tuo pieni muutos, jonka hän
tarkalla silmällään havaitsi, ei laisinkaan rumentanut. Kärsimys oli
korostanut hänen henkevää, eetterimäistä ilmettään. Sisällisesti riitti
tarkastajalta huokaus filosofiselle mietelmälle, että kärsimys sittenkin
on ihmistä enimmin hienostava vaikutin.

»Kuka tämä on?» kysyi hän kylmästi.

Baziret ilmoitti hänelle, ja sillä välin Chauvinière edelleen katseli

potilasta.
 »Haa!» virkahti hän vihdoin. »Hän ei tosiaan näytä mielipuolelta,
tämä neitonen.»

»Ah, usein niiden laita on niin! Heidän ulkonäkönsä pettää

tarkimmankin.»

»Mutta jos te lääkärit voitte erehtyä yhteen suuntaan, niin voitte

erehtyä toiseenkin.» Hän tuijotti Baziretiin peloittavan epäilevillä
silmillä. »Voinpa kuvitella mielessäni olosuhteita, joissa te
mielellännekin soisitte erehtyvänne.»

Baziretia puistatti. »Tarkoitatte, kansalainen…?»

»Pyh! Te ymmärrätte minua varsin hyvin! Tämä tyttö

esimerkiksi…» Hän keskeytti puheensa, katsellen tyttöä jälleen ja
nojaten kättä leukaansa. Sitten hän äkkiä kuin mies, joka tekee
nopean päätöksen, viittasi lääkäriä poistumaan. »Minä puhuttelen
häntä», virkkoi hän. »Minun velvollisuuteni on ottaa selvää kaikesta,
missä…» Jälleen hän keskeytti lauseensa. »Odottakaa minua
käytävän päässä. Äänen kantamattomissa.»

Lääkäri kumarsi jälleen säikähtyneessä nöyryydessään ja lähti.

Chauvinièren silmät seurasivat häntä. Ne olivat viekkaat, ivalliset,
halveksivaiset. Vihdoin hän astui huoneeseen ja sulki oven.

»Nyt se ilveilynäytös on esitetty», sanoi hän lempeästi, ikäänkuin

tehdäkseen tytön uskotukseen, osalliseksi tarkoituksiinsa.

»Esitättekö te ilveilynäytelmää, monsieur?»

Tyynenä ja tasaisena kuului kysymys heleäsointuisella äänellä. Se

säpsähdytti edusmiestä. Hän kumarsi hiukan.
 »Teitä palvellakseni, kansalainen.»

Tyttö oli noussut ja seisoi nyt suorana ja solakkana

musliinihuivissaan ja pitkässä hameessaan, jossa oli leveitä sinisiä
raitoja harmaalla pohjalla. Hänen selkänsä oli ikkunaan päin ja
vaaleankellervää maaliskuun päivänpaistetta kohti, niin että hänen
varjostetut kasvonsa jäivät epäselviksi. Ääni kuitenkin vakuutti
vierailijalle, että hänen itsehallintansa oli mitä täydellisin.

»Mutta se ei minusta ole säädyllisyyden mukaista ilveilyä.»

»Säädyllisyyden…?» Edusmies tunsi pistoksen. Tytön tarkoitus jäi

häneltä käsittämättä, eikä hän pitänyt siitä, ettei hän tajunnut
tarkoituksia. Eikä sellaista usein tapahtunutkaan. »Ja miksi ei
säädyllisyyden mukaista, jos saan kysyä?»

»Siksi, että olette jotakin unohtanut.»

»Mitä muka olen unohtanut?»

»Ottaa hatun päästänne.»

Miehen kuuluva hengityksen salpautuminen ilmaisi hänen

kummastuksensa. Sitten levisi nauru hänen kasvoilleen, mutta se ei
ollut kovaäänistä naurua, sillä hän muisti lääkärin käytävän toisessa
päässä.

»Ne ovat olleet oikeassa, jotka ovat todistaneet teidät

mielipuoleksi», sanoi hän lempeästi. »Varmasti on teidän lähdettävä
täältä oikeaan hulluinhuoneeseen.»

Tyttö perääntyi, kunnes hänen olkapäänsä koskettivat ikkunan

tankoihin.
»Mikä kauheus! Mikä hävyttömyys! Te tiedätte, etten minä ole hullu.
Teidän vehkeilyllänne minut…»

»Hst, hiljaa, hiljaa! Ei hiiskaustakaan!» Hänen pelkonsa oli

todellinen. Hänen silmänsä vilkaisivat pelokkaasti ovelle. »Noin
haastelemalla, kansalainen, te tuhoatte meidät molemmat.»

Neitonen päästi pari naurunhelähdystä, jotka pilkkasivat

edusmiestä ja hänen äkillistä pelkoaan.

»Tässä vapauden maassa, monsieur, tällä Järjen aikakaudella,

teidän ollesssanne yksi Järjen papeista, saanee nainen tuhota
itsensä kenelläkään olematta siihen mitään sanottavaa. Ja teidän
tuhonne taas — voitteko kuvitella, että se minua liikuttaisi?»

Edusmies huoahti. »Minä olen ihaillut teidän uhmaavaa älyänne,

kansalainen. Alan pelätä, että teillä on sitä liiaksi.» Hän lähestyi
askeleen, pari. »Te olette hyvin nuori. Joko teiltä on voitu siihen
määrin riistää kaikki se, mitä nimitämme toiveiksi ja haaveiksi, että
ehdottomasti näette jokaisessa miehessä vihollisenne? Jos niin on
laita, niin sitten olisi turhaa väittää olevani teidän ystävänne,
työskenteleväni antaakseni teille takaisin vapauden ja elämän, joiden
teidän iällänne tulisi olla hyvin rakkaita, ja että sitä varten olen
suunnitellut ja tehnyt työtä, ollen sitä valmis edelleenkin jatkamaan
oman kaulanikin uhalla. Jolleivät saamanne todistukset voi tehdä
teitä siitä varmaksi, jollette tahdo niiden varaan uskaltaa elämäänne,
joka muutoin on mennyttä, niin sitten, kansalainen, minun olisi
parasta taas lähteä ja jättää teidät kohtalonne haltuun. Antautuisin
liian suureen vaaraan pyrkiessäni saamaan teidät luottamaan
minuun, samoin kuin voisi minulle olla vaarallista, jos minut täällä
nähtäisiin avopäin, mikä oli ainoa syy, miksi en ottanut hattua
päästäni.»
 Kun ihminen käsittää tehneensä yhden vääryyden, voi hänen koko
katsantokantansa jonkun verran järkkyä. Ja kun mademoiselle de
Montsorbier nyt tunsi saaneensa riittävän selityksen edusmiehen
hattua koskevasta vähäpätöisestä seikasta, kummeksui hän, eikö
hän sittenkin kenties ollut tuominnut liian harkitsemattomasti ja yhtä
väärillä perusteilla vakavammissakin kysymyksissä.

Neitonen katseli edusmiestä ja huomasi hänessä nyt jotakin

arvokkuutta, joka ei voinut olla häneen tehoamatta.

»Mutta miksi», kysyi hän tyynesti, »te haluaisitte minua palvella?»

Hetkiseksi vienonsi hymy miehen lyijymäiset kasvot. »En luule,

että hamasta maailman alusta asti on elänyt miestä, joka ei joskus
olisi halunnut palvella jotakuta naista.»

Tuo oli kylläkin selvää, ja ne tavat ja ennakkoluulot, joissa

neitonen oli kasvatettu, tekivät sen loukkaavaksi hänen silmissään.
Hän osoitti sen selvästi äkkiä jäykistymällä, kohauttamalla
leukaansa, kulmain rypistymisellä sinivihreiden silmien yläpuolella ja
kiukunpunalla, joka levisi hänen hienosti väritetyille kasvoilleen.

»Te unohdatte asemanne, hyvä herra», sanoi hän, puhuen kuin

röyhkeälle rengille. »Te olette sietämättömän julkea ja edellytätte
kovin paljon.»

Jos tuo koski mieheen, ei hän ainakaan osoittanut mitään

loukkaantumista. Hänen lempeä hymynsä muuttui vielä
lempeämmäksikin, surumieliseksi. Hän oli kyllin perehtynyt
sielutieteeseen käsittääkseen, että sen, joka tahtoi valloittaa naisen,
piti aloittaa tekeytymällä hänen orjakseen.
 »Edellytänkö? Onko siinä mitään julkeutta jos esittää historiallisen
tosiasian? Pyydänkö minä mitään? Vaadinko palkkaa tarjotusta
palveluksestani? Minä olen teidän käskettävissänne, kansalainen,
pelastaakseni teidän henkenne, koska…» Hän vaikeni tehden
pienen puolustelevasti torjuvan liikkeen. »Koska halu palvella teitä
ilman palkkiota tai palkkion toivoa on minua itseäni voimakkaampi.
Eikö sitä voi olettaa?»

»Ei, monsieur. Se on uskomatonta.»

Chauvinière katseli vakavana tyttöä, joka seisoi siinä solakkana ja

suorana, vartaloltaan melkein poikamaisena, lukuunottamatta
vähäistä kumpua musliinihuivin alla, hienopiirteiset kasvot niin
tavattoman levollisina ja päiväpaisteen takaapäin luodessa
hehkuvan sädekehän hänen kultakutrisen päänsä ympärille.

»Uskomatonta kylläkin», myönsi hän vihdoin. »Sellaista on

minusta usein väitetty. Minun luonteessani on jokin ristiriita.
Mielenlaatuni muovattiin ivalliseksi. Odottamaton houkuttaa minua.
Jonakin päivänä se kai viettelee minut turmioon. Mutta minä lähden
hymy huulilla nauttien hetkestä.» Hän ei odottanut mitään
vastaselitystä, vaan jatkoi kiihoittaen äänensä nopeampaan vauhtiin.
»Me tuhlaamme aikaa, kansalainen. Kuunnelkaa ja päättäkää sitten
itse. Teillä on miettimisaikaa tämän hetken ja ratkaisun välillä.
Epäilkää minua, niin joudutte piankin mestattavaksi; tai uskokaa
minuun ja sallikaa minun viedä teidät takaisin elämään. Olkoon asia
niinkuin haluatte. Minä teen tarjouksen, mutta minä en houkuttele.
Kuunnelkaa nyt.»

Nopeasti, lyhyesti hän piirsi tulevien tapausten sarjan. Hän toimisi

niin, että mielisairaat Archevêchésta siirrettäisiin Rue de Bacin
hulluinhuoneeseen, josta pakeneminen olisi helppoa. Siirtäminen
tapahtuisi seuraavana päivänä. Heti kun se oli tapahtunut, lähtisi hän
Nivernaisiin, johon konventti jo oli hänet määrännyt
tarkastusmatkalle. Hänen passinsa olivat valmiit, ja niihin oli merkitty
olematon kirjuri. Sen paikan täyttäisi neitonen, jos hän suostui
ehdotukseen, sitä varten sopivasti puettuna miehen asuun.
Mademoiselle de Montsorbier saisi miettiä asiaa ja ilmoittaa hänelle
päätöksensä huomenna, kun hän kävisi talossa Rue du Bacin
varrella. Toivottavasti nuori kansalainen valitsisi viisaasti.
Nivernaisissa hän olisi vapaa menemään, minne tahtoi, ja
epäilemättä kykenisi löytämään turvaa siellä
syntymämaakunnassaan ja kenties hankkimaan itselleen apua
voidakseen lähteä Ranskasta, jos niin halusi. »Me olemme
molemmat kotoisin Nivernaisista», muistutti hän puheensa lopulla.
»Kenties yhteinen syntymäseutumme vahvistaakin harrastustani
teitä kohtaan.» Hän vilkaisi nopeasti ovelle ja sieppasi sitten
vihdoinkin hatun päästänsä, tehden syvän kumarruksen. »Nöyrin
palvelijanne, kansalainen. Jääkää hyvästi.»

Hän oli lähtenyt äkkiä, suomatta neitoselle aikaa vastata, jättäen

hänet sinne seisomaan hämillään, otsa rypyssä, kuolemanpelon ja
suojelijaansa kohdistuvan epäluulon vaiheille.

Sinä iltana pauhasi Chauvinière kansalliskonventin korkealta

puhujalavalta raivokkaasti vankilajärjestelmää ja sitä asiaintilaa
vastaan, jonka oli tavannut Archevêchén vankisairaalassa. Hän oli
suurenmoinen rohkeudessaan, leimuava ivassaan, joka ei säästänyt
ketään vastuunalaisista, eipä hän edes kavahtanut syyttämästä
oikeusministeri Camille Desmoulinsiä. Hän väitti puhuvansa
ihmisyyden nimessä, oikean ja vanhurskaan suuttumuksen tulen
poltteessa.
 Muuan edustaja alisen Loiren piiristä rohkeni keskeyttää hänet
letkauksella, joka saavutti jonkun verran hyväksymistä täyteen
sullotusta salista.

»Herra presidentti, sallitteko tämän miehen jatkaa kohtuutonta

puolustustaan aristokraattien aseman lieventämiseksi?»

Seisoen jäykän suorana ja näyttäen hyvin kookkaita,

mustatukkainen pää takakenossa, hienojen käsien levätessä
kummallakin puolen sulkatöyhtöistä hattua puhujapöydän syrjällä,
tukehdutti Chauvinière heti tuon purskahtelevan hyväksymisen
kipinät.

»Aristokraattienko?» Hänen äänensä kajahti edustajien päiden yli

kuin ukkosen jyrähdys, ja hän toisti: »Aristokraattienko?»

Äänettömyys seurasi silmänräpäyksessä. Hänen närkästynyt,

kysyvä huudahduksensa oli kiinnittänyt heidän huomionsa. Hän
pysähtyi nyt puheessaan, ja hänen ivallinen, käskevä katseensa etsi
joukosta tuon Loiren uskalikon ja naulitsi hänet. Hän tunsi
jännityksen arvon, ja pitkän tuokion hän piti heitä jännityksessä.
Sitten hän laukaisi vastauksensa:

»Vapaiden miesten valtiossa, kansalaiset, tulee oikeuden olla

samalla kertaa hellittämätön, sokea ja horjumattoman puolueeton.
Se ei saa sietää ennakkoluuloja eikä ennakkopäätelmiä, sillä ne ovat
tositeossa oikeuden kieltämistä. Oikeuden jumalattaren silmissä,
jotka muinaiset kansat viisaudessaan vertauskuvallisesti sitoivat, ei
ole aristokraatteja eikä plebeijejä, vaan ainoastaan syytettyjä. Ja
jottei oikeus erehtyisi havainnoissaan — mikä vaara olisi
tyrmistyttävä valistuneille ihmisille tällä järjen aikakaudella, — täytyy
sen edellyttää syytetyt viattomiksi, kunnes sen oma todistusten
siivilöiminen pakottaa langettamaan heille tuomion.»

Hyvä-huudot vyöryivät kuin yhteislaukaukset avaraa salia pitkin.

Chauvinière, joka niin hyvin tunsi sanojen voiman ja osasi niitä

käyttää, tunsi myöskin näytelmällisen asennon arvon. Hän jäi nyt
tyyneksi, täsmälliseksi, hievahtamattomaksi — täysiveriseksi
isänmaan ystäväksi, jolla oli velvollisuutensa täytettävänä ja joka ei
itse ollut mitään. Enää eivät hänen silmänsä etsineet äskeistä
keskeyttäjäänsä, jottei hänen epäiltäisi nauttivan miehen
hämmentymisestä. Hän ei edes huomannut — ei siihen ainakaan
vastannut — Arrasin edustajan hyväksyvää hymyä, tuon tunnetun
ihmisystävän, hennon ja kelmeän Maximilien Robespierren, joka
poisti toisen parin silmälaseja kohotetulta nenältään säteilläkseen
puhujalavalla riehuvaa kohti.

Tämän jälkeen ei hänen ehdotuksensa menestys enää ollut

epätietoinen. Hänen vaatimuksensa, että uudistuksen aloittamiseksi
mielisairaat heti siirrettäisiin pois Archevêchésta, jotta kärsiville
potilaille varattaisiin niiden kipeästi kaipaamaa tilaa, sai yksimielistä
kannatusta.

Laskeutuessaan puhujalavan askelmia hän mietti kyynillisen

huvitettuna, kuinka mademoiselle de Montsorbierin sinivihreät silmät
joutuisivat vastuunalaisiksi Ranskan sisäpolitiikasta. Mutta olihan —
sitä hän myöskin muisteli — historiassa runsaasti esimerkkejä
sellaisesta niistä päivistä asti, jolloin erään Helenan nenänkuosi oli
aiheuttanut Troijan piirityksen.
KOLMAS LUKU

Dumey, Rue de Bacin hulluinhuonetta hoitava keski-ikäinen lääkäri,

sai myöhään iltapuolella seuraavana päivänä ottaa vastaan vierailun
edusmies Chauvinièrelta. Tämä saapui kyytivaunuissa, joista hän
astui ulos matkalaukku kädessä.

Sen hän laski tohtorin yksityishuoneeseen. Hän kävi suoraan

asiaan käskevällä, häikäilemättömällä tavallaan.

»Mielisairaiden vankien joukossa, jotka tänä aamuna uskottiin

hoivaanne, on muuan entinen aatelisneiti, kansalainen mademoiselle
de Montsorbier.»

»Aivan niin!» Lihavan lääkärin kasvot osoittivat innokkuutta.

»Hänen laitansa…»

»Älkää siitä välittäkö. Hän on kuollut.»

»Kuollut!» Dumey oli kuin ukkosen lyömä.

»Ettekö te senvuoksi lähettänyt kutsumaan minua?»

»Teitäkö? Mutta enhän minä ole teitä kutsuttanut.»

 »Teidän muistinne alkaa pettää, Dumey. Onneksi meille
molemmille minulla on hyvä muisti.» Hänen äänensävynsä kävi
äkkiä tuimaksi ja hiukan synkäksi siinä värähtelevän ikuisen ivan
uhallakin. »Te kutsutitte minut hallituksen lähimpänä vastuunalaisena
jäsenenä toteamaan kuoleman ja nimikirjoituksellani vahvistamaan
kuolintodistuksen, jonka te kohta laaditte ja allekirjoitatte. Kirjurini
todistaa minun nimikirjoitukseni. Hän saapuu piakkoin. Olkaahan nyt
hyvä ja viekää minut tarkastamaan ruumista.»

Dumey katseli vierastaan kauan ja tiukkaan. Heidän välillään oli

jotakin, minkä nojalla sananen Chauvinièrelta olisi pudottanut
Dumeyn pään Sansonin vasuun, ja siksipä juuri Chauvinière olikin
kaikkien Pariisin houruinhuoneiden joukosta valinnut Rue de Bacin
varrella sijaitsevan Archevêchésta siirrettyjen potilaiden
vastaanottopaikaksi. Tätä vaaraa vastaan Dumeyllä oli toiselta
puolen pantavana edusmieheltä saamansa suosionosoitukset, jotka
epäilemättä jatkuisivat ja joista yksi oli juuri tämä nykyinen
potilastulva hänen sairaalaansa ja hänen siitä johtuva oma
rikastumisensa.

Molemmista syistä oli Dumeyn tehtävä, mitä ikinä Chauvinière

käski. Ja se silläkin uhalla, että hänen päänsä oli ilmeisesti
vaarassa, sillä jos hän ei olisi totellut, olisi se varmasti irroitettu
hänen hartioiltaan.

Dumey hymyili vihdoin ymmärtäväisesti ja kohautti olkapäitään

alistumisensa merkiksi. »Vastuunalaisuus…» aloitti hän hiukan
arasti.

»On minun, koska minä vahvistan teidän todistuksenne. Pitäkää

suunne kiinni, niin ei mitään kysymystä vastuunalaisuudesta nosteta.
Vähintäänkin kuukauteen ei teidän hoidokeistanne mitään
tiedustella. Kun se tapahtuu, esitätte todistuksen. Tapauksesta on
siihen mennessä kulunut liian pitkä aika, jotta päästäisiin millekään
jäljille.»

Dumey kumarsi ja opasti häntä. Avattuaan oven yläkertaan hän

aikoi astua edellä, mutta edusmies pysähdytti hänet.

»Odottakaa ulkopuolella tai, vielä parempi, menkää alas

huoneeseenne. Pattovala käy teille helpommaksi, jollette enää näe
potilastanne elävänä.»

»Mutta minun täytyy nähdä hänet. Minun…»

»Erehdytte. Teidän ei ole tarvis häntä nähdä. Menkää. Älkää

kuluttako minun aikaani.»

Dumey lähti. Chauvinière astui huoneeseen matkalaukku kädessä.

Mademoiselle de Montsorbier, jolle hänen äänensä oli tiedoittanut
hänen tulonsa, seisoi jo valmiina häntä vastassa. Hän kumarsi tytölle
kunnioittavasti ja oli tällä kertaa kyllin epätasavaltalainen ottaakseen
hatun päästään. Sitten hän laski matkalaukkunsa pöydälle huoneen
keskikohdalle.

»Te olette tehnyt päätöksenne, kansalainen?» virkkoi hän

kysymyksen ja väitöksen välisellä sävyllä. Tämä sielutieteilijä ei
mielessään ensinkään epäillyt, että aika ja harkinta olivat voineet
kannustaa tuon ikäisen henkilön vain yhteen päätökseen. Oli perin
tuskallista ehdoin tahdoin kuolla kaksikymmenvuotiaana.

»Minä olen tehnyt päätökseni, herra edusmies», vastasi neitonen

tyynen arvokkaasti.
 »Kansalainen», oikaisi Chauvinière terävästi. »Tässä maassa on
enää vain harvoja herroja jäljellä, ja giljotiini katkoo niiden päitä niin
nopeasti nykyisin, että heitä piakkoin ei ole laisinkaan. Jos olette
päättänyt elää ja ottaa vastaan minun tarjoamani palvelukset,
kansalainen, niin tehnette minulle mieliksi edes käyttämällä
vapaudensanastomme silmäänpistävimpiä nimityksiä.»

Hänellä oli se esitystavan täsmällisyys, joka usein heijastaa

ivallista mielenlaatua. Mademoiselle de Montsorbier alkoi havaita
siinä jonkinlaista hiipivää huumoria, mutta ei ollut varma, oliko se
tietoista vai itsetiedotonta, ilkkuiko tämä kansalliskonventin jäsen
tahallaan vai viisasteliko hän vain niinkuin niin monet hänen
virkaveljensä.

Neitonen tarkkasi häntä nyt tiukasti harmailla silmillään, etsien

hänen kasvoiltaan vastausta lausumattomaan kysymykseensä.

Mies hymyili ikäänkuin olisi lukenut hänen ajatuksensa. »Ja te

olette päättänyt elää», sanoi hän. »Se on hyvin viisasta.»

»En ole niin sanonut.» Edusmiehen terävä vaisto säpsähdytti

häntä hiukan.

»Ettekö? Mutta minä edellytän yhtä ja toista», puolusteli

Chauvinière. »Minä otaksun sen teidän tyyneydestänne, siitä
uhmattomasta vastaanotosta, jonka minulle soitte. Minua surettaisi
kuulla siinä pettyneeni.»

»Herr… kansalainen, jos olen tuominnut teitä väärin, toivon teidän

olevan kylliksi jalomielisen antaaksenne minulle anteeksi. Minä…
minä emmin lausua ilmi ajatukseni teidän… teidän
huolenpidostanne, teidän ystävällisyydestänne.»
 »Empikää edelleenkin. Lauseihin kuluu aikaa, eikä meillä ole sitä
hukata.»

Hän avasi matkalaukun. »Tässä, kansalainen, ovat vaatteet, joihin

puettuna te matkustatte.» Hän veti muutamia esille. Tyttö perääntyi,
kasvot tulipunaisina.

»Nuo, nuoko! Mahdotonta!»

»Oh, ei mahdotonta. Ei ollenkaan mahdotonta. Hiukan hankalaa

ehkä. Mutta toivoakseni se vaikeus on voitettavissa. Kun tutkitte
näitä vaatteita, niin salaisuus, kuinka ne puetaan ylle ja kuinka niissä
ollaan, häviää vähitellen.»

»Niin, mutta siinä ei vaikeus olekaan. Te ymmärrätte minua

tallallanne väärin.»

»Vain saadakseni teidät käsittämään, kuinka järjetöntä teidän

kainostelunne on. Kirjurini ei voi matkustaa raidallisessa hameessa,
ja kun koetatte noita polvihousuja… Mutta meillä ei ole aikaa hukata.
Minä poistun, jotta voitte kiirehtiä pukeutumistanne. Kun olette
valmis, tapaatte minut käytävässä.»

Puoli tuntia myöhemmin, jonka ajan edusmies odotti kuumeisen

levottomana, tuli naisen huoneesta nuorukainen, pyöreä hattu
päässä ja puettuna ratsastakkiin, saappaisiin ja polvihousuihin.
Hetkiseksi Chauvinière pysähdytti hänet tarkastaakseen häntä
silmällä, joka ei jättänyt mitään yksityiskohtaa huomioon ottamalta.
Tässä asussa tyttö näytti muutamaa tuumaa lyhyemmältä, mutta
hänen vartalonsa meni varsin hyvin mukiin, ja hiusrykelmä oli
taitavasti kätketty. Edusmies lausui hyväksyvän sanansa ja riensi
hänen kanssaan alas. Dumey odotteli heitä valmiina todistuksineen.
Se homma oli pian suoritettu, ja kirjurin seuratessa hänen
kintereillään edusmies Chauvinière astui odottaviin vaunuihin.
Dumey sulki oven heidän jälkeensä, ja ajopelit vierivät pois.

Mitään sanaa ei vaihdettu heidän välillään, ennenkuin he

lähestyivät tulliporttia, jolloin Chauvinière ojensi toverilleen ison,
mustan nahkasalkun, raotti sitä ja sanoi: »Passit ovat tuossa
ylimmäisenä. Vaadittaessa te näytätte ne. Se on teidän virkanne.
Puhua ei tarvitse.»

He pysähtyivät Rue d'Enferin päässä olevalle rautaportille.

Sinitakkinen upseeri, jolla oli punaiset, villaiset olkalaput (sillä kulta

oli poistettu yhdenvertaisuuden aikakaudella sopimattomana),
tempasi vaununoven auki ja kysyi komentavalla sävyllä matkustajilta:

»Kuka siellä on?»

Nurkastaan vastasi Chauvinière yksikantaan:

»Kansalainen edusmies Chauvinière, hallituksen määräämällä

virkamatkalla. Näytä hänelle paperit, Antoine, ja jatkakaamme
matkaamme.»

Silmäripsiensä alta hän tarkkasi toveriaan, valmiina tulemaan

väliin, jos tämä näkyisi tekevän pienimmänkin kommelluksen. Mutta
mitään vaaraa ei ollut. Erehtymättä otti valekirjuri salkusta hänen
osoittamansa paperit, ojentaen ne tarkastajalle kädellä, joka ei edes
vavissut.

Upseeri, joka oli paljon hellittänyt ankarasta sävystään

kuullessaan, kenen kanssa oli tekemisissä, tarkasti paperit, antoi ne
takaisin, teki jäykästi kunniaa ja sulki huolellisesti oven jälleen. Sitten
kajahti hänen komentava äänensä: »Päästäkää kansalainen
edusmies Chauvinière lävitse.»

Rautaportit vongahtivat auki, ajaja napsautti ruoskaansa, vartija

teki kunniaa kiväärillä, ja he ajoivat tullin läpi. Pariisin ulkopuolelle.

»Olemme päässeet Rubiconin yli», virkkoi Chauvinière kuivimpaan

sävyynsä ja heittäysi taaksepäin nurkassaan, pitkät, laihat sääret
työnnettyinä suoraan eteen. Täten nojaten hän edelleenkin tarkkasi
salavihkaa toveriaan, joka taivutti tyynesti papereita takaisin
laskoksiinsa ja sitten pisti ne salkkuun. Hänen ihmettelynsä ja
ihailunsa oli niin valtava, että hän lausui ajatuksensa ääneen:

»Teissä on totisesti ryhtiä!»

Tyttö napsautti salkun lukon kiinni ja katsahti häneen, hymyillen

hiukan.

»Se on veressä», virkkoi hän hiljaa. »Ettehän te sitä tiedä. Siksi te

ihmettelette. Ette liene tavannut monta naista minun säädystäni,
kansalainen edusmies.»

Pienempi mies olisi närkästynyt vihjauksesta, jota hän ei ollut kyllin

hupsu otaksumaan harkitsemattomaksi. Mutta Chauvinièrella oli se
harvinainen erittelylahja, joka teki hänelle mahdolliseksi ihailla
näppäryyttä silloinkin, kun se kohdistettiin häntä itseään vastaan.
Hän nyökkäsi hyväksyvästi.

»Huomaan, että te olette taipuvainen otaksumiin», lausui hän

arvostelevasti. »Sekin lienee veressä ja syynä siihen, että sitä niin
paljon vuodatetaan. Hm, hm! Puhukaamme muista asioista.
Velvollisuuteni kutsuu minua Neversiin. Nyt on torstai. Meidän pitäisi
päästä sinne lauvantai-iltana. Minä en säästä hevosia
matkustellessani kansakunnan asioilla.»

Neitonen oli sen jo aavistanut siitä hurjasta vauhdista, jolla vaunut

nyt kiitivät eteenpäin. Edusmies jatkoi:

»Minä teen teille seuraavan ehdotuksen…» Hän pysähtyi

puheessaan, ja tuon lyhyen vaitiolon aikana tyttö havaitsi
valtimoittensa sykkivän kiivaammin ja hengityksensä käyvän
läähättäväksi. Mutta Chauvinière, joka tarkkasi häntä kaiken aikaa,
kun tällä harkitulla jännityksellä koetteli häntä, huomasi ainoastaan
hänen ulkonaisen järkkymättömän tyyneytensä. Hän jatkoi
verkalleen: »Jos olisitte vilkaissut niihin passeihin, olisitte nähnyt,
että ne ovat laaditut tinkimättömään muotoon. Niissä käsketään
kaikkia kuoleman uhalla antamaan meille kaikkea mahdollista apua
matkustellessamme kansakunnan asioiden vuoksi. Kun pääsemme
Neversiin, huomaan tarvitsevani täsmällisiä tietoja tapahtumista
Burgundin itäisimmissä seuduissa. Mutta kun minulla Nivernaisissa
on liian paljon asioita hoidettavina lähteäkseni sinne itse, päätän
lähettää teidät sijastani. Sitä tarkoitusta varten ja passiemme
valtuudella Neversin vallankumouskomitea toimittaa teille
tarpeellisen suojeluskirjan ja saattueen matkustaaksenne Rhônen
rannoille. Senjälkeen on teidän asianne — eikä sen tarvinne teille
käydä vaikeaksi — keksiä keinoja päästäksenne rajan yli Sveitsiin,
missä olette turvassa.»

Hän vaikeni; mutta tytön hengitys ei vielä tasaantunut. Se, mitä

hän kuuli, oli hänestä ihan uskomatonta. Se osoitti selvästi, että tuo
mies toimi puhtaasti epäitsekkäistä syistä, ilman mitään
omanvoitonpyyntöä. Oliko mahdollista, että hänen pulansa tai jokin
hänessä itsessään oli tosiaan hellyttänyt vieraan miehen näin