Response
Debate on articles in Contemporary Nurse
Susan Tregoning
School of Nursing and Midwifery, University of South Australia, SA
PP: 097 - 099
Article Text
My initial response to Sara Henderson's Exemplar Physical assessment skills - use them Vol 4(1) was in sympathy with the student. In this exemplar a clinical educator, found that her nursing student had cared for a patient without diagnosing a deep vein thrombosis or ensuring prompt medical attention. The question begging is, what is learnt in this type of reflective process? Although I do not know all the circumstances of this situation, I would like to tentatively offer some critical questions and thoughts which may turn this exemplar into a more fruitful team situation for both participants.
What is meant by 'technical care'? What sort of technical care was the nurse so preoccupied with? Was it important? What would have happened if she had not been able to monitor this patient and ensure intravenous fluids and medicines were administered correctly? How did the educator make this nursing student feel? This nurse had noted the patient's pain in her leg and the doctor was due any minute. Was it necessary to do a formal assessment when the doctor would repeat it (Homan's test and even gentle palpation are uncomfortable)? These examinations are both done to make a diagnosis but in whose interest is it that the nurse and the doctor make a diagnosis? There is no doubt that a nurse is quite capable of recognising a deep vein thrombosis (especially one that is as classically symptomatic as this) but as the doctor is the one who will prescribe the therapy required, it seems reasonable that she or he takes the responsibility for making the diagnosis. I do believe that nurses should be able to make thorough physical assessments, however, this ability should be used in the patient's best interests, not to impress colleagues. While it was important that heparin therapy was commenced as soon as possible, the heparin would not make a patient any more comfortable. 'Any minute' was probably a reasonable time for the doctor to come. The patient was immobile and I don't imagine the clot growing larger by the minute (if the doctor had been ignoring the nurse's calls, this would be a different matter).
Instead of concentrating on the student's failure, the clinical educator might have considered these ideas: Was the patient still receiving low dose heparin following recent surgery?-as this might have made the student think that a deep vein thrombosis was unlikely. I also presume that the patient was receiving, or at least, was prescribed analgesia for the pain from her recent surgical incision (probably opiates). What else could be done to ease the discomfort in the patient's leg? Was another type of analgesic required? At this stage I think the student may have been, quite reasonably, out of his or her depth. The arrival of the clinical educator should have been timely. She could have helped the student to clarify what was happening, and what was the best course for the student to take to:Ensure the doctor attended and therapy was startedRelieve the patient's discomfort; andEnsure the patient was kept informed. It might have been appropriate for the clinical educator to help with the 'technical' work so that the student had time to think about, and deal with, these problems which she or he may not have encountered before.
At a later stage, the clinical educator could have used the situation to discuss with the nursing student a number of interesting points, regarding this situation.
I may have read this situation incorrectly, however, the point that I wish to make is that this exemplar has effectively shown the clinical educator's acumen and the student's failing. The message is, remember the principals and 'use them'. I would prefer the message to be, remember what you learn in school and use theory with discrimination according to the situation.
Mary FitzGerald RGN DipN(Lond)
CertEd MN Candidate PhD
School of Health
University of New England, Armidale
Rosemary Jones' Soapbox: Nurse or not? Vol 4(1) cries of anger and frustration came through very clearly, and I have much sympathy with her view. Attrition from nursing programs in Australia has been researched and what she is experiencing is not a new phenomenon. Some details from a study in which I was involved, may throw some light on several dimensions Jones refers too.
In the mid 1980s a study (Adams et al 1988) was undertaken to ascertain why students in one of the new NSW Diploma of nursing programs had entered nursing, had withdrawn and what might have prevented their attrition. Over a three year period, 71 of the 88 students who were deemed eligible from the 90 who had withdrawn (out of a student population of 584) responded to a questionnaire. Reasons given why applicants entered the selected tertiary nursing course were: its focus on professional aspects, including items pertaining to professional development; career focus and autonomous practice. A further 49 per cent entered because of the focus on the helping and caring role associated with the nursing profession, while 34 per cent cited job availability as their reason.
As Jones points out, this caring is why we are there, however, it is clearly not the universal motivator for entry. In the current employment climate, job availability is no longer a certain outcome of tertiary study. But for 13 per cent, this course represented the student's last option for tertiary entry, which Jones clearly sees as a problem. Forty one per cent of students who left, intended to do a non-nursing tertiary course and 37 per cent left to find employment-which is consistent with the findings that students (21 per cent) left for financial reasons and would have remained had financial assistance been available. Interestingly, 11 per cent intended to enrol in nursing elsewhere or return to the program they had just left at a later date. A further 21 per cent recognised their personal unsuitability to nursing as the reason for their departure, while 17 per cent stated dissatisfaction with the program as there reason for leaving. Those who recognised their unsuitability after enrolment probably deserved the opportunity to achieve this awareness, although at some expense to the staff and the system, and no doubt themselves. Thirteen per cent stated they left for reasons of personal health-which could offer us another focus of concern, that is, how much was the course contributing to this problem?
Attrition is expensive at both an economic and personal level for all the players, and Jones' experience seems to lie with the first year students. They are certainly the 'least costly' on all fronts, compared with those who scrape through because they perform adequately- although their hearts may lie elsewhere. These types of students often graduate or complete several years of nursing then leave the field. This causes me greater distress than those earlier departees. I do not think, as Jones does, that it is any more risky to expose patients to those who do not wish to be nurses, because this does not actually mean they are either careless or uncaring. Many well-intended students can put patients at risk because of their understandable lack of knowledge. As all other tertiary courses with lower TERs, nursing will have to accept some impact on the student population as a result of preferences and access to preferred courses. To contemplate a return to the old hospital style interview would be a retrograde move. Careful observation, monitoring and counselling as early in the program as possible, would be more productive. It should not be forgotten that in this study (Adams et al 1988) the issue of financial status emerged as the only significant variable in their withdrawal, and this was in the pre HECS days! Inevitably, we will have to live with some level of attrition, despite best efforts to select and support students in the often difficult tertiary environment.
Dianne Pelletier RN BScN DipEd BEdSt MscSoc MC FRCNA
Senior Lecturer, Faculty of Nursing
University of Technology, Sydney
Kennode and Brown in their article Where have all the flowers gone? Nursing's escape from the radical critique Vol 4(1) examine the basic tenets of the radical critique and claim that competing paradigms within nursing have silenced this critique for nursing. They assert that nursing has avoided the attack of the radical critique and failed to develop its own. The radical critique has impacted on nursing through the curriculum revolution, leading to the development of curricula based on a process critical model. Nursing education is seen as a political process which these curricula seek to make explicit. Nurses and midwives educated within this critical framework are encouraged to question the underlying power interests in health care. Other indications that nursing has been touched by the radical critique, can be found in the feminist literature and critiques of caring. Also there is an emerging radical critique within the nursing ethics literature.
Professionalisation
Kermode and Brown critique the professionalisation movement and suggest more may be accomplished through a strategy of professionalisation and demystification. Can nurses claim any occupational territory if this argument is followed to its logical conclusion? A strong professional grouping within nursing might assist in critiquing the power structures directing health care. Instead, New Zealand nursing is divided, with characteristics of oppressed group behaviour, allowing no room for a critique of power relations. The shift of nursing education to the universities is, according to Kermode and Brown, in danger of placing control of nursing in the hands of a powerful elite. Control by a small powerful group of nurses is not new; recall the hierarchical systems that previously existed in our hospitals. With the shift to the universities and the attendant pursuit of higher degree, academic debate and writing has allowed a radical critique to begin.
Empowerment and caring
Kermode and Brown define caring as co-dependency which disempowers clients, implying nurses can choose to be either co-dependent or uncaring. Would clients be satisfied with uncaring nurses? It is doubtful whether nurses today are able to develop co-dependent relationships when client turnover is very rapid. If there is no room in a co-dependent relationship for self-reflection and critique, why would nurses be consumed by guilt about non-caring episodes in their practice? The caring discourse in nursing and the curriculum revolution call for reflective practice through journals and exemplars.
Health promotion
While the problems identified by Kermode and Brown with regard to health promotion are evident in the behaviourist nature of the models used, the value of these models is being questioned within critical curricula.
Holism
Holism is regarded by the authors as a naive attempt by nursing to reject positivist philosophy. It is argued, holism in nursing arose from a radical critique of the dualistic construction of the person which did not fit with the reality of nursing practice. The fact that nurses embraced holism, should be seen as radical and evidence of sophistication. There is a need for the radical critique in nursing to extend from education to practice. It is not, however, completely accurate to claim the radical critique has by-passed nursing altogether. We believe the radical critique begun in academia, will spread to practice through the graduates of critical curricula.
Georgina Casey ROON BSc PGDipSci
Candidate MPhil, Massey University
Department of Nursing and Midwifery
Otago Polytechnic
Anne Coup ROON ADN BA DipGrad
Candidate MPhil, Massey University
Department of Nursing and Midwifery
Otago Polytechnic
References
Adams A, Donoghue J, Duffield C, Pelletier D (1988) An exploratory study-of attrition in a tertiary nursing program. Australian Health Review 1(4):247-255.
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