A recent work assignment has prompted me to consider the manner in which cast technicians are trained in the UK. It has been repeatedly demonstrated over the years that something is very seriously awry with the training provided to cast technicians in the UK. The latest work scenes have shown once again that the British Casting Certificate (BCC) training for cast technicians is wholly inadequate.
There cannot be many occupations which require the worker to demonstrate a high level of technical understanding, excellent manual skills and an ability to constantly evaluate the technical quality of the work within its context after undertaking a formal five week training course. It does not acknowledge that the pre-requisite time spent in a cast room may not have adequately prepared the trainee. Once the formal course is completed there is no requirement for the operator to undertake any further formal training after the initial qualification is gained.
The temporary assignment found me in a hospital cast-room where sickness had depleted the usual workforce. The cast room was staffed by two BCC qualified staff and one trainee orthopaedic practitioner. There were three working areas which were approximately similar, with an electric couch/chair and a set of mobile drawers which nominally permitted the operator to apply and remove casts without having to leave the side of the patient. Each area was separated from the others by a curtain.
There was a single computer on the extreme edge of the clinical work area and it was used for all of the tasks of an NHS trust computer rather than serving as a radiograph viewing station. Viewing radiographic evidence of injuries to be cast was an afterthought and the radiograph viewer remained on screen for a few minutes before logging off automatically. This type of radiograph viewing system is useless for any complex casting tasks which require constant image reference. It cannot be viewed from behind the separating curtains while treating a patient.
The method of detailing the clinical work to be completed was a scrap of A5 sized paper with several tick boxes appended. It could be completed by various clinic staff at HCA or nurse level, clinic reception staff or the treating clinician. It carried a patient ID sticker and a scribbled tick which could have been appended by anybody. Sometimes the tick was not in the correct place. It was not a clearly written clinical prescription and it was undated.
The clinician's name may or may not have been appended and the instructions were brief to the point of being unnecessarily short, frequently without a signature. The diagnosis was not usually written on this sheet. Some pieces of paper had nothing whatsoever written on them. The work detailed on the paper scrap was then completed by the technician who merely signed it. The paper sheet was shredded after the clinic had finished! There cannot be any single case made for destroying current clinical records, however inadequate.
The details were transferred from the paper instruction to a register. A second register required the operator to enter the same patient details into a book where cast care instructions were given to the patient. The registers were kept as a record of work completed. Hospital number, patient name, condition treated and treatment completed and initials of operator were all appended to the register in a small space on a single line.
The spaces were so small that a name had to be written as family name and given name on two lines within the same space. With diagnosis information not being appended to treatment sheets, the operator had to guess what was wrong from the cast configuration or the patient's recall. Whether the information "ROC" or "BE cast" is sufficient detail for a judge, in the event of a legal dispute, remains to be seen but it is very clearly not best clinical practice.
The provided registers should not permit the casual observer to identify the patients nor should they be able to discern any treatment which the patient may have had. The local BCC qualified staff should have referred the matter to the local Caldicott Guardian as a matter of urgency.
The use of patient names alongside hospital numbers is a clear breach of Caldicott principle 2; that is to say that the principle requires that identifiable patient information is not used unless it is necessary. We don't use patient identifiable information unless it is necessary. A hospital number is unique to the patient and the casual observer could not identify who the patient is or where they live from the hospital number.
What is very clear is that these registers could never constitute a clinical record of treatment completed. The continuity of care to which every patient is entitled is not assured. An orthotist, hand therapist, physiotherapist or clinician would not have been able to gather a complete picture of the treatment cycle to date.
How would wound care and treatment progress get noted? How would a finding of a fixed flexion deformity or the patient having been weight-bearing (when non-weight bearing was the clinical instruction) become recorded in the patient's clinical care record? Regular wound care for diabetic patients could not be recorded. I witnessed two BCC qualified staff working in this unacceptable manner in the false belief that they were working to a high standard.
The issue is further compounded by not providing temporary staff with an adequate induction into the processes, procedures and working practices approved by that particular NHS Hospital Trust. Not providing the temporary member of staff with an induction often concludes with complaints that local process have not been complied with by the temporary staff member.
The issues only arise after the non-compliant treatment had been delivered or local processes have been bypassed. It is disrespectful to the temporary staff member to attempt to force an experienced holder of the casting certificate into casting according to local methods of work, which may well be wrongheaded or mistaken.
It is inevitable that trainee staff will witness the local practices and conclude that local methods are the correct manner with which to undertake the clinical work. Regardless of any BCC training delivered on the BCC course, the trainee will have spent time assimilating any poor practices of the nominating hospital cast-room.
The powerful effect of the BCC qualified staff delivering negligent care, in the presence of the trainee orthopaedic technician, should not be underestimated; insofar as its lifelong influence on the clinical practices of the trainee cast technician.
I had spent some time explaining technical matters to the trainee orthopaedic practitioner as they arose during the course of my work. The local qualified staff took exception to this conduct and complained about it undermining them. The justification for this position was the statement that the trainee would have to do exactly as they were taught on the casting course in order to pass it. It was implied that the permanent staff had been using the taught methods of the casting course for over two decades and therefore their methods were 'right' when judged against my own.
What a sorry state of affairs the training must be in if any questions a student may have about technique are left unanswered. There are many different approaches to the work and it is completely wrong for cast technicians, who have limited experience and little to no interest in their work, to prevent relevant knowledge from being passed on to the next generation of cast technicians.
The Code of Conduct, Performance and Ethics for Orthopaedic Practitioners which was produced by the British Orthopaedic Association (BOA) sub-committee on casting techniques demands that knowledge is passed on. Inter alia the code demands that cast technicians do "Communicate effectively and share your knowledge, skill and expertise with other members of the team". Additionally, there is a requirement to "assist in the development of your colleagues’ professional competence in accordance with their needs and the needs of the service within the context of the individual’s knowledge".
Where BCC qualified staff feel that knowledge being passed from an experienced practitioner to a student cast technician is inappropriate, just because it does not accord with their own limited understanding and experience, it demonstrates both the inherent failings of the course and the errant candidate's misapprehension of the information imparted at RNOH Stanmore.
For what it is worth, the BCC qualified staff were applying undercast wool to a depth of four layers under slabs and some casts. To the observer (trainee) it must have appeared as a random selection of layers being applied with no particular method or rationale. Removing adequate full casts and then applying so-called 'removable casts' in the exact same configuration, highlights the failure of the local staff to think about their methods. Applying full casts over surgical wounds and then removing the cast to remove sutures/clips one week later demonstrated another gross failure to understand the rationale behind the assigned work.
I am not in favour of sitting patients on a plastering couch to have an upper limb cast unless there is a need to raise the patient to working height. The seat is usually far too wide to sit on comfortably and often the leg sections do not rest in the vertical position, making it difficult to put a patient onto the seat. Uncomfortable patients do not make the best subjects for casting an upper limb. There were no limb supports in use at this location. Someone had put a couple of theatre overshoes onto a piece of wood that was used when casting a leg.
In 2016 I would expect to see the use of a limb support solution which considered the patient's comfort and I am mindful of the fact that the two BCC qualified staff accepted this poor practice. It suggests to me that they both could have benefitted from attending a re-training course. The absence of any clinical work record detailing the casting work completed, in a manner which could be used in the event of a legal dispute, is a major failing and once again highlights an issue with the depth of the BCC course. There is an abject and continuing failure of the BCC to provide modular and advanced courses for every aspect of the clinical work.
Poor clinical practice, uninterested staff, trainees accumulating bad habits and poor clinical practice over an extended period of time; allied with the failure to provide advanced training are just some of the issues which beset the current BCC training. The persistence of the BOA and the leaders of our occupation in refusing to provide adequate training opportunities is completely inexplicable.
The latest standards for casting are a joke. They are same inadequate standards that were produced in 2000. The fact that these so-called standards have exerted little effect on the state of casting and its associated work within the NHS; is a silent witness to the misguided approach of the great and good who purport to run our occupation. A completely novel approach to our clinical standards would do something about the futility of the dead-end training program that counts as the only formal training in casting in the UK.
For departments that may employ temporary staff
PACS access is essential and the work of casting technicians cannot be completed safely without it. A temporary code should be set up and allocated to temporary staff on day one, rather than have them working for a week while paperwork and requests between managers and departments is signed and agreed.
A formal induction process should be undertaken on arrival in the new post. The hospital will need to have a system of allocation for name badges (especially where door access is controlled by them) and ensuring that the temporary worker is aware of any special local practices.
The induction should include introducing the temporary staff member to staff with whom they are expected to have contact. Specific local procedures will be included in this induction. e.g. where a consultant will only permit one form of treatment for a particular clinical instance, the temporary staff member should be made aware from day one. Local knowledge of tissue viability services, bleep system, portering, waste disposal and stock ordering and deliveries should be passed on to the temporary employee.
The clinical judgement of the temporary worker is not to be dismissed as of little account by dint of the fact that they are merely a temporary staff member. Techniques learned during their work experiences and their associated technical knowledge are two of the factors which have helped them to develop their skills. The local work environment and its functioning may be unknown to the temporary staff member and they will need some assistance to understand the local methods of work.
The aim should not be to make the temporary worker an exact fit (clone) for the staff they are working in the stead of but to facilitate their smooth induction into the patient workflow. This is the means by which the disruption can be kept to the minimum during their tenure.