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‘The seeds of time’—or the future of nurse education
NURSE EDUCATION TODAY
'The seeds of time'-or the future of nurse education Caroline Cox Nursing Education Research Unit, Chelsea College, University of London
Text of a paper delivered to the 1982 AIDCN annual conference.
'If you can look into the seeds of time, And say which grain will grow, and which will not, Speak then to me . . .' (Macbeth, I, 3, 58 ff). SO SPOKE BANQUO to the witches in Macbeth. And these words seemed particularly apt when I received the invitation to come to Scotland to share with you my ideas about the future of nurse education. Although I will not dwell on the implication that I am a witch, I will try to meet the challenge of undertaking, as requested, some 'crystal-ball gazing', and try to identify among current trends and developments 'which grain will grow and which will not'. This is indeed a challenge, given the rate of change in the theory and practice of both nursing and education. The challenge is further heightened by the fact that one cannot consider changes in nursing education in isolation: there are many other related variables which need to be taken into account. I can therefore only attempt to offer a very personal account of some of the changes as I see them. And I would like to start first by defining what I mean by education, and then by offering a framework for discussion. Education We know that the roots of our education system can be found in the ancient civilisations of Greece and Rome. I always like the story of Socrates when he described his own attitude to education: referring to his parents' occupations, he pointed out that his father was a sculptor and his mother was a midwife; he then claimed that he thought of education as being more akin to his mother's occupation than his father's. In other words, he did not see it as moulding and shaping other people to his own ideas, but as helping to bring out the potential they had within them. This attitude to the purpose of education as a means of self-realisation has been a significant strand in the history of education in Western societies across the centuries to the present day. However, education also has other well-established and important functions. These include the preservation and transmission of knowledge (the 4
teaching and learning functions); the extension of knowledge (the research function); and the training in the advanced skills needed by society. And professional education has an important and specific remit: the preparation of students for the competent fulfilment of professional responsibilities. Thus, when we discuss changes in nursing education, we can consider the extent to which they promote the functions of education in general and of professional education in particular. Framework for discussion The second aspect of my introduction is the attempt to bring together some of the variables which I suggest we must bear in mind when looking at changes in nursing education. I have put them together in the form of a diagram, to indicate their interrelatedness (Figure 1). I will discuss each of these areas in turn, highlighting some of their implications for nursing education. CHANGING HEALTH NEEDS AND PATTERNS OF HEALTH CARE Clearly, one of the most fundamental factors influencing nursing practice and therefore nursing education will be changes in the patterns of mortality and morbidity. I will only refer to three of the most obvious changes-which are virtually inevitable; I will not waste time discussing them, as they are familiar to us all. Changing demographic structure The well-known phenomenon affecting all industrial societies is the increasing proportion of people who survive to old age. Another feature of modern societies, associated with developments in medical science and in the quality of health care, is the growing number of people who survive various illnesses or accidents which would previously have been fatal, but who are left with a degree of handicap and/or dependency. \Ve can therefore predict that there will be growing numbers of people subject to the frailties of old age and also sizeable numbers of younger people with chronic infirmity of some kind, many of whom will need some form of care. Thus, the quintessential and timeless functions of nursing, so well described by Henderson, are going to be in more rather than less demand.
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The second predictable development is the continuing growth of high technology medicine. This will inevitably make demands of a very different kind on those nurses who work with physicians and surgeons in the care of patients undergoing sophisticated treatment. Thus we have twin developments with very different, almost divergent, demands on nursing. At one end of the continuum, there will be an increasing number of people who need nursing care to help with their activities of daily living, on account of the infirmity of old age or chronic handicap; at the other end of the continuum there will be an- increasing number of patients requiring nursing care associated with high technology treatment. The third area of development should be the growth of preventive health care. The implications for nursing education of these trends in health care are clearly recognised by UKCC Working Group 3 in their Consultation Paper on 'Education and Training': 'Changes in the programme for registration are essential in order that the nurse may be able to promote health in the home, at school, and at work; to prevent illness and also to give supportive nursing care at home as well as in hospitals and other institutions.' I would now like briefly to mention some of these changes as I see them.
IMPLICATIONS OF CHANGING HEALTH NEEDS AND PATTERNS OF HEALTH CARE FOR NURSING EDUCATION In the classroom setting There are two aspects here which I would like to put forward for discussion.
1. Meihods of teaching and learning
Given a continually changing situation it is crucial that we educate our students in ways which enable them to be adaptable. This means that we need to ensure that basic principles are understood and can be applied to changing situations. Therefore, I agree with those who favour a 'problem-solving approach' in nurse education which requires students to think out for themselves the implications of their knowledge and their practice. The same consideration applies to other approaches in education, often seen as part of the same constellation of ideas about learning-such as selfdirected and/or 'discovery' learning. In so far as these promote self-motivation, initiative and better understanding, retention and application of knowledge, well and good. However, in the letter inviting me to speak at this conference, I was asked to consider whether I believe that such approaches could take over to the extent of abolishing traditional teaching methods such as lectures; it was also suggested that I might even consider whether we need to retain the teacher at all. This is compatible with an attitude I have noticed among many educationalists-a very negative attitude towards lectures as a teaching method: at best, they are seen as a necessary evil; at worst, as something obnoxious. In response to these suggestions, I must confess that I am an unashamed 'traditionalist' in that I believe that there will always be a need for considerable amounts of formal and structured teaching and learning in the form of lectures, and for teachers to organise this and other kinds of learning (including 'unstructured'). I base my position on two kinds of argument. First, research such as that by Spencer (1980) or Hopkins and Wright (1978) suggests that while the more able students may thrive 5
NURSE EDUCATION TODAY on self-directed learning, others benefit from more 'formal' lectures, in terms of retention and recall of knowledge. This supports the common-sense view, that students vary a great deal in the ways they respond to different kinds of teaching. Therefore, teaching methods must be versatile, and the pendulum should not swing so far in anyone direction that it might disadvantage some students. It would also be useful if research such as that by Spencer or Hopkins and Wright could be replicated, so that we have more research-based knowledge on which to make decisions about teaching methods in nurse education, to attain the optimum balance between more didactic forms of teaching and other approaches, requiring more active involvement of learners. Thus, I believe that there will always be a case for . the lecture as a teaching method. It is an extremely efficient way of imparting knowledge-and is not necessarily;. as is so often claimed, a merely 'passive' experience for the student. A well-structured lecture which really engages students can be a thoughtprovoking and demanding exercise. I remember to this day some of the lectures I attended as a student nurse a quarter of a century ago. Also, a lecture can be the most time-saving way of introducing students to aspects of vast bodies of knowledge, which would take much longer if they had to rely on their own initiative. Ausubel makes this point in his critique of discovery learning: 'Learning by discovery is, in fact, a repudiation of one of the most significant aspects of culture, namely that the original discoveries of millennia can be transmitted during the course of childhood and youth through the ingenious and marvellously efficient devices of expository teaching and meaningful reception learning, and need not be rediscovered by each new generation.' I would like to make one additional point. Some of the doubts and criticisms of the lecture as a teaching method have arisen from a concern, often valid, about an overdependence on the formal lecture in past decades; another root of disaffection can be found in the shift in educational theory arising from changing ideas about the nature of learning. I suggest that we need to exercise some caution here. Education theories share many characteristics with theories in the other behavioural sciences. These disciplines are new and inevitably generate many ideas and theories which are still to be put to any rigorous tests. I was always struck, when I was studying sociology, how one of the criteria of apparent worth in recommending reading for courses was the recency of publication of a book or articlethe dates of textbooks on reading lists for courses illustrate this. The emphasis was all too often on the 'newest' and 'latest' theory: last year's was likely to be the most acclaimed, except for this year's, which was even better. \\That a contrast to the solid and substantial developments in the natural sciences 6
where there is a commitment to the principle that new ideas and theories should be subjected to rigorous testing before gaining credence and application. I am not suggesting that we should not be receptive to new ideas, practices, and theories. \\That I am suggesting is that we should not accept them too avidly and uncritically. \\Te need to subject old and new ideas and practices to constant scrutiny, so that we can retain what is valuable in the old and foster what is enriching in the new. 2. Interdisciplinary collaboration The second point concerning teaching and learning in the classroom refers to the need for more interdisciplinary collaboration. I have argued elsewhere (Cox 1982) for the advantages of drawing upon the expertise of people with deep knowledge of other disciplines in the development, through research, of a body of nursing knowledge. I think that this is a principle which should also be developed in teaching. \\Te need to contemplate, as Jack Hayward suggested in his lecture to the Royal College of Nursing last year, the transition from generalist teaching in schools of nursing to using more specialist input from lectures· in other disciplines, in both the basic medical sciences and in the behavioural sciences. This could relieve some of the pressures on nurse teachers, who would not have to keep abreast of so many developments across so many subjects. They could then concentrate on their own professional subject, nursing-and also have time to be more involved in clinical areas. However, it might pose challenges which should be anticipated. For example, it would be important to ensure that the lectures from other disciplines really took the trouble to adapt their teaching to the educational needs of student nurses, and nurse educators would have to be prepared to usc their professional judgment to ascertain the value of what was being taught-and their professional authority to require changes where indicated. Too often, nurses have been far too deferential, and accepted unsatisfactory service teaching. Critical assessment is particularly important at the present time when, in many colleges, there are a number of staff hungry for students and eager to move into the fertile terrain of nursing, health visiting, and midwifery. Let us make sure that we select those who are worth having-not just those who are fleeing from other courses which are in danger of closing down. The criterion to be applied is the extent to which the contribution from lecturers in other disciplines helps students to improve the quality of their nursing practice. If it does, good; if not, let us say so, and require some 'behavioural modification' from our colleagues in other disciplines.
Teaching and learning in the clinical setting There are three topics I would like to put forward for consideration here concerning:
NURSE EDUCATION TODAY • preparation of ward sisters for their teaching role; • supervision of learners; • sequence of clinical learning experiences. Preparation of ward sisters A great deal of research has been undertaken into students' experiences in clinical settings. I think particularly of the work by Orton (1981), Ogier (1980), Fretwell (1978), and Lewin and Leach (1982). A common theme is the significance of the ward sister in creating a learning environment for students. In this context, work such as that by Famish is perhaps particularly disturbing. She found that a majority (nearly two-thirds) of ward sisters felt inadequately prepared for their general teaching role when they took up post; they also felt inadequately prepared for the specific task of preparing objectives for their students. This does not necessarily mean that they did not rise to the challenges of teaching and setting objectives. What matters is that many newly appointed ward sisters were put into a responsible position with little or- no preparation for this important part of their role. There are surely clear implications here for post-basic education and for criteria of appointment to senior clinical posts. In view of this, it is reassuring to read the recommendation in the UKCC's Working Party document: 0
'Students should be allocated to specifically designated training areas where all Registered nurses would be required to have undergone some preparation in supervision and -teaching'. 0
This introduces the second point. Supervision of learners The UKCC consultative document also states that:
'The Group is convinced that the art and science of nursing is best learned in the clinical setting, whether it be in the hospital, the health centre or the home ... The Group is certain of the need for students to be, in some measure, involved in the care being provided .. .'. I personally welcome this commitment to the value of apprenticeship learning in nursing. However, given this commitment to an apprenticeship model, we should ensure that learners really do have the opportunity to work with 'master craftsmen' while they are learning how to nurse 'for real'. I suggest that there is a real cause for concern, therefore, in situations where students are left to their own devices without the benefit of supervision. The results of the pilot study of the Nursing Education Research Unit's clinical learning project suggest that students may be left to work alone for a very high proportion of the time, and data from a study currently being undertaken in Ulster also indicate this. The Ulster data arc particularly significant, because they suggest that the practice of students working alone or with other learners is not a result of unavoidable
circumstances, such as staff shortages; it was equally likely to occur during periods when there were a large number of trained staff on duty with plenty of opportunity for some supervision. I believe that the principle of the apprenticeship system, which gives all our learners some experience of responsibility for patient care and for continuity of care, is of immense value. I would deeply regret any developments which deprived them of these opportunities-particularly in the light of some of the developments which have occurred in some other countries which have jettisoned this principle and have lost what I believe are invaluable ingredients of nurse education as a consequence. However, I also believe that we must accept the corollary of the apprenticeship model-that the learner learns by role modelling through working alongside the master craftsman and that service priorities must not destroy educational opportunities. If it is impossible to provide an adequate number of trained staff to teach students by working with them on a ward, then that ward should not be designated as a training ward for students. Without adequate supervision and teaching on the wards, our students are getting short-change in educational terms, and the quality we give to patients may leave much to be desired. Sequence of clinical exp erience A different point which I would like to put forward concerns the sequence of clinical experiences provided for students. Many, if not most, of our students are sent very early in their training to nurse on medical wards which are in effect geriatric wards, and often to wards which are explicitly for geriatric patients. However, I was recently visiting Norway and I was struck by a very different approach in one of their nursing education programmes. There, students' clinical experiences in the early stages of the course were primarily concerned with health care in the community-and with seeing patients in their home and social contexts, and becoming familiar with a wide range of health and welfare services. Thus, students obtained their clinical experience in acute medical and surgical wards and other 'acute' areas such as Intensive Therapy Units and Accident and Emergency Departments. It was not until the third year that they were given responsibility for caring predominantly for the elderly and the dying. Part of the philosophy underlying this approach is that this kind of nursing perhaps requires the greatest maturity, sensitivity, and experience; also, it was said that it represents the 'nursing of the future'. I think the Norwegians have an important point here; I know that a similar policy is adopted in some places in Britain, but it might be beneficial to consider extending it, for at least three reasons:
• It might enhance the quality of care given to elderly patients. • It might help students to have more positive attitudes towards this kind of nursing; too often, when confronted with the care of the elderly too 7
NURSE EDUCATION TODAY early in training, they tend to underestimate the. value of this kind of learning experience, and if sent back to similar wards later, they sometimes feel there is 'nothing more to learn' there. • It is this kind of nursing which, as we have seen, and as the Norwegians are emphasising, represents a significant aspect of the nursing of the future.
PROFESSIONAL RESPONSIBILITY, AUTONOMY, AND ACCOUNTABILITY As already mentioned, one of the criteria of successful professional education is the extent to which it prepa~es students effectively for the fulfilment of professional responsibilities. The other side of this coin is the extent to which students, once trained and qualified, are able to put the knowledge and skills acquired during training into practice. There is thus a need for professional education and practice to satisfy two conditions. There must be both: • an adequate preparation for each level of responsibility; • adequate opportunity to take responsibility for which one is prepared and qualified. Lack of adequate preparation will result in the risk of unsatisfactory role performance with possibly detrimental effects on patient care; lack of preparation or of adequate opportunity to take responsibility will tend to lead to role ambiguity and so to destroy job satisfaction. Adequate preparation Preparation for each level of responsibility clearly involves the development of post-basic education. Here, recent discussion papers contain what I believe are immensely valuable recommendations, and it is very encouraging to find striking parallels between the proposals put forward in the Scottish Working Party's publication Continuing Education for the Nursing Profession in Scotland, the DHSS Report Professional Development in Clinical Nursing-the 1980s, and the Rcn discussion document A Structure for Nursing. Although there are differences between the proposals in these publications, they are all premised on two very important commitments: 1. the commitment to the idea of professional
development as a continuous educational process; 2. an acceptance of the principle of accreditationie a situation wherein the acquisition of certain knowledge/skills/experience enables the practitioner to enhance his/her contribution and either move from one 'level' to another or to qualify for additional reward. This theme also recurs in the UKCC paper: 'Continuing education is a sine qua non of any professional person today. Every opportunity must 8
be offered to all professional nurses for updating of clinical knowledge.'
the
And although these different documents vary in the detail specified, they also all share some fundamental recommendations. I. There should be a compulsory period of consolidation (followed by formal assessment) within a clinical area for newly registered nurses. 2. Systematic arrangements should exist for continuing education and assessment during a nurse's professional career, with the requirement that the nurse must fulfil specified criteria before promotion to a senior post. 3. Some of the criteria should be identified which might serve as a basis for accreditation-such as appropriate clinical experience; training in teaching skills; research; appropriate management training. It is also suggested that this management training should be more specifically geared. to the management responsibilities of the area in which the nurse will be working than many of the management courses currently provided. Also, the explicit training in teaching skills for ward sisters should help them to be better prepared for their teaching role and enable them to provide a better learning environment for students than may now be the case. I believe that these proposals are extremely welcome and worthy of support in both principle and practice. However, they obviously need resources of two kinds: to enable staff to pursue a programme of continuing education; and to provide staff with the necessary salary to enable them to develop their professional careers. Resources for continuing education The importance of backing proposals for continuing education with financial support was clearly recognised in the DHSS paper. There it was recommended:
'that opportunities for continuing education should be available, as of right, as a built-in provision in conditions of service for regular study leave with financial support'; and that 'refresher courses should be a mandatory requirement for all registered nurses (including part-time staff returning to the clinical field after a break)'. These recommendations must be taken seriously if we are to develop as a responsible profession; without them, we are being essentially professionally irresponsible. And as far as funding is concerned, let us take advantage of the precedent set for us by our medical colleagues, with their statutory right to annual paid study leave. Salary implications Although it is not appropriate to discuss in detail salary levels, it is also not appropriate entirely to
NURSE EDUCATION TODAY ignore them. For salary scales matter, not only in terms of the fundamental issue of ensuring an adequate standard of living, but also because they represent symbolically the value which society places upon the contribution of a particular occupational group. They are therefore inevitably and inextricably bound up with long-term issues such as job satisfaction, morale, and retention or loss of staff. These in turn affect the quality of the care given to patients and the quality of the educational experience provided for students. So, without dwelling excessively on this subject, I suggest that we should not let it pass without recognising its fundamental importance and without arguing that in nursing we should, we must, press hard for comparability of salaries with other occupations deemed relevant as a basis for comparison. I suggest 'our swords should not sleep in our hands' until present anomalies have been rectified. While salaries are an important component of job dissatisfaction, they are only one aspect. I now return to another aspect-the opportunity to use one's professional knowledge and the skills in which one has been trained.
Opportunity to use professional skills and knowledge This is an area riddled with anomalies, yet full of tantalising potential. There are many situations where nurses are able to work in ways which enable them to use to the full the skills and knowledge which they had acquired during training. But there are very different situations where staff cannot use to the full their professional judgment in the application of knowledge and skills which they have learnt in training and which have been formally recognised by qualification. A· prime example here lies in midwifery, where data from the research project undertaken in our Unit (Robinson et al 1981) have shown the extent to which many midwives' clinical skills and judgment are being wasted. The most frequently quoted example refers to antenatal examinations of mothers with normal pregnancies: data showed that in nearly 60 per cent of cases in hospital antenatal clinics,· the midwives would undertake procedures such as abdominal examination, which would then be repeated by a member of the medical staff. This is a nonsense. It worries the mother; it insults the midwife, and it wastes medical staffs time which could more profitably be spent on caring for those mothers with pathological conditions who need their specialist obstetric help. The time has come when we have to say, as a profession, that our professional judgment must be recognised and respected. We need to define those areas which are the prerogative of our professional responsibility and to assert our right to professional autonomy within them. Unless we do this, nursing and midwifery's unique contributions to health care will be curtailed and diminished, and staff will suffer job dissatisfaction, possibly culminating in
, withdrawal. It is therefore crucial to foster 'initiatives which give appropriate autonomy and authority to nurses and midwives. Examples include the development of the DHSS experimental scheme of nursing nomes, which is absolutely compatible with the rational use of professional resources: for in them, decisions which are essentially nursing decisions can be made by nurses, and medical colleagues consulted only when deemed necessary by the nurse in charge. Another appropriate development which could be fostered would be the establishment of many more midwives' clinics which mothers could attend instead of having to visit hospitals for antenatal care. These could provide continuity of care, instead of the fragmentation and depersonalisation often associated with visits to big hospitals' antenatal clinics. However, the wheel now comes full circle. The development of professional autonomy is premised on the recognition of a professional qualification. This in turn presumes appropriate educational opportunities at both basic and post-basic levels. And all these assume a body of nursing knowledge which underpins both education and practice. This brings us to the final topic: research. There is no need to labour the case for research here, but the model would be incomplete without mentioning it. Until and unless nursing becomes a genuinely 'researchbased profession' all the developments under discussion will be built on unsure foundations.
.CONCLUSION We" need-we must h,ave-development, change, and adaptability to the new situations which will inevitably confront us. So) do not argue against change; in fact, I am arguing for many changes-some of them radical, some expensive, some controversial. I hope these challenges will not deter us from considering them as goals to be worked towards in the not-too-distant future. To return to Macbeth: these are the seeds or grains which I hope will grow. However, let us not, in our commitment to change, jettison old values and traditions which have stood the test of time. In social affairs, there is always a tendency for the pendulum of change to swing violently. Responses to the problems of one situation can lead to the establishment of new situations with new problems as troublesome as those they replace. We have, therefore, to recognise the inherent challenge of combining change with the preservation of the quintessentially changeless functions of nursing. There are many changes which have occurred in nursing in certain other countries, which I would deeply regret were they to take place here. I would regard them as seeds or grains which I hope will not take root in this country. I will give just three examples. 1. There are certain countries where the nursing profession has lost the freedom to select students for nursing courses. This has sometimes occurred where nursing is entirely college based and is one among 9
NURSE EDUCATION TODAY many options for which students apply. All students are processed through a central clearing scheme with decisions made on the basis of academic attainment. Some are allocated to nursing who have put it as one of their lowest choices-and may thus be very poorly motivated. 2. There are some countries where students' clinical experiences are associated with supernumerary status to such an extent that they have little or no responsibility for patient care and no experience of continuity of care. 3. In other countries virtually all bedside nursing has been relinquished by nurses and delegated to nursing assistants or auxiliaries. \Vhen I think of these developments, I am reminded of one Major Laballiere.. I came across him while I was walking on the hill above Dorking. I saw a tombstone by the path and I stopped to read the inscription carved upon it, which said: 'Here lies the body of Major Laballiere, He believed the world was topsy turvy and asked to be buried upside down so that he would be right way up at the end'. I think that the developments in these countries which I have just described are quite 'topsy turvy', and they are in danger of losing some of the quintessential characteristics of nursing education and practice. However, I think that we, too, have much in our system which is topsy turvy. I have cited some examples, but I also believe that many of the proposals for change which are currently under discussion would go a long way towards righting these situations, and to enable nursing to develop, in
the years ahead, its unique contribution as 'the major caring profession'.
REFERENCES Ausubel D, Novak J, Hanesian H 1978 Education Psychology: A Cognitive View, Holt, Rinehart & Winston. Cox, C 1982 Frontiers of nursing in the twenty-first century: implications for nursing education, International Journal of Nursing Studies, 19, 1, 1-9. DHSS 1982 Professional development in clinical nursing-the 1980s, HMSO. Famish S 1982 Thrown in at the deep end, Nursing Times, 78, 10, 10-16. Fretwell J 1978 Socialisation of nurses: teaching and learning in hospital wards, PhD thesis. Hayward J 1982 Universities and nursing education, Journal of Advanced Nursing, 7, 4, 371-377. Hopkins R, Wright V 1978 The best way to lecture in rheumatology. Nursing Times, 74, 51. Lewin D, Leach J 1982 Factors influencing the quality of wards as learning environments for student nurses, International Journal of Nursing Studies, 19;3, 125-137. Ogier M 1980 The effect of ward sisters' management style upon nurse learners. PhD thesis, University of London. Orton H 1981 Ward learning climate: a study of the role of the ward sister in relation to student nurse learning on the ward. Royal College of Nursing, London. Robinson S, Golden J, Bradley S 1981 A preliminary report on the research project on the role and responsibilities of the midwife: Part I, Midwives Chronicle & Nursing Notes, 94: 1116. Royal College of Nursing 1981 A structure for nursing. Report of the Reo Group on a professional nursing structure for the NHS: A discussion document, Rcn London. Spencer M 1979 Did the student learn? Nursing Times, 75, 1,3537. UK Central Council 1982 Education and training. The development of nurse education. \Vorking Group 3, Consultation Paper 1. Working Party on Continuing Education & Professional Development for Nurses, Midwives & Health Visitors 1981 Continuing education for the nursing profession in Scotland, Edinburgh.
Nursing practice--fantasy or reality? Robert Tiffany Chief Nurse, Royal Marsden Hospital, London and Sutton Text of a paper delivered to the 1982 AlDeN annual conference
IT WOULD, of course, be easy to paint a rosy picture of nursing, highlighting those areas of development that have professional significance, and to ignore those aspects that are firmly rooted in an industrial or, at best, vocational system. However, I was conscious that such an auspicious audience would not like to hear an address concerned more with professional fantasy than fact... Perhaps for too long a period now nursing has been preoccupied with what could be, rather than what is happening around us (Pilkington, 1977). I am also conscious that it might be a dangerous assumption to believe that we all share the same concept of professionalism. 10
Although innumerable books have been written on the subject, I found it exceedingly difficult to establish a common concept or succinct definition of the term profession-any profession-and therefore difficult to decide whether or not nursing could meet the criteria to call itself a profession. I was pleased that I was not alone in this dilemma; Carr-Saunders and Wilson (1964), after a study of various professions, failed to put forward a definition but concluded: 'The term profession ... clearly stands for something. That something is a complex of characteristics'. I propose, therefore, to look at what are the generally accepted characteristics or hallmarks of a
'The seeds of time'-or the future of nurse education Caroline Cox Nursing Education Research Unit, Chelsea College, University of London
Text of a paper delivered to the 1982 AIDCN annual conference.
'If you can look into the seeds of time, And say which grain will grow, and which will not, Speak then to me . . .' (Macbeth, I, 3, 58 ff). SO SPOKE BANQUO to the witches in Macbeth. And these words seemed particularly apt when I received the invitation to come to Scotland to share with you my ideas about the future of nurse education. Although I will not dwell on the implication that I am a witch, I will try to meet the challenge of undertaking, as requested, some 'crystal-ball gazing', and try to identify among current trends and developments 'which grain will grow and which will not'. This is indeed a challenge, given the rate of change in the theory and practice of both nursing and education. The challenge is further heightened by the fact that one cannot consider changes in nursing education in isolation: there are many other related variables which need to be taken into account. I can therefore only attempt to offer a very personal account of some of the changes as I see them. And I would like to start first by defining what I mean by education, and then by offering a framework for discussion. Education We know that the roots of our education system can be found in the ancient civilisations of Greece and Rome. I always like the story of Socrates when he described his own attitude to education: referring to his parents' occupations, he pointed out that his father was a sculptor and his mother was a midwife; he then claimed that he thought of education as being more akin to his mother's occupation than his father's. In other words, he did not see it as moulding and shaping other people to his own ideas, but as helping to bring out the potential they had within them. This attitude to the purpose of education as a means of self-realisation has been a significant strand in the history of education in Western societies across the centuries to the present day. However, education also has other well-established and important functions. These include the preservation and transmission of knowledge (the 4
teaching and learning functions); the extension of knowledge (the research function); and the training in the advanced skills needed by society. And professional education has an important and specific remit: the preparation of students for the competent fulfilment of professional responsibilities. Thus, when we discuss changes in nursing education, we can consider the extent to which they promote the functions of education in general and of professional education in particular. Framework for discussion The second aspect of my introduction is the attempt to bring together some of the variables which I suggest we must bear in mind when looking at changes in nursing education. I have put them together in the form of a diagram, to indicate their interrelatedness (Figure 1). I will discuss each of these areas in turn, highlighting some of their implications for nursing education. CHANGING HEALTH NEEDS AND PATTERNS OF HEALTH CARE Clearly, one of the most fundamental factors influencing nursing practice and therefore nursing education will be changes in the patterns of mortality and morbidity. I will only refer to three of the most obvious changes-which are virtually inevitable; I will not waste time discussing them, as they are familiar to us all. Changing demographic structure The well-known phenomenon affecting all industrial societies is the increasing proportion of people who survive to old age. Another feature of modern societies, associated with developments in medical science and in the quality of health care, is the growing number of people who survive various illnesses or accidents which would previously have been fatal, but who are left with a degree of handicap and/or dependency. \Ve can therefore predict that there will be growing numbers of people subject to the frailties of old age and also sizeable numbers of younger people with chronic infirmity of some kind, many of whom will need some form of care. Thus, the quintessential and timeless functions of nursing, so well described by Henderson, are going to be in more rather than less demand.
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CLlIlICAL EDUCATIONAL MANAGERIAL
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NEED FOR ADAPTIVE PROFESSIONAL PRACTICE AND CAREER PATTERNS
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PROFESSIONAL RESPONSIBILITIES -
SPHERES OF AUTONOMY ACCOUNTABILITY AUTHORITY
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ROLE RELATIONSHIPS ROLE
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DEFINITION AMBIGUITY CONFLICT
JOB SATISFACTION . - - - - - - . . /
~r------_--I_------,~ RECRUITMENT. RETENTION. LOSS OF STAFF
Fig. 1.
The second predictable development is the continuing growth of high technology medicine. This will inevitably make demands of a very different kind on those nurses who work with physicians and surgeons in the care of patients undergoing sophisticated treatment. Thus we have twin developments with very different, almost divergent, demands on nursing. At one end of the continuum, there will be an increasing number of people who need nursing care to help with their activities of daily living, on account of the infirmity of old age or chronic handicap; at the other end of the continuum there will be an- increasing number of patients requiring nursing care associated with high technology treatment. The third area of development should be the growth of preventive health care. The implications for nursing education of these trends in health care are clearly recognised by UKCC Working Group 3 in their Consultation Paper on 'Education and Training': 'Changes in the programme for registration are essential in order that the nurse may be able to promote health in the home, at school, and at work; to prevent illness and also to give supportive nursing care at home as well as in hospitals and other institutions.' I would now like briefly to mention some of these changes as I see them.
IMPLICATIONS OF CHANGING HEALTH NEEDS AND PATTERNS OF HEALTH CARE FOR NURSING EDUCATION In the classroom setting There are two aspects here which I would like to put forward for discussion.
1. Meihods of teaching and learning
Given a continually changing situation it is crucial that we educate our students in ways which enable them to be adaptable. This means that we need to ensure that basic principles are understood and can be applied to changing situations. Therefore, I agree with those who favour a 'problem-solving approach' in nurse education which requires students to think out for themselves the implications of their knowledge and their practice. The same consideration applies to other approaches in education, often seen as part of the same constellation of ideas about learning-such as selfdirected and/or 'discovery' learning. In so far as these promote self-motivation, initiative and better understanding, retention and application of knowledge, well and good. However, in the letter inviting me to speak at this conference, I was asked to consider whether I believe that such approaches could take over to the extent of abolishing traditional teaching methods such as lectures; it was also suggested that I might even consider whether we need to retain the teacher at all. This is compatible with an attitude I have noticed among many educationalists-a very negative attitude towards lectures as a teaching method: at best, they are seen as a necessary evil; at worst, as something obnoxious. In response to these suggestions, I must confess that I am an unashamed 'traditionalist' in that I believe that there will always be a need for considerable amounts of formal and structured teaching and learning in the form of lectures, and for teachers to organise this and other kinds of learning (including 'unstructured'). I base my position on two kinds of argument. First, research such as that by Spencer (1980) or Hopkins and Wright (1978) suggests that while the more able students may thrive 5
NURSE EDUCATION TODAY on self-directed learning, others benefit from more 'formal' lectures, in terms of retention and recall of knowledge. This supports the common-sense view, that students vary a great deal in the ways they respond to different kinds of teaching. Therefore, teaching methods must be versatile, and the pendulum should not swing so far in anyone direction that it might disadvantage some students. It would also be useful if research such as that by Spencer or Hopkins and Wright could be replicated, so that we have more research-based knowledge on which to make decisions about teaching methods in nurse education, to attain the optimum balance between more didactic forms of teaching and other approaches, requiring more active involvement of learners. Thus, I believe that there will always be a case for . the lecture as a teaching method. It is an extremely efficient way of imparting knowledge-and is not necessarily;. as is so often claimed, a merely 'passive' experience for the student. A well-structured lecture which really engages students can be a thoughtprovoking and demanding exercise. I remember to this day some of the lectures I attended as a student nurse a quarter of a century ago. Also, a lecture can be the most time-saving way of introducing students to aspects of vast bodies of knowledge, which would take much longer if they had to rely on their own initiative. Ausubel makes this point in his critique of discovery learning: 'Learning by discovery is, in fact, a repudiation of one of the most significant aspects of culture, namely that the original discoveries of millennia can be transmitted during the course of childhood and youth through the ingenious and marvellously efficient devices of expository teaching and meaningful reception learning, and need not be rediscovered by each new generation.' I would like to make one additional point. Some of the doubts and criticisms of the lecture as a teaching method have arisen from a concern, often valid, about an overdependence on the formal lecture in past decades; another root of disaffection can be found in the shift in educational theory arising from changing ideas about the nature of learning. I suggest that we need to exercise some caution here. Education theories share many characteristics with theories in the other behavioural sciences. These disciplines are new and inevitably generate many ideas and theories which are still to be put to any rigorous tests. I was always struck, when I was studying sociology, how one of the criteria of apparent worth in recommending reading for courses was the recency of publication of a book or articlethe dates of textbooks on reading lists for courses illustrate this. The emphasis was all too often on the 'newest' and 'latest' theory: last year's was likely to be the most acclaimed, except for this year's, which was even better. \\That a contrast to the solid and substantial developments in the natural sciences 6
where there is a commitment to the principle that new ideas and theories should be subjected to rigorous testing before gaining credence and application. I am not suggesting that we should not be receptive to new ideas, practices, and theories. \\That I am suggesting is that we should not accept them too avidly and uncritically. \\Te need to subject old and new ideas and practices to constant scrutiny, so that we can retain what is valuable in the old and foster what is enriching in the new. 2. Interdisciplinary collaboration The second point concerning teaching and learning in the classroom refers to the need for more interdisciplinary collaboration. I have argued elsewhere (Cox 1982) for the advantages of drawing upon the expertise of people with deep knowledge of other disciplines in the development, through research, of a body of nursing knowledge. I think that this is a principle which should also be developed in teaching. \\Te need to contemplate, as Jack Hayward suggested in his lecture to the Royal College of Nursing last year, the transition from generalist teaching in schools of nursing to using more specialist input from lectures· in other disciplines, in both the basic medical sciences and in the behavioural sciences. This could relieve some of the pressures on nurse teachers, who would not have to keep abreast of so many developments across so many subjects. They could then concentrate on their own professional subject, nursing-and also have time to be more involved in clinical areas. However, it might pose challenges which should be anticipated. For example, it would be important to ensure that the lectures from other disciplines really took the trouble to adapt their teaching to the educational needs of student nurses, and nurse educators would have to be prepared to usc their professional judgment to ascertain the value of what was being taught-and their professional authority to require changes where indicated. Too often, nurses have been far too deferential, and accepted unsatisfactory service teaching. Critical assessment is particularly important at the present time when, in many colleges, there are a number of staff hungry for students and eager to move into the fertile terrain of nursing, health visiting, and midwifery. Let us make sure that we select those who are worth having-not just those who are fleeing from other courses which are in danger of closing down. The criterion to be applied is the extent to which the contribution from lecturers in other disciplines helps students to improve the quality of their nursing practice. If it does, good; if not, let us say so, and require some 'behavioural modification' from our colleagues in other disciplines.
Teaching and learning in the clinical setting There are three topics I would like to put forward for consideration here concerning:
NURSE EDUCATION TODAY • preparation of ward sisters for their teaching role; • supervision of learners; • sequence of clinical learning experiences. Preparation of ward sisters A great deal of research has been undertaken into students' experiences in clinical settings. I think particularly of the work by Orton (1981), Ogier (1980), Fretwell (1978), and Lewin and Leach (1982). A common theme is the significance of the ward sister in creating a learning environment for students. In this context, work such as that by Famish is perhaps particularly disturbing. She found that a majority (nearly two-thirds) of ward sisters felt inadequately prepared for their general teaching role when they took up post; they also felt inadequately prepared for the specific task of preparing objectives for their students. This does not necessarily mean that they did not rise to the challenges of teaching and setting objectives. What matters is that many newly appointed ward sisters were put into a responsible position with little or- no preparation for this important part of their role. There are surely clear implications here for post-basic education and for criteria of appointment to senior clinical posts. In view of this, it is reassuring to read the recommendation in the UKCC's Working Party document: 0
'Students should be allocated to specifically designated training areas where all Registered nurses would be required to have undergone some preparation in supervision and -teaching'. 0
This introduces the second point. Supervision of learners The UKCC consultative document also states that:
'The Group is convinced that the art and science of nursing is best learned in the clinical setting, whether it be in the hospital, the health centre or the home ... The Group is certain of the need for students to be, in some measure, involved in the care being provided .. .'. I personally welcome this commitment to the value of apprenticeship learning in nursing. However, given this commitment to an apprenticeship model, we should ensure that learners really do have the opportunity to work with 'master craftsmen' while they are learning how to nurse 'for real'. I suggest that there is a real cause for concern, therefore, in situations where students are left to their own devices without the benefit of supervision. The results of the pilot study of the Nursing Education Research Unit's clinical learning project suggest that students may be left to work alone for a very high proportion of the time, and data from a study currently being undertaken in Ulster also indicate this. The Ulster data arc particularly significant, because they suggest that the practice of students working alone or with other learners is not a result of unavoidable
circumstances, such as staff shortages; it was equally likely to occur during periods when there were a large number of trained staff on duty with plenty of opportunity for some supervision. I believe that the principle of the apprenticeship system, which gives all our learners some experience of responsibility for patient care and for continuity of care, is of immense value. I would deeply regret any developments which deprived them of these opportunities-particularly in the light of some of the developments which have occurred in some other countries which have jettisoned this principle and have lost what I believe are invaluable ingredients of nurse education as a consequence. However, I also believe that we must accept the corollary of the apprenticeship model-that the learner learns by role modelling through working alongside the master craftsman and that service priorities must not destroy educational opportunities. If it is impossible to provide an adequate number of trained staff to teach students by working with them on a ward, then that ward should not be designated as a training ward for students. Without adequate supervision and teaching on the wards, our students are getting short-change in educational terms, and the quality we give to patients may leave much to be desired. Sequence of clinical exp erience A different point which I would like to put forward concerns the sequence of clinical experiences provided for students. Many, if not most, of our students are sent very early in their training to nurse on medical wards which are in effect geriatric wards, and often to wards which are explicitly for geriatric patients. However, I was recently visiting Norway and I was struck by a very different approach in one of their nursing education programmes. There, students' clinical experiences in the early stages of the course were primarily concerned with health care in the community-and with seeing patients in their home and social contexts, and becoming familiar with a wide range of health and welfare services. Thus, students obtained their clinical experience in acute medical and surgical wards and other 'acute' areas such as Intensive Therapy Units and Accident and Emergency Departments. It was not until the third year that they were given responsibility for caring predominantly for the elderly and the dying. Part of the philosophy underlying this approach is that this kind of nursing perhaps requires the greatest maturity, sensitivity, and experience; also, it was said that it represents the 'nursing of the future'. I think the Norwegians have an important point here; I know that a similar policy is adopted in some places in Britain, but it might be beneficial to consider extending it, for at least three reasons:
• It might enhance the quality of care given to elderly patients. • It might help students to have more positive attitudes towards this kind of nursing; too often, when confronted with the care of the elderly too 7
NURSE EDUCATION TODAY early in training, they tend to underestimate the. value of this kind of learning experience, and if sent back to similar wards later, they sometimes feel there is 'nothing more to learn' there. • It is this kind of nursing which, as we have seen, and as the Norwegians are emphasising, represents a significant aspect of the nursing of the future.
PROFESSIONAL RESPONSIBILITY, AUTONOMY, AND ACCOUNTABILITY As already mentioned, one of the criteria of successful professional education is the extent to which it prepa~es students effectively for the fulfilment of professional responsibilities. The other side of this coin is the extent to which students, once trained and qualified, are able to put the knowledge and skills acquired during training into practice. There is thus a need for professional education and practice to satisfy two conditions. There must be both: • an adequate preparation for each level of responsibility; • adequate opportunity to take responsibility for which one is prepared and qualified. Lack of adequate preparation will result in the risk of unsatisfactory role performance with possibly detrimental effects on patient care; lack of preparation or of adequate opportunity to take responsibility will tend to lead to role ambiguity and so to destroy job satisfaction. Adequate preparation Preparation for each level of responsibility clearly involves the development of post-basic education. Here, recent discussion papers contain what I believe are immensely valuable recommendations, and it is very encouraging to find striking parallels between the proposals put forward in the Scottish Working Party's publication Continuing Education for the Nursing Profession in Scotland, the DHSS Report Professional Development in Clinical Nursing-the 1980s, and the Rcn discussion document A Structure for Nursing. Although there are differences between the proposals in these publications, they are all premised on two very important commitments: 1. the commitment to the idea of professional
development as a continuous educational process; 2. an acceptance of the principle of accreditationie a situation wherein the acquisition of certain knowledge/skills/experience enables the practitioner to enhance his/her contribution and either move from one 'level' to another or to qualify for additional reward. This theme also recurs in the UKCC paper: 'Continuing education is a sine qua non of any professional person today. Every opportunity must 8
be offered to all professional nurses for updating of clinical knowledge.'
the
And although these different documents vary in the detail specified, they also all share some fundamental recommendations. I. There should be a compulsory period of consolidation (followed by formal assessment) within a clinical area for newly registered nurses. 2. Systematic arrangements should exist for continuing education and assessment during a nurse's professional career, with the requirement that the nurse must fulfil specified criteria before promotion to a senior post. 3. Some of the criteria should be identified which might serve as a basis for accreditation-such as appropriate clinical experience; training in teaching skills; research; appropriate management training. It is also suggested that this management training should be more specifically geared. to the management responsibilities of the area in which the nurse will be working than many of the management courses currently provided. Also, the explicit training in teaching skills for ward sisters should help them to be better prepared for their teaching role and enable them to provide a better learning environment for students than may now be the case. I believe that these proposals are extremely welcome and worthy of support in both principle and practice. However, they obviously need resources of two kinds: to enable staff to pursue a programme of continuing education; and to provide staff with the necessary salary to enable them to develop their professional careers. Resources for continuing education The importance of backing proposals for continuing education with financial support was clearly recognised in the DHSS paper. There it was recommended:
'that opportunities for continuing education should be available, as of right, as a built-in provision in conditions of service for regular study leave with financial support'; and that 'refresher courses should be a mandatory requirement for all registered nurses (including part-time staff returning to the clinical field after a break)'. These recommendations must be taken seriously if we are to develop as a responsible profession; without them, we are being essentially professionally irresponsible. And as far as funding is concerned, let us take advantage of the precedent set for us by our medical colleagues, with their statutory right to annual paid study leave. Salary implications Although it is not appropriate to discuss in detail salary levels, it is also not appropriate entirely to
NURSE EDUCATION TODAY ignore them. For salary scales matter, not only in terms of the fundamental issue of ensuring an adequate standard of living, but also because they represent symbolically the value which society places upon the contribution of a particular occupational group. They are therefore inevitably and inextricably bound up with long-term issues such as job satisfaction, morale, and retention or loss of staff. These in turn affect the quality of the care given to patients and the quality of the educational experience provided for students. So, without dwelling excessively on this subject, I suggest that we should not let it pass without recognising its fundamental importance and without arguing that in nursing we should, we must, press hard for comparability of salaries with other occupations deemed relevant as a basis for comparison. I suggest 'our swords should not sleep in our hands' until present anomalies have been rectified. While salaries are an important component of job dissatisfaction, they are only one aspect. I now return to another aspect-the opportunity to use one's professional knowledge and the skills in which one has been trained.
Opportunity to use professional skills and knowledge This is an area riddled with anomalies, yet full of tantalising potential. There are many situations where nurses are able to work in ways which enable them to use to the full the skills and knowledge which they had acquired during training. But there are very different situations where staff cannot use to the full their professional judgment in the application of knowledge and skills which they have learnt in training and which have been formally recognised by qualification. A· prime example here lies in midwifery, where data from the research project undertaken in our Unit (Robinson et al 1981) have shown the extent to which many midwives' clinical skills and judgment are being wasted. The most frequently quoted example refers to antenatal examinations of mothers with normal pregnancies: data showed that in nearly 60 per cent of cases in hospital antenatal clinics,· the midwives would undertake procedures such as abdominal examination, which would then be repeated by a member of the medical staff. This is a nonsense. It worries the mother; it insults the midwife, and it wastes medical staffs time which could more profitably be spent on caring for those mothers with pathological conditions who need their specialist obstetric help. The time has come when we have to say, as a profession, that our professional judgment must be recognised and respected. We need to define those areas which are the prerogative of our professional responsibility and to assert our right to professional autonomy within them. Unless we do this, nursing and midwifery's unique contributions to health care will be curtailed and diminished, and staff will suffer job dissatisfaction, possibly culminating in
, withdrawal. It is therefore crucial to foster 'initiatives which give appropriate autonomy and authority to nurses and midwives. Examples include the development of the DHSS experimental scheme of nursing nomes, which is absolutely compatible with the rational use of professional resources: for in them, decisions which are essentially nursing decisions can be made by nurses, and medical colleagues consulted only when deemed necessary by the nurse in charge. Another appropriate development which could be fostered would be the establishment of many more midwives' clinics which mothers could attend instead of having to visit hospitals for antenatal care. These could provide continuity of care, instead of the fragmentation and depersonalisation often associated with visits to big hospitals' antenatal clinics. However, the wheel now comes full circle. The development of professional autonomy is premised on the recognition of a professional qualification. This in turn presumes appropriate educational opportunities at both basic and post-basic levels. And all these assume a body of nursing knowledge which underpins both education and practice. This brings us to the final topic: research. There is no need to labour the case for research here, but the model would be incomplete without mentioning it. Until and unless nursing becomes a genuinely 'researchbased profession' all the developments under discussion will be built on unsure foundations.
.CONCLUSION We" need-we must h,ave-development, change, and adaptability to the new situations which will inevitably confront us. So) do not argue against change; in fact, I am arguing for many changes-some of them radical, some expensive, some controversial. I hope these challenges will not deter us from considering them as goals to be worked towards in the not-too-distant future. To return to Macbeth: these are the seeds or grains which I hope will grow. However, let us not, in our commitment to change, jettison old values and traditions which have stood the test of time. In social affairs, there is always a tendency for the pendulum of change to swing violently. Responses to the problems of one situation can lead to the establishment of new situations with new problems as troublesome as those they replace. We have, therefore, to recognise the inherent challenge of combining change with the preservation of the quintessentially changeless functions of nursing. There are many changes which have occurred in nursing in certain other countries, which I would deeply regret were they to take place here. I would regard them as seeds or grains which I hope will not take root in this country. I will give just three examples. 1. There are certain countries where the nursing profession has lost the freedom to select students for nursing courses. This has sometimes occurred where nursing is entirely college based and is one among 9
NURSE EDUCATION TODAY many options for which students apply. All students are processed through a central clearing scheme with decisions made on the basis of academic attainment. Some are allocated to nursing who have put it as one of their lowest choices-and may thus be very poorly motivated. 2. There are some countries where students' clinical experiences are associated with supernumerary status to such an extent that they have little or no responsibility for patient care and no experience of continuity of care. 3. In other countries virtually all bedside nursing has been relinquished by nurses and delegated to nursing assistants or auxiliaries. \Vhen I think of these developments, I am reminded of one Major Laballiere.. I came across him while I was walking on the hill above Dorking. I saw a tombstone by the path and I stopped to read the inscription carved upon it, which said: 'Here lies the body of Major Laballiere, He believed the world was topsy turvy and asked to be buried upside down so that he would be right way up at the end'. I think that the developments in these countries which I have just described are quite 'topsy turvy', and they are in danger of losing some of the quintessential characteristics of nursing education and practice. However, I think that we, too, have much in our system which is topsy turvy. I have cited some examples, but I also believe that many of the proposals for change which are currently under discussion would go a long way towards righting these situations, and to enable nursing to develop, in
the years ahead, its unique contribution as 'the major caring profession'.
REFERENCES Ausubel D, Novak J, Hanesian H 1978 Education Psychology: A Cognitive View, Holt, Rinehart & Winston. Cox, C 1982 Frontiers of nursing in the twenty-first century: implications for nursing education, International Journal of Nursing Studies, 19, 1, 1-9. DHSS 1982 Professional development in clinical nursing-the 1980s, HMSO. Famish S 1982 Thrown in at the deep end, Nursing Times, 78, 10, 10-16. Fretwell J 1978 Socialisation of nurses: teaching and learning in hospital wards, PhD thesis. Hayward J 1982 Universities and nursing education, Journal of Advanced Nursing, 7, 4, 371-377. Hopkins R, Wright V 1978 The best way to lecture in rheumatology. Nursing Times, 74, 51. Lewin D, Leach J 1982 Factors influencing the quality of wards as learning environments for student nurses, International Journal of Nursing Studies, 19;3, 125-137. Ogier M 1980 The effect of ward sisters' management style upon nurse learners. PhD thesis, University of London. Orton H 1981 Ward learning climate: a study of the role of the ward sister in relation to student nurse learning on the ward. Royal College of Nursing, London. Robinson S, Golden J, Bradley S 1981 A preliminary report on the research project on the role and responsibilities of the midwife: Part I, Midwives Chronicle & Nursing Notes, 94: 1116. Royal College of Nursing 1981 A structure for nursing. Report of the Reo Group on a professional nursing structure for the NHS: A discussion document, Rcn London. Spencer M 1979 Did the student learn? Nursing Times, 75, 1,3537. UK Central Council 1982 Education and training. The development of nurse education. \Vorking Group 3, Consultation Paper 1. Working Party on Continuing Education & Professional Development for Nurses, Midwives & Health Visitors 1981 Continuing education for the nursing profession in Scotland, Edinburgh.
Nursing practice--fantasy or reality? Robert Tiffany Chief Nurse, Royal Marsden Hospital, London and Sutton Text of a paper delivered to the 1982 AlDeN annual conference
IT WOULD, of course, be easy to paint a rosy picture of nursing, highlighting those areas of development that have professional significance, and to ignore those aspects that are firmly rooted in an industrial or, at best, vocational system. However, I was conscious that such an auspicious audience would not like to hear an address concerned more with professional fantasy than fact... Perhaps for too long a period now nursing has been preoccupied with what could be, rather than what is happening around us (Pilkington, 1977). I am also conscious that it might be a dangerous assumption to believe that we all share the same concept of professionalism. 10
Although innumerable books have been written on the subject, I found it exceedingly difficult to establish a common concept or succinct definition of the term profession-any profession-and therefore difficult to decide whether or not nursing could meet the criteria to call itself a profession. I was pleased that I was not alone in this dilemma; Carr-Saunders and Wilson (1964), after a study of various professions, failed to put forward a definition but concluded: 'The term profession ... clearly stands for something. That something is a complex of characteristics'. I propose, therefore, to look at what are the generally accepted characteristics or hallmarks of a