Soapbox
Your say about nursing issues
Helen Calabretto
School of Nursing, University of South Australia, SA
PP: 089 - 091
Article Text
Changing ritualistic practice
Cost containment and cost effective care, are themes of the 90s in health care delivery. Rather than being viewed negatively, this time can instead be viewed as one of challenge and opportunity to review and evaluate traditional nursing practice. Nurses have to be able to shake off ritualistic practice and reward a 'thinking' rather than 'doing' approach to nursing care delivery. The role of research in clinical nursing practice is vital in achieving this goal and cannot be emphasised enough.
It is disturbing enough to witness the continuation of practices that have been demonstrated by research to have little, if any, therapeutic effect. This should not be seen purely as a nursing responsibility given that, in many cases, the nurse is constrained by the directives of other health care professionals. An example that comes to mind, is the use of iodine-based solutions in the management of wounds. Despite research findings that identify the use of iodine as impeding wound healing, it continues to be used in clinical settings as if 'on sale'. Infection control nurse specialists/consultants battle with this, but have to struggle with changing the attitudes of other health professionals.
There are many areas however, in which ritualistic practices continue that are within the control of clinical nurse practitioners. In-roads have been made, but not necessarily by nurses. The utilisation of linen in health care facilities provides a fitting example. Linen utilisation, as a result of the need to contain costs, has been targeted by managers as an area of inefficiency. The old days of 'changing the top sheet to the bottom and one clean pillow case' have been rationalised for us by managers faced with laundry expenses that contribute to budget blow-outs.
Ritualistic practice translates into cost when nursing staff time is taken into account. It is a sad indictment for nursing that it is the lowest common denominator which is catered for when policy procedure manuals are written as practice directives. Again, a striking example is the use of blanket policies for the attendance of client observations. Routine four hourly body temperature and pulse continue to be done for clients whose condition does not justify the expense of the time and resources used. Rationale used to support such practice, hinges on catering to staff who do not have the education and clinical assessment skills to identify potential problems in clients and to ensure that they are 'properly cared for'.
Time honoured traditions of pressure area care still linger on. The research findings that support frequent repositioning continue to fall on deaf ears as bowls of warm water, soap, washers and towels are brought out to 'do the 2 o'clock backs'! This is often despite the use of devices such as floatation mattresses, lambswool underlays and the like. It would seem in such instances that we continue to value 'doing' rather than 'thinking' with the result that we are working 'harder' rather than 'smarter'.
What can nurses do to turn ritualistic practice around? Certainly, updating knowledge and keeping abreast of research findings is an important first step. Implementing change as a result of such findings represents a greater hurdle. Not only do we have to convince our peers who may be caught on the 'this is how we have always done it' treadmill, but also other allied health care professionals and the public at large. The increasing education levels and autonomy that accompany professional status are slowly but surely impacting on the nurse's ability to defend changes in clinical practice. Research provides the evidence to support the defence.
Forums such as clinical review meetings wherein staff critically evaluate their own clinical practice at a ward level and discuss the appropriateness of current practice can be valuable if approached in a constructive way. Clinical nurse specialists can play a vital role by way of ongoing education to nursing and allied health care professionals so that awareness of clinical issues is raised. Case study reviews that highlight the rationale behind nursing practice may also foster open debate.
At a time when the health care system is being overwhelmed by economic rationalist strategies, nurses need to take control of their domain and critically evaluate clinical practice rituals before other disciplines see fit to do so on their behalf.
Vicki Conyers RN Bed(Nsg) MHealth Admin
Necessary illusions in nursing education
There are many necessary illusions which exist in nursing education today. Such illusions are fostered by the fact that nursing education is in a bad way. But this cannot be admitted to, for surely it will initiate a crisis of confidence within the halls and corridors of learning.
The rapidity of change experienced by nurse education over the last ten years has resulted in a state of flux and lack of direction. Changes include moving from Diploma being the first point of entry into tertiary institutions to Degree being the glittering prize to aspire to. From nurse educators having to possess a Diploma, then a Degree then a Higher Degree and in some instances a Doctorate, the demands increased. Good or even excellent teaching was no longer enough to secure a job or promotion. In keeping with the requirements of university status, the teacher had to develop or possess a research portfolio. The acquisition of research dollars became the focal point of many faculties concerned with the education of nurses so much so that the staff were employed not in response to student needs but in response to institutional needs. The losers in this shift of priorities being pre-registration students.
Institutions, and those who staff such institutions are notorious for looking after their own interests first, and it is no exception with institutions that house departments concerned with nursing education. So we see nurse educators making choices. They have found that self-interested behaviour is rewarded, therefore they spend less time on wards, in clinics, or the community and more time at desks, in meetings, in libraries, or in front of a computer. Gradually they become more and more unskilled, narrow and uncertain. Surrounded by a wall of paper they realise that they have nothing worthy to sell but their words.
For words to generate cash flow they require an audience. As undergraduate student numbers drop in response to market demands, creation of an audience becomes a matter of survival. To facilitate a steady number of eyes and ears, an air of uncertainty must be generated. Albeit that the majority of nurses are highly skilled and competent in the job that they are doing, they must be made to feel inadequate to keep the coffers filled. A false perception is then perpetrated that if a nurse has not got certain paper qualifications then that nurse is somehow or other incomplete, lazy or incapable. The illusion of inadequacy thus festers on highlighting weaknesses and marginalizing strengths in nursing performance.
Complementing the process, a discourse is set up by those who have time to write to journals, and language is used in such a way that reasonable protest against this rise of a paper meritocracy is marginalized and deemed heretical with regards to the progress of nursing. Having captured the moral high ground through language, the process of destabilisation spreads.
Nursing education thus becomes a tool of discontent and emotional trauma. Instead of freeing nurses from ignorance, it locks them into an existence over which they feel that they have very little control. Education, motivated by income generation, thus becomes a fetter, a chain by which the educator and the educated feel bound. The illusion of freedom and power through knowledge acquisition is nevertheless promulgated.
Surely it is time that we asked ourselves if nursing education has become primarily a vehicle whereby the powerful in the nursing hierarchy use nurses as a means to their own ends. By dictating the needs for more qualifications these people accrue more power and status. There becomes a greater need for more Lecturers, Senior Lecturers, Associate Professors, Professors, and Deans. The viability of these people's position, the status that goes with it, and the large salaries that they make, is very reliant on student numbers, particularly postgraduate student numbers.
Today then, it is these potential postgraduates who are being targeted as income. On the international scene, economically poorer countries are being scoured for overseas fee-paying students and many opportunists with market orientated characteristics in nursing education are not slow in helping to perpetuate this form of cultural imperialism. In time, if strategies are successful, a direct transfer of wealth from poorer to richer economies occurs. Of course this is often rationalised and disguised around talk of international cooperation, understanding, and caring; the economic aspect is uncoupled. An illusion of concern for the well-being of the world justifies such incursions, the bottom line is still to be measured in dollars and business sense.
Despite the recognition by some nurses that they are no more than economic units, they still enter into the student role only to meet with bitter disappointment. All too soon, the bright and shiny brochures extolling the virtues of this or that course do not surrender what they have promised in matters of teaching supervision, and support.
Due to the constraints on spending, teaching quickly gives way to do-it-yourself practices cloaked in the language of adult learning principles. In the 'mind market' that nursing education has become, competition for numbers is so fierce that courses are being shortened all over the place in order to attract students. As a consequence, the name of Mickey Mouse is being mentioned so often that one would think Disneyland had relocated to Australian campuses. I believe that it is well past the time of protecting much of the poor teaching that passes itself off as nursing education in Australian universities today. Nurse educators must be made more accountable for the quality of their teaching. Shortsighted decision makers have swung too far in the promotion and employment of individuals with no more than good research portfolios, and have marginalised the importance of good teaching and leadership.
It is now time for nurse educators to be moral agents in matters regarding nursing education and not merely servants of the power of market forces. The silence from academia on the difficulties facing nursing education is deafening. Surely it is time to debate and discuss our problems out in the open, for failure to do so will strengthen the belief that academics care only for themselves and their career aspirations.
Therefore, the illusions of well-being must be tackled in order for us to be truly progressive. More importantly, the demand for nursing education to give up the illusions about its condition should be coupled with a struggle to reject conditions which require illusions.
Archie McKay RN DipAppSci(NEd) BA MScSoc
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