Nurse education - theory and practice

Since Beakie’s post about nurse education seems to have sparked a lively debate, I think I’ll add my own thoughts on this subject.

I’ve just taken up my first staff nurse post, having passed the nursing degree with first class honours. From the tone of some posts on the blogosphere, this must mean that I must therefore consider myself far too posh/clever to give a patient a bath, wipe their bum or make them a cup of tea, the over-educated, sociology-sniffing little ponce that I am.

For the record, I suspect that if somebody said that to my new set of nursing colleagues, they’d be utterly livid and set them straight right away. I do all of those things, and more besides. I don’t think this is because I’m some kind of robo-nurse who has somehow managed to bridge the theory-practice gap where every other nurse has failed. I think it’s because the critics of nurse education are wrong.

To help illustrate why I think this, let’s make a potted summary of some of the criticisms of nurse education that are doing the rounds. Such a summary might look something like this.

Nurse education is far too much theory and far too little practice. Lectures ignore the practical stuff like wound care, bathing, dressing etc. There’s not enough lectures on anatomy, physiology and pharmacology. There’s too much sociology. Newly-qualified nurses just aren’t ready for the role as a result.

I’ll take those five sentences in turn, and craft a response to each of them.

1. Nurse education is far too much theory and far too little practice.
My response: The theory-practice balance is currently about right.

Okay, I can see I’m losing some of you already, so let’s look at some of the numbers. On my nursing degree, we operated on a rotation of 8 weeks in university, 6 weeks out on placement.

Aha, you say, that’s a ratio of 4:3 between university and placement, so there’s a weighting in favour of theory over practice. But…

When we were in university, one day a week was devoted to practical clinical skills workshops. In the first year this concentrated on core skills like manual handling, bathing, nutrition, injection technique, blood pressure monitoring and so on. In the second and third years we moved onto more specifically mental health skills - counselling, cognitive-behaviour therapy, family therapy, motivational interviewing, de-escalating aggression. Add that one day a week into the mix, and the theory:practice ratio approaches closer to 50:50, which is what it should be.

Also add to that the final module of the degree, where instead of 8 weeks in uni and 6 weeks on placement, you do 2 weeks in uni and 12 weeks on a placement in which you take on more and more the roles of a staff nurse, so as to help ease you into thinking and acting like the qualified nurse you soon will be.

2. Lectures ignore the practical stuff like wound care, bathing, dressing etc.
My response: Of course they do. You don’t learn that sort of thing in a lecture theatre. You learn it on a ward.

Personally, I would have thought this point would be slightly obvious. Why would one use a series of lectures to teach someone how to wipe a bum? Perhaps a series of powerpoint slides detailing the theory and concept of bum-wiping, with some discussion of the research base on the optimum angle for the Conti wipe to approach the sacrum?

The reason you don’t have lectures on the practical tasks is because the best place to learn is by having a quick training session in the clinical skills workshop, then hitting the wards and doing it with real live patients. I never had many lectures on wound care, but I did spend six weeks on a district nursing placement in which I learned 56 varieties of wound dressings that I applied to a non-stop procession of different wounds in various stages of healing.

Thinking about it, here’s a short list of things I learned how to do without the assistance of a lecture theatre:

Wound care
Nebulisation
Trachaeostomy care
Blood sugar monitoring
Preparing a patient for ECT
Enemas
PEG feeding

There’s probably a lot more I could add to this list, but you get the point. Learning takes place in many settings. The lecture theatre is just one of them. The most intense, and most effective classroom is the ward itself. If the lectures are theoretical, it’s because that’s what lectures are best used for.

3. There’s not enough lectures on anatomy, physiology and pharmacology.
My response: There’s only a certain amount you need to learn, and you’ll learn more when you hit the ward anyway.

I used to repeat number 3 myself, but looking back I now feel that the demand for more physical science was slightly misplaced. Remember that you’re not a pharmacist or a biochemist. You’re a nurse. Take the administration of antipsychotics as an example. I don’t really need to know the way in which an antipsychotic acts upon the dopamine receptors in the brain. It’s more important that I know what the drug is for, the likely onset of action, the potential side effects, what an oculogyric crisis looks like (and what to do about it) and so on. I learned all these by administering drugs out on the ward and seeing the effects (good and bad) that they had on people.

If any more complicated scientific questions come up, I have colleagues who have studied anatomy, physiology and pharmacology in depth and made it their skill set. They are called doctors and pharmacists. I can ask them for advice. This is called multi-disciplinary teamworking.

It’s also important to remember that again, you pick up a lot of knowledge about these things on the ward rather than in the lecture theatre. I learned about the pancreas when working with diabetics, the brain while in neuropsychiatry, the ageing process in elderly psychiatry. What I was learning was the basic principles and practical applications, but that’s what a nurse needs to know.

3. There’s too much sociology.
My response: What’s wrong with sociology?

Let’s forget the snobbery about “proper” academic subjects. The bottom line is nursing is a people-oriented profession, and sociology is the study of people.

Admittedly there are certain aspects of the social sciences that nursing can do without. I think we can forget about the vast amounts of postmodernist and poststructuralist “cultural and critical theory” guff that emerges from wilfully tortuous French thinkers like Lacan, Derrida and Baudrillard. However, I can only remember one single seminar over the course of my degree where this particular strand was even discussed, and we all came to the conclusion that it was a load of obscurantist bollocks and not useful for nursing.

On the other hand, nurses need to know about the huge effects that social inequality and differences of class, culture, ethnicity, gender and sexuality can have on health outcomes. It’s more important that a nurse know about this than that he/she could demonstrate a complex understanding of the anatomical structure of the kidney.

5. Newly-qualified nurses just aren’t ready for the role
My response: You’ll never be ready. You just have to throw yourself in.

You have three years to try to learn how to be a nurse. You have a far more intensive programme of learning than the average Bachelor of Arse student at Redbrick University, but the job is just too complicated and too demanding for even the best educational programme to prepare a student for.

Whatever you learn at university, the transition from student to nurse will always be a shock. From what Beakie has said about his own experiences back in the 80s, it always was a shock. It probably always will be.

It’s also important to remember that nurse training and education never ends. You stop learning how to be a nurse on the day you retire, not on the day you qualify. Therefore it’s no surprise if today’s newly-qualified nurses don’t feel ready for the task when they first start work. As far as I can gather, they never have.