Are We Teaching the Practice of Nursing or Something Else?
Updated: Apr 30, 2019
I recently read with much interest a paper by Yancey (2019) who discussed concerns related to the emphasis on evidence-based practice (EBP) in nursing. While not opposed to EBP, Yancey was concerned about the use of evidence that does not come from nursing science--research within a nursing theoretical framework. With the current focus in PhD programs away from research that develops and tests nursing theory, the availability of research with a nursing theory basis is declining, and with it the science of nursing. Research framed within another discipline, whether sociology, psychology, physiology, or any other, contributes to that other discipline, not nursing. Yancey asked if we are seeing the demise of nursing and the development of a generic healthcare practice. Good question.
Over the past several years, I noticed this movement away from a nursing theory basis in education. Increasingly, it seemed that nursing program curricula were based on a medical model instead of a nursing model. I feared that we were losing the uniqueness of nursing through curricula that focused more on tasks, medical diagnoses, and medication administration than on nursing practice, what we used to say as dependent (or collaborative) nursing interventions (based on need for a physician's order) vs independent nursing interventions that are based in the practice of nursing. In our many 72-hour sims and even the 12 hour daily sims, students often asked for orders for care that should have been a nursing decision--orders to turn patients, monitor intake and output, teach patients about their health, etc. Students were increasingly believing (or being taught) that all of nursing care is based on direction from a physician, thus invalidating (unknowingly at the prelicensure level) that there is a separate nursing profession with its own body of knowledge.
Further, now that nursing education is firmly ensconced in simulation education using high fidelity human patient simulators, we have this added push to medical-model nursing care. As I have said many times, I believe these experiences are beneficial. But they should not be the primary simulation method used in nursing because they are not based within a nursing model of care. With these short, simulator experiences, we get emphasis on disease process and the medical model of care. Students certainly need training related to how to intervene in crisis situations. But, this type of training can be viewed as task training related primarily to a medical diagnosis, such as pulmonary embolism, stroke, sepsis, etc.
Couple all of this with student clinical experiences which are more and more observational in nature and where there is an increasingly novice nursing workforce with nurses who have been trained in the medical model focus, it seems that this loss of nursing perspective is a never-ending cycle. For some time, I was looking for a better way. Enter our 72-hour, multi-patient integrated simulations.
What tests and develops nurses' ability to intervene is the occurrence of critical events within a typical assignment over time. It is in this type of scenario that nurses need to be thinking about nursing care beyond technical, medication administration focused care. Nurses who care for four or more patients should anticipate patient issues, take action to prevent problems and keep their patients safe, all the while providing this care within a nursing model of care. Having a patient develop a complication within an already busy day and busy assignment builds the critical thinking skills that nurses need. Beyond that, though, is that this is where we can focus on the NURSING care needs of patients. In a continuous experience like this, nursing care becomes paramount, where holistic needs of patients can be identified and met. A short, simulator scenario doesn't allow for this nursing focus. I believe this type of experience that focuses on nursing is what is needed in nursing education. We are designing a simulation curriculum that focuses on nursing; it has a culminating nursing experience in our 72-hour multi-patient integrated simulation that will achieve this goal. We can keep the focus on truly practicing nursing.
Yancey, N.R. (2019). Evidence-based practice in nursing for teaching-learning: But is it really nursing? Nursing Science Quarterly, 32(1) 25-28.