Soapbox Your say about nursing issues - Contemporary Nurse: Healthcare Across the Lifespan

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Soapbox

Your say about nursing issues

Helen Calabretto
School of Nursing, University of South Australia, SA

PP: 080 - 082

Article Text

Nursing knowledge: Myth or reality?

Nursing has rapidly developed over the last two decades. A new student entering a nursing course will be introduced to nurse academics, specialist nursing literature, nursing research, and an emphasis on viewing the client/ patient from a perspective which is radically different to that of the 'medical model'. All of this is discussed in the context of the role of the registered nurse.

What appears to be missing from this education process is a clear explanation of why registered nurses actually exist. This confusion occurs when the student is assigned to a clinical venue for some 'hands on' experience. The student is confronted with the reality of 'personal care attendants' and 'nursing assistants'. These latter groups of people will be seen to be doing work which was formerly performed by registered nurses. In hospital wards, where 'attendants' and 'assistants' will be less numerous, enrolled nurses will also be found doing the bulk of work which involves direct patient/client care.

On returning to the lecture room, the student will ask why these various levels of personnel exist. This question may be partly answered by resorting to discussions about health politics which involve economics and budgets. However, another important reason for this hierarchy is that the registered nurse role remains poorly understood by the community at large. The result of this lack of comprehension is that registered nurses are not seen to be essential in all facets of patient/ client care.

Nursing is not appreciated as being a true profession. One reason for this is a lack of recognition that nursing has a unique body of knowledge. As a result it is thought that a registered nurse can be replaced by less qualified staff.

Recent nursing literature discusses the nature of nursing knowledge. Despite repeated assertions that such knowledge exists, it is difficult to find a description of this knowledge.

Nursing gains knowledge from a variety of areas, e.g. biological science, psychology, sociology which are then adapted or applied to the nursing context. This is a difficult position to argue to a community which is trying to spend every public dollar as wisely as possible. Perhaps the answer lies in moving the discussion away from the nature of the knowledge and concentrating instead on the functions and goals of nursing. That is, to highlight what it is that nurses actually do rather than simply asserting the right to a professional status.

Nursing could be said to have two main goals-health promotion and client advocacy. Health promotion relates to aiding the patient/ client to achieve or maintain maximal physical and mental wellness. Client advocacy refers to the empowerment of individuals who seek assistance from the health sector. Advocacy is undertaken to ensure the rights of the individual are maintained, the care delivered is appropriate, and that the client fully understands what is going on and why. Advocacy is the 'humanization' of the health system.

To achieve these two goals, the nurse performs a number of functions: provides physical and emotional care; consults with other personnel regarding the planning of care; provides health education, and undertakes health assessment.

In addition to these functions, the nurse conducts research, acts as a co-ordinator between health personnel, and evaluates the effectiveness of health interventions. The priority given to each of these functions depends on the setting in which the nurse works, although the goals remain constant across settings.

To prevent further erosion of employment opportunities for registered nurses, and to create more satisfactory working conditions for those who are employed, nurses need to act to increase public awareness of these goals and functions. Some suggested ways for increasing this awareness are by: greater utilisation of the media to comment on health issues; increased participation in health policy planning, and focussing research activities which demonstrate the benefits of having registered nurses as opposed to lesser qualified staff caring for people.

If the above strategies are effective, then the student will not witness a further deterioration in the status of registered nurses. The reality will then match the vision being taught in nursing courses.

James Kevin RN

Clinicians, please educate diabetic clients

Diabetes mellitus is a lifelong condition requiring medical care and education to prevent acute complications and to reduce the risk of long-term complications. However, when I ask nurse clinicians, 'Whose role is it to educate diabetics while in hospital?' the repeated response is, 'It's the diabetes educator's role, not ours, we shouldn't be expected to teach the diabetics'.

My concern relates to the clinician's lack of commitment in ensuring that hospitalized diabetic people receive adequate information and education about their condition. It troubles me, because approximately 75% of the population with diabetes will die from arterial disease. Unless the clinicians are prepared to educate these clients to manage their condition and reduce the number of risk factors associated with arteriosclerosis, then diabetic clients will remain the most frequently hospitalized group. Diabetic clients are admitted into all ward units in the hospital; surgical, medical, obstetric and paediatric. Length of stay and cause for admission varies, but the most frequent reason for diabetic admissions, besides elective surgery, is the acute complications relating to hypoglycaemia and hyperglycaemia. Added to an often prolonged stay, the client is discharged on an altered regime of management. A change in the insulin dose may lead to more hypo/hyperglycaemic attacks because the client does not understand the significance of the changes and possible side effects.

As a result, I believe clinicians need to accept the role of educator and develop the confidence and skills to advise their clients on all aspects of diabetes, in an attempt to promote good understanding of the disease and reduce unnecessary hospital admissions. Ultimately, the primary areas the clinician needs to assess are the client's understanding of diet, medication (insulin and tablets) and the importance of exercise. However, for some clients an element of social stigma plays a pivotal part in their perception of diabetes.

While I was working as a diabetes educator, clients would make negative comments to me. Some examples of these are:

I don't tell anyone I have diabetes because they treat me as if I have leprosy' (20-year-old student). 'The thing that bugs me most is to have other kids say you have diabetes because you ate too much sugar (14-year-old boy).

I have people tell me I shouldn't have children and risk them getting diabetes (34-year-old mother of two).

Now that I've got this disease, I guess there's nothing much left in life (65 year old man).

Statements like those reflect a level of helplessness and cannot be ignored. Thus, the purpose of education should be to provide a combination of knowledge, skills and heightened self-awareness to help the diabetic understand that diabetes does not limit quality of life.

Society has created fallacies regarding diabetes such as 'You can't eat sugar' or 'If you have more than two injections a day then you must be a bad diabetic'. This stereotyping makes it difficult for the individual, and significant others, to be able to make informed choices and decisions for their care. Here, clinicians need to dispel this misinformation and plan strategies, which include other health workers, to arrest such bias.

Nurse practitioners consist of approximately 65% of the health profession, are available 24 hours a day are familiar with the client's needs, have access to client files, past medical records and pathology results. More importantly, the clinician is in a position to gain the confidence of clients and ultimately develop an affinity with them. So please, clinicians, take on this fundamental role in diabetes education!

Do not believe that it is solely the domain of a diabetes educator: not all hospitals employ diabetes educators and if they do, invariably their hours of work are between 8.00 am and 5.00 pm, Monday to Friday. Furthermore, they are limited in the time they can spend with clients to develop rapport and meet their needs. Additionally, a significant part of the clinician's role is to act as client advocate and educator.

Lupton and Najman (1989) indicate that when patients receive instruction from nurse practitioners, the level of patient compliance improves. Ideally, health care, especially health education, is about empowering people to have control over their illness.

People with diabetes require rigorous and scheduled care, so point out that various aspects of diabetes management makes good sense for all. For example, a diet consisting of complex carbohydrates, breads, vegetables and fresh fruit, moderate amounts of protein with low fat and no added sugar, would be the most ideal diet for society as a whole. Nutritionists have been trying to educate people to pursue such an approach for years. Thus, suggest to the client that this diet is the 'best', particularly in combination with other aspects of diabetes management.

Treat all clients as individuals. Be aware of your own values and beliefs. It is quite possible that your client is of ethnic origin and requires recognition of his/her values and beliefs. Finally, for your client to achieve a level of normalcy, remember that psychological considerations are as important as physiological factors.

Julie Bligh RN DNE BA MDS

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