Should Community Nursing Secede from the Other Types of Nursing?

Somedays I feel like community nursing should secede from nursing in acute settings. I understand and value the approaches that are common across nursing contexts but I'm becoming increasingly frustrated that the dominant discourse in nursing is about secondary and tertiary care, about medical based knowledge and interactions and about hospitals. The voice of nurses who work in the community is seldom heard within healthcare organisations. I'm a lecturer at a University and I would love to be able to teach my students from a perspective of person-centred, primary health care influenced, nursing care. I understand that this can occur in acute settings, but too often the messages that students recieve are that the important bits are doing tasks efficiently, having medical knowledge and talking in nurse speak. Lip service is given to ideas like empowerment, but the reality is that the health care system doesn't easily support this and I suspect, that neither do many nurses as it is far quicker to just do things themselves. I would love to teach in a program centred on nursing in the myriad of community contexts to help students understand this context without it being tainted (and undermined) by the narrow vision that nursing only occurs in hospitals. I'm interested in the UK model of community nursing. It does seem quite distinct from acute care nursing. Maybe community nursing should secede.

A research proposal? What is community nursing anyway?

The seed for my research idea is in a desire to articulate the artistry in community nursing. The true work that community nurses do is often unrecognised as it occurs in the spaces between nursing tasks. As a community nurse I used to describe my role as consisting of wound management, palliative care, a little bit of medication management and some post acute, surgical care. After a time I became uncomfortable in describing my role in this way as I felt that most of my energy was being spent in other ways. I was helping people negotiate tricky family circumstances; helping find ways that compression bandaging didn’t interfere with weekly lawn bowls or helping doctors think that they had made decisions about management plans for the clients that I worked with. My role was more about supporting self management, building self efficacy, increasing health literacy and collaborating with patients and the broader health care team.
Related to this was an emerging awareness of what made a good community nurse. As a nurse unit manager in community nursing I recognised that in recruiting new nurses, it was not always the best clinician that made a good community nurse. I saw excellent clinicians from the acute sector find community nursing unbearably stressful and invariably these nurses had short careers in the community and often returned to the acute sector. Some nurses seemed to find the autonomy that went with the role, very stressful and burdensome. I remember one nurse, who put a dressing on in the morning, rang the patient at morning tea to see if it was ok, visited to check again at lunch time and on the way home, visited again the next day (after a sleepless night) to remove the dressing to see if everything was ok. Another nurse may have had the same concerns but would possibly have been more comfortable with a partnership with the patient to monitor the dressing in the short term and confidence to leave the dressing undisturbed for a longer time. The fact that there was no 24hr care, no medical, clinical leader to defer to and that the nurse was required to make clinical decisions on the spot in locations that were physically removed from her colleagues was not an easy thing for her.
I recently had a conversation with colleagues in community nursing regarding a former student, an exceptionally bright and motivated student, who found her community graduate rotation stressful. She expressed feelings of an inability to cope and despite nearing the end of her rotation it was decided that she would move into an acute area.
This has inspired me to conduct research into the preparation of students to work in primary health care settings.

Theory and Practice are not separate

There is much written about the theory – practice gap in nursing (and in other professions – e.g. teaching). In my reading of the issues, writers seem to be coming from an ideological position of either making practice more closely linked with theory or making theory more relevant to practice. People writing about this seem to me to be saying one of two things. Either clinicians need to be more aware of the theoretical underpinnings of practice in order to be more responsive to a changing world or that academics need to acknowledge the real world of practice where the theoretic ideals are almost impossible to implement. These arguments may underpin the expectations placed on new graduates that I’ve discussed here earlier. University tries to prepare students to be able to think critically, use research and solve problems, while health care organisations are interested in skilful practitioners who can function well in busy, changing environments. Theory v. Practice.
I am increasingly of the opinion that the two points of view are not really so different but that there are difficulties in articulating the perspectives. I’ve been reading some work by Gary Rolfe that explores this.
Maybe one of the problems is that the empirical, scientific, testable, theory-type-things that are taught at university are seen to exist in isolation from practice. The same doesn’t seem to be true of practice existing in isolation from theory though. So, we have students learning quite definite theory at university that is sometimes difficult to see in practice. One example off the top of my head is in communication theory, where students are taught to use open ended questions and non-verbal cues to encourage effective communication with clients. In my experience, in practice, this approach sometimes makes it difficult to fill in the admission paper work (for example) as your patients may give very expansive answers to questions, encouraged by your active listening, which has implications for how much time you really have allocated for the task. The approach can also make some people cranky.
This isn’t to say that the theory doesn’t apply to practice though. As I understand it so far, one of the most important things that Rolfe describes is a kind of an extra layer of theory. He suggests that the more formal, empirical, perhaps scientific theories learnt at university inform a suite of personal theories that are interconnected and are able to be drawn on quickly in practice. When combined with Schön’s ideas of artistry in practice – practice that practitioners agree is good practice without necessarily being able to describe it – it makes sense.
So as students collect the formal theory, practice them in authentic situations at university and in clinical practice, they are developing this internal theory. It doesn’t make the formal theory useless or disconnected; it reframes it as a foundation on which good decision making and good practice exist.
I think this reframing of theory into the personal context would be helpful in explaining what students learn and how they are able to apply it in practice. It has implications for the education of students, and the support of new graduates and in how the profession understands itself.

Community nursing wordle

This is a wordle of the raw transcripts of interviews that were conducted for my research on what students learn in a community nursing clinical placement.  We asked students and former students what they did in their placement, what they learned in their placement and what elements of the placement could they see that currently influenced their practice.  This wordle is what they came up with.

The value of artistry

There are different ways of knowing things.  Some are priveleged over others.
I've just been rereading Donald Schön's work on artistry in practice (http://books.google.com.au/books?id=FLJfQgAACAAJ).  He says that artistry is embedded in skilful practice and that people use this artistry to help them act in "situations of uncertainty, uniqueness and conflict."  Sometimes people can't explain why they do the things that they do, but it can be recognised in competence and making good decisions.  Schön says that this presents problems for universities that prepare professionals (like nurses) as the preferred ways of knowing are systematic and scientific.
I'm not sure that this is any longer the case with nursing.  Nursing literature acknowledges different forms of knowledge and acknowledges that for nurses to engage in safe and thorough practice they must draw on multiple perspectives and discourses.  See for example Barbara Carper's work and the many authors who have drawn upon her ideas (http://en.wikipedia.org/wiki/Carper's_fundamental_ways_of_knowing).  Thinking across multiple discourses and drawing on different ways of knowing is alive and well in nursing education.
I think the problem sits more with the health care industry and the community.  I think that Schön's assertion that the scientific knowledge is priveleged over other, important ways of knowing rests more within the expectations of the world outside universities.  I think it arises because nursing is not well understood or articulated.
I have thought this for a while but two things recently came up to reinforce it for me.  Firstly, I had a long conversation with a nurse who's role it was to support newly graduate nurses.  The conversation went along the lines of how he felt gradutes needed to be better prepared for practice.  He believed that graduates needed more scientific, biomedical knowledge regarding the specific clinical area that they will be working in.  This is fair enough I suppose but the problem that I have is that nothing else that the beginning practitioners offered was valued and no other strengths were acknowledged or considered important. Graduates are checked for competence across a range of clinical tasks with a biomedical focus.
When the current graduates were students, they were deemed competent by the university and the Nursing and Midwifery Board of Australia.  I'm not convinced that they have a deficit in biomedical knowledge but that maybe the employers of new nurses have a focus on this one type of knowledge.  I'm not saying that biomedical knowledge is not important, it most certainly is, but that other ways of knowing are important and that new graduates come prepared with a suite of skills that are unrecognised or undervalued.  Further (and a bit of a side note), I believe that students are well prepared to find out what they don't know and that an environment that asks practitioners to be intrinsically accountable for their own knowledge and practice is an environment that fosters excellence in which the former students will thrive - even with regard to biomedical knowledge.
The second thing that I wanted to mention was that I recently posted a response to an article "Overhauling Nurse Education" on Nurse MedPulse (http://www.medscape.com/viewarticle/736236?src=mp&spon=24 - you might need to sign up or log in).  I was a little bit staggered at the number of responses that went along the lines of "there's too much critical thinking being taught we need nurses who are good at finding a vein". 
It seems to me that whether or not universities are able to lead students to artistry in their practice, it is a very narrow band of knowledge that is valued, or even recognised by the world at large.

Authentic workplace in the classroom

I'm about to start work with some colleagues from different discipline areas (teacher education and medicine)on a project that aims to use videoconferencing technology to bring the workplace into the class room.  The idea is that the work setting could be beamed in to a classroom where students get to see and participate in things that they might not get a chance to otherwise.
There are several things about the idea that interest me.

Seeing the hard to get at places
Not every student will get to undertake a clinical placement in every area.  Some clinical areas are quite small and don't have the capacity to look after many students.  The project offers the opportunity for every student to have a little taste of these smaller areas.

Myths and assumptions
My background is community nursing and this is an area that I feel I know well.  Amongst students and out in the world, there are a lot of incorrect assumptions about what nursing is in this setting.  Community nursing is also placed within a health care system that has an emphasis on acute care and hospitals, which I think further exacerbates how little it is understood.  Having students in a classroom, seeing the work as it happens and hearing the nurses talk about what they are doing would be a great way of showing the real work.

Artistry
Exposing the artistry that underlies the work is one of the key things that interests me about the project.  I suppose it is really an extension of dispelling the myths and assumptions that students might hold, but it goes a lot further.  There is an opportunity here to go beyond the surface activities and the tasks of nursing to see and hear about the things that underpin nursing practice.  These are often the things that are not well described and not easy to see.  It's easy to see a nurse do a wound dressing, but, unless you are looking, it is hard to see the nurse building self efficacy at the same time. 

Classroom v Practice learning
The setting itself is interesting and important.  It seems that students sometimes privilege learning in the practice setting over learning at university.  Without question the practical learning is important - but so are the theories and other knowledge that underpins practice.  Bringing the authentic workplace into the classroom has the potential to bring practice and theory together in a way that the students can really see the way that they are interwoven.  One of the keys to this is to have the things that are happening interpreted by someone.  I like the idea of having a tutor with the students who can point out some of the things that are going on.  The clinician would also add to the learning if they could share their thoughts in action or on action

Other things that would be interesting are the students interacting with the clinician and patient, the clinician debriefing after she has provided care, student discussions following care.  For me one of the main things is the opportunities to find ways of describing the nursing work through capturing an episode of care and carefully looking at what has occurred.

Along the way it's going to be interesting exploring the technology, the ethics and the pedagogy of something like this that brings the authentic practice setting, live, into the classroom.