Educating tomorrow's nurses

 How do we educate tomorrow's nurses?

To answer this question, I went back to some of the materials that I studied as a student nurse and in that study one of the first things I learned was that nursing comprised of three important skills that are basic to high quality practice. These are cognitive skills, technical nursing skills and interpersonal skills.

The first in the trio refers to the knowledge and education that a nurse receives and its application in providing comprehensive care to patients. The skills we use in nursing including education such as anatomy and physiology, pharmacology and the art of nursing is derived through education and practice. Our interpersonal skills are derived from psychological and social disciplines - but in the context of nurse and patient, we strive to achieve mutual acceptance and a personal relationship through which we deliver care and support the patient's self determination.

It is important to recognise that nurses increasingly play an important role in taking the history of a patient - the patient's particular narrative. Today we all rely on diagnostic innovations such as X-rays CAT scans, MRIs and endoscopies. To diagnose a patient you no longer have to listen so closely to what the patients says. Today we can examine a diseased organ separately from the patient to whom it belongs. Promoting if we are not careful a disconnection between the person and their body parts.

As we biopsy and investigate and analyse this could represent a shift from the person to the organ, from the reliance on human dialogue to a reliance on what the machine suggests. A shift from the subjective to objective, where the subjective once considered the patients context and ultimately a shift where the sign could become more important to a clinician than the symptom being experienced by the patient.

In a rushed world of hospital clinics, four hour waits, wards and waiting time targets few have the time to listen to their patients anymore and some don't even have the interest. Thanks to medical technology it is the patient's own histories that have receded to be replace by narratives of their body told to us by in animate machines.

From Descartes onwards, the body seems to have become a mechanical object, a system that allocates the body's human characteristics to the heart being a pump and the limbs levers of bones and muscle, its diseases are due to mechanical breakdown. Doctors (perhaps with the exception of GPs and those who have taken on human attributes!) have always been like absent fathers who dart in and examine or treat a patient, but it is nurses who provide the ongoing care.

In this frenetic world of medicine we should no longer be surprised that our patients have decided to turn to integrated care where they experience care that asserts their rights, identity and focuses on treating or alleviating symptoms that affect them. Care that includes and necessitates a knowledge of them and their stories.

Nurses of tomorrow will need to understand the treatments that patients are likely to seek out so that we build up a body of knowledge that is able to feed into our core skill requirements.

In my experience of nursing over some several years I have seen hundreds of patients and many of them have used integrated care alongside care prescribed by medics (such as chemotherapy) - and I have to say they look better for it.

I grew up in a household in which the use of herbal tea to control the symptoms of asthma changed my father's life from being a patient every weekend to being my father at weekends. And personally I and my other siblings stopped panicking as we observed him no longer fighting for his breath on a weekly basis.

Medically, folks, I cannot explain it. I do not know or understand what the brewed teas or any of the other remedies that he took to stop him gasping for breath, but they worked. As anecdotal as this may sound I would have no hesitation in seeking out support for any diagnosis that I receive, for I recognised way back on the haematology ward in 1986 that the survivors were those in control of their self as far as decision making was concerned. Many nurses have long recognised the part that meeting psychological and social needs and not just physical needs have played.

The inherent danger is that our patients fail to tell us of the 'other care' they are receiving because we become judgemental and critical and sometimes by taking a polarised stance we can make it unsafe for them by our attitudes. And for those of you that say it is only the placebo effect - as though it is unreal, immaterial and quite irrelevant an epiphenomenon of real task of scientific medicine:

As member of MREC I have always pondered at how often in trying to promote a new drug for healing stomach ulcers or some other ailment that the drug representative states 'Well in trials 75% of patients given X are healed after taking the drug for 6 weeks and in the other group that were given a placebo only 41% were healed.' And I am thinking wow 41% were healed by taking a lump of sugar - just by the power of their beliefs!

And there are negative to beliefs often the nocebo effect or negative consequences of powerful thought. To many of us, this is manifest by those who believe they will die as a result of a curse. Many of us say this is unreal, but coming from a family with many medics in it, I remember as young girl my brother pointing out to me one such phenomena in an elderly relative who for months convinced everyone she was pregnant. She had yearned for a child for years, she developed many of the physical changes of normal pregnancy including being able to secrete breast milk . My brother told me that Doris had pseudocyesis and I ran to a medical dictionary to look it up. The power of her beliefs or delusion had transformed her body from within. Subsequent medical knowledge has taught me that this is as a result of unusual hormonal changes in the pituitary gland.

So what do our patients want from us in this world of integrated care?

It is no different to what Jeanette Watson described in the late 70s - high quality care, respect and dignity, the right to life, information, the privilege of making decisions and controlling a situation that involves self are important for individual security and sense of worth, freedom of expression privacy, and the presence of family and friends.

These are my insights into what we need to do to educate tomorrow's nurses; they are not new or specific. I draw on the body of knowledge that nurses have always taught and tried to deliver and as integrated care is now more recognised and widely accepted it is my belief that we need to expand our knowledge base to include it, in the same way that we have for years embraced medical advances.

I view integrated care as care for which the scientific knowledge base has yet to catch up and as a nurse I take seriously Jeannette Watson's words, high quality health care includes the 'co-operation in and co-ordination of multidisciplinary care'.