Learning to be a ward sister

Learning

to be a ward

sister

John Fowler

InitialI), this article argues that although general nurse training usually produces a conrpetent and caring staff nurse, it contains little to develop the variety of skills needed by a ward sister. Genera1 nurse training concentrates on the theoretical and practical concept of’nursing and places little emphasis on the teaching of interpersonal skills, particularly in relation to the management role of the ~zarcl sistc,r. ‘l’he ways in which these interpersonal skills are learnt and can best be taught are briefly discussed. The concept of experiential learning is described and the problems of its application highlighted. The question is then posed, ran expcricntial learning methods be used in a two-dimensional setting, creating the drama within the student’s mind, using only the written word? In an attempt to illustrate this. there is an espcricntial problem-solving ‘game’. The reader is asked to participate in the csercise and judge for him/herself the sort of learning it has fbstered. ‘I Ire d;rys

when

nurse

OI a class

and

spoonfed

their

students

to grasp

of‘ nurses

I0

our

de\ rlop

1orl;l\.,

it.

tilrurr

competence,

The to

we mean5

will

have

foundation seems

learn’

to

them

competence its meaning

how

are

enabling

competence

learn

and

for

to he the (Argvris

! ISfiYi said,

~~II(x~ IS not

I)r

the outcome process

rrcrivc

01‘ training

of training.

practical

or

of people

Muytx

do,

the tml

01‘ t hrer-and-a-bit

registcxrr-d

nurse

co-ordinating \Vithin as \v;ird

dircctirlg

to three

training,

IlIIrscs guitlnllc,r on

)‘rars.

;I stafl’

th(.ir

nurse

training.!

1.c.t .II

110 Ilot.

\.c’ars‘

\vill at times and

tuo

further

durirlg I I hink.

most,

the.

rnalr\

thcoreticxl

mana,grment some

rat her than

How

trxiniy,

A

t)c rc~sponsit~lc the

fi)r

i;t,tlt‘ 1111tlur~, \vith

usually

(‘m

t;,,

I)(. ;Iplx)illtcti

nurse.

sister/charge

Cyr

how

how

we

‘The

much

brhavr

true

test of intelli-

we know

when

we

how do

not

to do,

the ‘li)stering I%rndall

L.iIl~.\ qovrrnitig

of an cnquiring

: 1985)

believes

profrssional

the

education

Obviously ahl\. the cnsurt‘

mind’.

that

THE DUTIES OF A NEWLY APPOINTED WARD SISTER

know

\\ Ililt tr, do.’ ‘I‘he major aims of nurse educal ion rr~ust be thr facilitating of ‘how to learn’ an(l.

phasise actual

1974).

.\h Zlolt INI

towards

tomorrow.

professional to

We are at

professional

‘LVhatever

to

the education If nurses

traching

by

cxl)acily Siphon

what

LVC’(‘an be sure

c~hayed

up in front knowledgr

is all about.

Ix s(‘cIl as having nlt~st gear

stood

factual

arc fast disappearing.

Ia\1 tqinning tr,iininy

tutors

UKCX rm-

meet

patients

this. the nurse

;2nothrr dell

J Fowler SRN RMN DN RNT, Nurse Tutor, Charles Frears School of Nursing, Leicester LE2 1 RJ

thilt

th
area

is

usualI>-

wrll

01‘ responaibilit~.

dt%fincd, is that

and leadership. is ill-prq~ared

and

\,aricd.

I’rol)-

r-tyollsilGlit\ is t(~ rrcri\.cs aclrqu,i tc can’. ‘To prtparrd.

Lhou&

less

of staff c-oht~sior~. tlisc~iplinc~

It is in this arra th,it the nurse to meet th(. rol(~ rtyIlirrcl o!‘

232

NURSE

them.

EDUCATION

The

becomes nurses

effect

of this

evident and

trained

lack

when

patients:

staff’s

TODAY

they

practical

but they do criticise

the sphere

of personal

to be a nurse learning

way

(patients)’ (Tomlinson Figure 1 represents draw

equally

terpersonal equal

of more

on theoretical,

than

learning

the process

of

to clients

practical

in the

areas

relationship

skills, but is able

upon

rarely

in

et al 1984). the ward sister who can

practical

it.

all

skills

three

and in-

and practice interpersonal

of theoretical interpersonal

to combine if

the

schools

emphasis

nurse training.

and

areas

Unfortunately,

put equal

during

the

skills. This ward sister not only has

competence

requires

I

and

situation of nursing

\

SPHERE OF INTERPERSONAL SKILLS Fig 2

The emphasis of RGN training

on these three areas

All too often the theory

are taught

at the expense

skills. This is illustrated

of the

in Figure

addition

to feeling

quately

prepared

that in

also felt inadequately

L.

Gott ing

(1985),

that

reported,

SPHERE OF PRACTICAL SKILLS

‘Learning

of relating

knowledge, draw

SPHERE OF THEORETICAL KNOWLEDGE

theoretical

their ability

It involves

a helpful

learner

criticise or

relationships.

consists

or procedures.

to

rarely skills

knowledge,

facts

of preparation

listening

in her examination

occurs ‘It

during

emerged

SPHERE OF THEORETICAL KNOWLEDGE

of the learn-

introductory that

some

courses,

students,

patients

socio-emotional

interaction

they

were

not

ade-

practical

nursing

skills,

prepared

to respond

needs: they lacked

skills demanded

to the

of a nurse.’

in

SPHERE OF PRACTICAL SKILLS

HOW PERSONAL RELATIONSHIP SKILLS ARE LEARNT Trial and error If some form of behaviour one situation,

or action

works in

we will tend to use it again when

given not only the same situation

but others as

well. Thus we learn by experience.

The problem

is that

although

a particular

success in one situation, ly mean

action

that it will be the best action

in another.

Take

achieves

this does not necessari-

the example

to take

of Sister Jones:

As a student nurse, Nurse Jones worked very hard. She could always be relied upon to

SPHERE OF INTERPERSONAL RELATIONSHIPS Fig 1 Diagram representing a ward sister who can draw equally on theoretical, practical and interpersonal skills

complete the care she was giving to her patients on time. This pleased the ward staff, and as a result she always ended up with good ward reports. Thus Staff Nurse Jones’ behaviour of working extra hard and extra fast when the ‘pressure was on’ was always reinforced as a succesful way to deal with a problem. After registration, Staff Nurse Jones found herself responsible for one or two learners on most

shifts. Being particularly IcJ make sure that all

conscientious, the patients

she wanted she or her

\tudcnts were looking after received the best possiblr tare. ‘1‘0 deal with this problem, she again usrd the behaviour which had been so successful till- her as a student, ie. she worked extra hard and cstra fast. Superficially, this hehaviour a,qain \ccmcd successful: the patients were well cared for, their nursing notes were accurate and informative. ,211 in all. the ward sister was well pleased. ‘I‘his ,lqairr reinforced Nurse Jones’ hehaviour of workinq (‘Ytra hard and extra fast when the pressure ~vas on. However, what had happened was that Staft‘ Nurse .Jones had in fact taken over the ytudcnts’ work. doing a number of tasks herself because it was quicker and she could do it bcttcr. ‘l’h(, old story of the nurse dressing a scmiparalyscd patient bccausc it is quicker.! Alier a fcu years as a ‘successful’ staff nurse, a Gstrr’s post becomes vacant and Nurse Jones is .lppointrd. She still uses the basic principle she icarnr as a student. of working extra hard and extra fast to solve a problem. Unfortunately, this IS not always appropriate for the problems she tac,cs as a sister, and no one has taught her any other, ways of dealing with different problems. Her ward is a busy one; operations most days, ditfrrcnt consultants, dependent patients, students to tx tau,ght. assessed, monitored and so on. She
1(x-n

Jones

the

had

skills

been

never

of

delegation,

student one

\$(’ had great

days or two

rrspect.

If we

most

the

and

should

That

thr

better

i 1985;.

Gott role

of

the

desirable

Often

as students

we model

practising at

have

which which

no

and underto adopt their

when dealing with the situation. ObscBrvation is a useful way of learning

on thr

states,

should

learn

arc

o\.(‘r

taught

traching

‘\\:hilr

it is disturbing

conLrnt

observational

it

skills that

is

from

thcrc~ ih

rithvr

tht,

\~a\.

thtx

ix)ic

rnodrts

or

trarning

its limitations.

On

introduce

ideas

spirit,

new

it merely

iI1

is usc,lilt, t)ul has

its own

it wit1 do

little

to

or fi1stc.r thr, ctu~stioniny

maintains

the stat115 quo.

Experiential learning Experiential

learning

ingly

used

what

exactly

The

Concise

perienlial

does

got

in1 0

to gain

last

live

that

to

be

experiencr

as

e-xperirntial

to

and

and

f’rrrm il. O\cr used

\xrious

in

rs-

nurse

lukor

can

and

opportunity

thoughts

CS-

is purpcJsrfull>

‘I’h(, tirsr

‘rsprrirncr’

rhc

drfincs Irarning

tiduc -

and

rstrnt, a~ a gcnrral cornponcnts icem

a situation

But meanP

rsperirncr,

techniques

lrarning.

of an

or

ax a psychiatric

before

diflierrnt

a person

I have

years

lo a tessrr ‘l‘wo csscntiat

requirrd

Thus

‘knonlrdgr’

tcarning initially

and

1,). stud)‘. situation.

increas-

learning

Dictionar!

\vhen

a

an

rducation.

‘of‘ txpcrience

occurs

placed

becxmx nurse

experiential

Oxford

‘knowledge learning

has in

stratcq

as

experiential a

XII idea

15 nc~t rrall\

are chosen.‘

Thus

tutor.

in a

nurses

tasks

although

observed

relatives

his teacher

sister,

nurses,

present

ation

ourselves

student.

up \vith

in a discussion

ward

that

the

remem-

man\

unwrittt‘n

1)~ rhe

come

than

until

thr

ib ;11\~a) s right

be challenged might

ap-

rarrl)

acccptablc.

or

for whom

is also

craftsman/teacher not

or solution

leadership,

sisters

There

student

encouraged

of us can

ward

ward sister talking to bereaved \1’;1\ which conveyed sympathy stand+, then we too will tend atjproach

that

an)

apprvntic,e

as his tcacttcr

passed.

law

Ah \\ith

the

as proficient

have

periential

bc,r- at least

disadvantages. scheme.

becomes years

to

Observation of an experienced and successful ward sister

oII tht,m.

have

prenticeship

encouraged

trr1sr.

F’rom our

however,

tats,

nurse’ 10 tx.

bt% classitied rc(/uirement

xc04

I\

ib

t tic7-r has

‘rspcrirtient

responses

as

12.ilh

within

that

[Fig. 3 ‘.

same

EXPERIENTIAL TEACHING METHODS inter-

pcxson;tt skills. Indeed, it is thr way children tram tllc Inajority of their social skills. It does,

Interpersonal experirntial

skills traching

arr

partic:ularl~ methods

suilrd Ixxcatlsr.

to as

234

NURSE

EDUCATION

TODAY

AN EXPERIENCE

learner’s

AN EXPERIMENT

action

is given,

be enhanced.) The most common

then

way that

learning

will

this sort of situ-

ation would be set up would be by the use of role play,

role reversal

particularly

general

etc. Yet

nursing

not all nurses,

students,

respond

well to role play. For some, the anxiety by the ‘drama’ any

becomes

learning.

groups,

Other

such

as large

little time, the use of distance

learning

make the practical situations

restraints

implementation

(1981)

identified

a further

arising from the learner’s

Fig 3

as a game

LEARNING

players

Experiential learning

their

which

become

are

of winning

et al (1984)

ial methods examine erated

also encourage

their by

pointed

actions

these

those

and

actions

out, ‘Experient-

the in

involved

to

feelings

gen-

themselves

and

Some

Is it possible periential

devoted

of the, most

personal

skills

leadership.

required

yet essential are

How, for example,

ties of gaining be taught

difficult

discipline

using

and

the principles

in

the

benefits

but

reduces

highlighted?

of

respect

experiment

a scenario

setting.

happen

The

following

this. Judge think

reader

that

will

at the

have skills,

are lacking. 2. Allow

the learner

disagree

periment

with

tions

various

in an attempt

earn respect.

behaviours

to gain

(If appropriate

to exand

discipline feedback

acand

of the

approach other

its

problems is via a

words,

the

and the

the learner’s

mind

earning with

the exercise the

reader’s

periential

is an attempt end

of the some

insight

a

into

gaining

discipline

Even

though

you

has sparked

learning

Do

exercise

namely

the responses mind,

to do

if it is successful.

gained

respect?

the opportunity

the

the experience

‘game’

for yourself

and

and respect

of

In

within

management

in which discipline

of ex-

using only the written word.

you

of a situation

to the

principles

One

aim would be to make

field

the

some

inter-

of experiential

Describe

to the immediate

of their learning

use

two-dimensional

learning? 1. Set up the experience.

more

in a way that maintains

nurse.

could the qualiearning

to

learning

previously to the ward sister/charge

‘The

outside world.’

others.’ Let us return

success:

in the game the more

and the less they reflect upon

the possible applications Tomlinson

problem

seeing the experience

requires

involved

thoughts

object

of role play

difficult.

Elgood EXPERIENTIAL

created

too high and inhibits

I

given,

a questioning would

judge

may

as long

as

spirit in that

ex-

has taken place.

Gaining discipline, earning respect Peter Harris is a staff nurse on a 30 bedded surgical ward. This is his first staffing experience since qualifying six months ago. Peter is not finding the transition from student to staff nurse particularly easy. His main problem is in regard to the learner nurses on the ward. He summed up his feelings one evening when discussing it with his girlfriend. ‘On the shifts when I’m in charge the learners seem to spend more time in the office just chatting. They don’t come back from coffee on time and will often make a cup of tea on the ward, without first asking my permission. Worst of all I don’t think they have much respect for me. I don’t want to seem bossy and start ordering them about but I feel I ought to do something.’

Latrr solving j~tpcr. A B C D E 1

that

evening

Peter

decides

principle of the nursing then sets out to identify

to tackle

process can his problems

the situation help him. regarding

in an objectivr

way.

He \~undcrs

Deciding that it probahly the learners. ‘l’hese arc:

ran.

hr

il the problrm-

takeu

a pencil

and

Lack of respect Not wanting to appear too bossy Extended coffee breaks Extra tea on the ward Unnecessary time spent in the o&e.

Hacrng identified hi.r problems

Peter then plans hi.r action by considerin,g his various alternatiws:

;I I I~~xuc the situation with the ward sister 11, P/CLoneproblem and work specr3cally on it I, Generally_ try _ to be more authoritative (1, home more alooffrom the learners. Il%ic h rw of‘ the choices do you think Peter .should put into action?

Response

I’ctcr fblt that if he were to become aloof from the learners (choice dj then this would take him cvcn tarthcr Irom the sort of professional relationship required. He thought of discussing the situation with the ward sister ,.hoice a; but did not think that his was the ideal solution. Becoming generally mom authoritative (choice c v+ould give Peter no obvious target to work to. He decided on choice ih), to pick one problem. plan his a(.tion and then after applying it to evaluate the effectiveness. L’. Pete1 then has to decide which particular ayrer’ 71’1 th Peter’., choice.

Response Lark of respect (problem A) bchaviours for Peter to work &ice (problem Ej were both c>bjcctive. He choose extended

and on.

problem

to work on. B’hich one !J‘ the problems

not wanting to appear Extra tea on the ward

worthy coffee

u&d

_you thoo.w.i .Xer {J’_you

too bossy (problem

(problem B) were not specific enough U) and unnecessary time spent in the of attention but Peter thought it might prove difficult to set a working breaks (problem C) as the most suitahlr.

3. Met c.ontinues to plan his action. His objective.far this particular htcaks on time. He considers the following courses of action:

problem

is /ha/ the learners r-+,turnJrom t/reir ra/Jbe

:L See the learners as a group t>! &P them individually c Ihw~ hints that_you realise they are taking extra-long coffee breaks, d) Szt them a specific time to be back. 1t’hir.h one of‘ these do-you think would be the best plan to put into artion?

Response Peter felt. and he wanted to be more open in his Dropping hints (course c) was rather underhand, relationships with the learners. To see them, either individually (course bj or as a group (rourse a). was a c1c.p he wanted to keep in reserve. He thus decided to give them a clear and precise hehaviour with which to cc,ntbrm (course d). 1. Pete, implements his plan the next dav. He sends the learners to coflee and .sayr verv clear-(y. 1IIN arc duu back at I(J.I.5.’ They arrive back on the ward at 10.25, IO minutes late. Obviousiv, his int’ttal plan has not achieved the original obiec tivr. On evaluation he considers further- alternatives.. ~1, &ore

ihe learners’ lateness and try course [d) again tomorrom return to the ward L‘) Call them into the office and ask them to explain d) Cdl them into the office, take a stand and tell them (IQ.

t11C’onjiontthem on their

.Srr’ !/:ynu agree u!ith Peter’s resporue.

236

NURSE

EDUCATION

TODAY

Response Ignoring the learners’ lateness (alternative a) would be in a sense to condone it, and this has been his problem in the past. However, the other extreme of confronting them as soon as they returned to the ward (alternative b) was alien to Peter’s nature. He felt this would only cause a confrontation and unnecessary illfeeling. Calling them into the office and telling them off (alternative d) might be a better way of doing it but in Peter’s view would only achieve an outward conformity from the learners. Asking them to explain (alternative c) gave both parties the opportunity for an adult-adult transaction. 5. Peter implements his nem plan minutes. Which one of the following a) b) c) d)

of action. In the off ICP the learners would be Peter’s best response?

trla to laugh it off

and sav it ze1a.s onC11a feua

Feel that you have made your point and let them go Explain to them their responsibilities and ask their opinion Tell them this has been going on for six weeks ‘Tell them that this is not a laughing matter.

Compare your response with Peter’s, Response The learners take a rather typical child-parent transaction response. Telling them that this is not a laughing matter (response d) would be a parental response which would reinforce their child response. Telling them that this has been going on for six weeks (response c) seems to be a threatening action which would easily put them on the defensive. Feeling that you have made your point and letting them go (response a) is really just a ‘cop out’ and will achieve nothing. Explaining their responsibilities and asking their opinion (response b) communicates on an adult-adult level and puts the responsibility for their behaviour back on to them. The learners soon realise that Peter is taking a firm assertive position. They begin to appreciate for themselves that their actions have not been responsible. Within them, their own self-discipline and professional behaviour begins to develop. A situation has been dealt with in a way which allows both parties to grow. A victory has not been won or lost, therefore each other’s feelings have not been damaged. This may not be the way everyone would choose to handle the situation. Each of us has different skills and personalities with which to work. What may be successful for one person and one group may not be for another. The important point about Peter’s approach, however, is the principle behind it, ie. it is systematic [as in the nursing process). If on evaluation the plan of action had not been successful it would be relatively easy to identify the cause and plan a new course of action.

In conclusion Would

this

mind? fostered

an

learner

attitude

actions

Rather

than

of gaining

stimulated him/her

which the

the

the

learner’s

thinking? will

Has

encourage

consequences

student

managing

a

the

earning to

‘As Eve need

Bendall

Association courses

which

Nurse will

problems to them

we have

problems

and

change, the skills

she

to help then,

will

be

her

to

however able

to

of solution.’

the

‘correct’ respect,

learn

similar

(1985) of

bring

to learn solve

of his/her

how

problem

way will to on

a go

the

wards? the

to

References

taught and

how

learn much it

on the ward? being

discipline

help

about

have

it get

to question

everyday

game

game

Would

learn

said

in her

address

Administrators: help

the

student

to ‘We to

Argyris C, Schon D 1974 Theory San Francisco, p 157

in practice.

Jossey-Bass,

Bendall E 1985 N&-sing Mirror 160 (15): 7 Elgood C 1981 Handbook of management games, 2nd edn. Gower, Aldershot, p 5 Gott M 1985 Learning nursing. Rcn, London, pp 11, 14 Holt J 1969 How children fail. Penguin Books, Harmondsworth, p 163 I’omlinson A, Macleod Clark J, Faulkner A 1984 Learning to rrlate. Nursing Times 80 138): 48-51