Whatever Happened to the Art of Nursing?
By Molly Carlile AM, 2013
Having been a nurse for longer than I care to disclose, I feel responsible for raising contentious issues with some level of impunity. I’ve always had views about nursing that are not necessarily popular, but need to be aired in order for us to think critically about what we do and how we do it. I’ve always been very aware that I bring a different and often controversial perspective to issues of contemporary nursing. I’m not an academic or researcher. I’m no longer a practicing clinician, however I’ve always thought that being a nurse is a bit like being a catholic…………..it’s a lifetime identifier, even if you don’t practice as you once did.
The time is ripe for us to explore some of the creative elements of nursing that I see as essential to us being truly able to care for each individual patient. The elements of nursing that enable us to be artists as well as health professionals. The elements I believe we have lost or discarded in our headlong rush to have our practice validated by other healthcare disciplines.
Nursing is a science, there’s no disputing that and our rich heritage of nursing research that began with Florence Nightingale insisting that hand washing influenced cross infection rates has contributed to the vast evidence base we now depend on to define our practice, but Florence Nightingale also said “… nursing is the finest of Fine Arts”.
Contemporary nursing research has guided not only general nursing education and practice, but the evolution of specialties as varied as paediatrics and continence management, infection control and palliative care. This growing specialisation within the profession has led to distinct research pathways that mirror specialist clinical practice.
In my field of endeavour palliative care, nursing research has evolved from a predominantly oral, anecdotal tradition to a robust, complex repository of proven nursing interventions for care of the terminally ill. Research and quality have become embedded in our day to day work and that’s a good thing, BUT does dependence on evidence based practice stifle our willingness to find singular, creative solutions to individual problems? Do standardised practice pathways inhibit our ability to provide individualised, holistic care?
J.M Barrie’s character Peter Pan said, “To die will be an awfully big adventure”.
I looked after my first dying patient when I was 19 years old. She was a 34 year old woman with liver cancer. She was the colour of an ‘Oompa Loompa’, in constant pain, was pruritic, agitated and confused. This didn’t look like a bloody adventure to me!
I felt like I had nothing to offer her. I made sure she was clean and dry, her mouth moist and lips smothered in Vaseline (best practice at the time). I attended her pressure care vigilantly and made sure her hair was combed and her pillows fluffed…………….but I couldn’t actually DO anything……I couldn’t “fix it”………….I had no magic wand. And yet…………when I came on duty, she was always pleased to see me. During her periods of lucidity, I sat by her bed and listened to her talk about her childhood and her fears for her own children. “Will they remember me when I’m gone?” she asked me one day.
How could I answer that? There was no answer. She looked at me expectantly, her sclera as yellow as her skin, waiting.
“How would you like them to remember you?” I asked finally, not knowing what else to say…………..and that was the beginning. When she died ten days later, that lady had recorded two full cassette tapes of thoughts, feelings, aspirations, hopes and dreams. A legacy for her children. Something for them to hold on to. To listen to in the future when they felt the intensity of her absence. Something that would always enable them to connect with their Mum. A small piece of her.
Biographical recording is now commonplace, but back then my colleagues questioned why I was encouraging this lady to make these recordings. “You’re just making her upset” they said “making her obsess about what she’s going to miss out on”……………….but she was already thinking about all of this. She was already feeling sad and frustrated and “ripped off”. Creating these tapes enabled her to take back some small piece of control over her life. It allowed her to feel like her final days were valuable. She was still able to do something useful instead of just lying in bed waiting to die. Is this art?
Finding a consensus view of what it is that constitutes art is a research endeavour in its own right and has consumed the careers of great thinkers from the beginning of time. Without getting into the whole maelstrom of ideas about how art is defined, an age old argument among theorists, philosophers, fine artists, crafts people and critics I’m going to avoid the esteemed views of Aristotle, Goethe, Tolstoy, Collingwood, Kant and Bell. 20th Century thinkers influenced by German Philosopher, Martin Heidegger have interpreted art as “the means by which a community develops for itself a medium for self- expression and interpretation”.
Dictionary.com defines art as “the quality, production, expression, or realm, according to aesthetic principles, of what is beautiful, appealing, or of more than ordinary significance”.
The Oxford dictionary says that art is “form and content”
For our purposes, I’m going to use the Encyclopædia Britannica version that defines art as “the use of skill and imagination in the creation of aesthetic objects, environments, or experiences that can be shared with others”.
English poet, critic and essayist, Sir Herbert Read in his book, The Meaning of Art, published first in 1930 said, “I believe that art is so much more significant than either economics or philosophy. It is the direct measure of man’s spiritual vision.” He went on to emphasise that the function of art was to enrich our lives by affording insights, values and emotional understanding, thereby deriving meaning. (from The Meaning of Art, 1968).
In his 2009 paper, Arts and Self, Psychoanalyst, George Hagman suggests that “Artistic creativity is a manner of thinking, of feeling, of being within a medium and symbolic language of forms”
So how can we relate this to nursing?
Again when we consider what “nursing” means we all have a different philosophy of nursing that contains multiple, common elements but will differ in terms of our individual interpretations of those elements. The International Council of Nurses definition, the one commonly utilised by Australian professional and peak bodies states,
“Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management and education are also key nursing roles.”
For me, there are five essential elements to nursing.
To nourish, to nurture, to care, to empower, to ‘hold”
The nourishing, nurturing and caring components are those with which we most readily identify. They are the “core business” of nursing and always have been.
We could be tempted to think that “empowerment” as a core nursing function is a relatively new concept. And yet Australian nurses during wartime provide the perfect example of how empowerment was the difference between death and survival for many wounded soldiers and prisoners of war. Nurses like Sr Vivan Bullwinkel during the Second World War who, badly wounded herself, nursed an English soldier for weeks on a deserted beach, scrounging food from unwilling locals, dressing his wounds with coconut fibres and ensuring his comfort with makeshift pillows, constructed from lifejackets that had washed up on the shore. Without Vivian’s constant gentle encouragement, support and care, the soldier may well have died on that beach and yet he was able to walk for several hours through difficult terrain, leaning on her for support, because of Vivian’s ability to not only empower him, but to convince him that surrender was their only option for survival.
The act of returning control to the patient for their own health and wellbeing provides us with challenges because it means that instead of us directing nursing interventions we are required to enter into partnerships with our patients. In contemporary nursing, patients are the central members of the healthcare team and this requires us to ensure we not only inform them about their care, but actively involve them in decision making and care planning. Our role in empowerment requires us to assist patients to regain their function and independence, and if this isn’t possible, to help them find a sense of accomplishment in returning to being as well as they can, within the constraints of their illness or disability. This can’t happen if we don’t know who our patient is, what matters to them, what their fears are, what their strengths are and where their priorities lie. We have to start by asking one simple question, “Who is this person?” each time we enter a patient’s room.
Our ability to empower people is dependant on us knowing “who” they are in the first place.
The “Who is this person?” question is a simple one. It doesn’t require a formal process. It doesn’t require a machine, and it doesn’t require a computer program or a double blind randomised control trial. But it does require willingness and persistence on our part. It requires spending time with a patient, not necessarily additional time, but quality time. It requires “being with” each, individual person. Mind, body and spirit. It requires “being in the present” during each interaction. It may happen while we are showering them or giving them medication or doing a dressing. But it requires focused attention in this moment of time, which can be a challenge for nurses whose minds are often consumed by what they have to do next.
If we do this well, if we are constantly asking “Who is this person” we not only build a holistic picture of the individual but we are able to understand the things that matter to them and we build the trust on which the therapeutic relationship depends.
Which brings me to the final element I consider essential to nursing, the ability “to hold”. In this context, “to hold” is not a physical action, but a psychological, emotional, spiritual and social one and can be the most confronting element of nursing, on a personal level, to do well.
If we are to “hold” our patients we must be prepared to suspend all judgement, acknowledge the subjectivity of that individual person’s lived experience and be prepared to sit with them in a space of emotional turmoil without imposing our own personal aspirations or values on them. It means we need to create a safe enclave, a refuge in which the person can do what it is they need to do at that moment. If we are to do this well, we must be able to empathise without pity. Be compassionate without sympathy. Connect without barriers but with clearly defined professional boundaries. We must be prepared to acknowledge that sometimes there is no solution, no magic pill and be prepared to accompany a person as they struggle to find resolution in the face of perceived failure. It is in this space of turmoil, instability and potential isolation where I believe the art of nursing resides. In our shared humanity.
Science provides our understanding of bodily systems, disease processes and treatment options but is nursing only about scientific knowledge? Have we fallen into the ‘clutches’ of the medical model where we have a mechanised view of patient outcomes based on causation and remediation? Have we become so dependant on evidence based practice (which by its very nature is retrospective), that we’ve forgotten the other part of the equation…………the individual?
Janet Barker (2010) described evidence based practice as “the conscientious, explicit and judicious use of theory based, research based information to make decisions about care delivery to individuals or groups of patients, taking into consideration individual needs and preferences.”
The evidence base is made manifest in therapeutic guidelines, policies and clinical pathways, and I can’t help but wonder if we only give lip service to the “individual needs and preferences” component as articulated by Barker. I also wonder if the rise in popularity of standardised pathways isn’t somehow influenced by an economic imperative. That is not to say that our practice should be haphazard or inconsistent or that we shouldn’t be investing in ensuring the quality and efficacy of nursing interventions by supportive research and evaluation. But healthcare is costly and if by standardising care pathways the cost impost for governments can be reduced, chances are they will promote this approach.
Clinical pathways (however named) exist currently for over 30 different diagnostic groups, and are structured, multidisciplinary plans of care designed to support the implementation of clinical guidelines and protocols. According to Tim Benson writing for OpenClinical, “Care pathways can be viewed as algorithms in as much as they offer a flow chart format of the decisions to be made and the care to be provided for a given patient or patient group for a given condition in a step-wise sequence”
From surgical management of patients undergoing hip replacement to management of heart failure. From diabetes management and tumour specific cancer treatment pathways to a clinical pathway in the diagnosis and management of delirium. From pre-natal pathways to end of life care pathways. Admit the patient, label them, put them on a pathway and discharge them within the allocated time and everybody is happy. On paper our outcomes are measured quantitatively by the impact of our interventions on reductions in physical pain, resolution of physical symptoms, increased functionality, falls reduction, infection containment and so the list goes on. In an economic sense our success is measured in terms of ALOS, achievement of bed bay targets, budget management and productivity. Get them in, sort them out, get them out.
We’re providing evidence based practice, the ward maintains their predetermined Length of Stay allocation for that diagnosis group, the budget bottom line looks healthy and governments can say the system is providing quality care, increasing productivity and reducing costs.
In my own specialty area of palliative care the Liverpool Care Pathway (LCP) has been embraced as the universal panacea to guaranteeing a good death for people in the last 48 hours of life, and yet clinical pathways have their detractors and I must admit, I have great concerns about the validity of a “one size fits all” approach to care. Where is the place for individualised care in a flow chart? Oh, yes, I forgot………….people who don’t fit neatly into the box are catered for, they are regarded as a variance, a “trouble-maker”. This being the case the LCP flowchart states “if you have charted “v” against any goal so far, please complete the variance sheet on the back page”
There is a growing body of literature beginning to question the ability of individualised or person centred care to coexist with clinical pathways. Questions are being asked about the flexibility of pathways and their ability to cater for changes in a patient’s condition. About their suitability for application in complex illness and their ability to ensure documentation and action on “variances” being but a few of the most common. Questions raised in the wider community, however, have been far more scathing. Recently The Independent, The Mail Online and The Daily Telegraph in the UK ran a number of stories under the headlines, “Care pathway used to “cut costs’ claim doctors” and “Top doctor’s chilling claim: The NHS kills off 130,000 elderly patients every year”
In a letter to The Daily Telegraph, Former Vice-Chairman of the Medical Ethics Alliance and retired geriatrician, Dr Gillian Craig along with five other doctors wrote “If you are (as) cynical about it as I am, you can see it as a cost-cutting measure, if you don’t want your beds filled with old people”.
Professor Patrick Pullicino a consultant neurologist for East Kent Hospitals and Professor of Clinical Neurosciences at Kent University, stated in an address to the Royal Society of Medicine recently, “The lack of evidence for initiating the Liverpool Care Pathway makes it an assisted death pathway rather than a care pathway. Very likely many elderly patients who could live substantially longer are being killed by the LCP. Patients are frequently put on the pathway without a proper analysis of their condition. Predicting death in a time frame of three to four days, or even at any other specific time, is not possible scientifically.”
Of course since these articles appeared in July last year there has been an avalanche of responses in online forums, blogs and in social media. Some of them in true conspiracy theory territory, some from the right wing, right to life movement, some from the pro euthanasia lobby, but once you exclude these, the body of responses are from fearful relatives, partners and friends, concerned that because their relative was on an LCP in their last days, they are somehow responsible for the untimely death of their loved one. Alyson White was one such Forum contributor. Her comment makes sad reading,
“I have a very good understanding of the L.C.P. My Nan was still able to eat and drink small amounts, until a Syringe Driver was placed in her arm. She never woke again after that. Her eyes popped open and she was unable to close them, they were so badly blood shot. We were told not to sponge her mouth anymore as there was no point. I asked a Nurse, who said of course you can, the sponge stick was dipped into medicated water. My Nan had not closed her mouth for three days and had not moved, her jaw was really low, she clamped down on the sponge stick. We were horrified, it is a very cruel, agonising way to die. How can any Doctor say it is not, sedated and given strong painkilling Drugs, who can tell you of their experience? My Nan was not terminally ill, the L.C.P. is misused….. and sadly so many thousands of vulnerable people are dying prematurely and unnaturally.”
The flow on effect of this media coverage is that people are now documenting in Advance Care Directives that they do not want to be put onto a Liverpool Care Pathway! Subsequently, the British government has announced an independent inquiry into the LCP which has been welcomed by consumers but criticised by its designers. Sadly, The Daily Telegraph reported that a review conducted by the Marie Curie Palliative Care Institute Liverpool and the Royal College of Physicians examined a representative sample of 7,058 deaths which occurred between April and June 2012, at 178 NHS hospitals. Of those, the paper reported 44% of conscious patients were placed on a pathway without there being any record of the decision being discussed with them.
LCP was developed as a pathway to ensure that dying people were palliated in a way that ensured they were as pain and symptom free as possible and able to die a comfortable and dignified death. Something palliative care specialists have been advocating for years. Where have we gone wrong?
And it’s not just end of life care pathways that are under fire. Triage pathways in the Emergency Department have been reported in Victoria and New South Wales as failing a number of women. Instead of being supported, cared for and nurtured during their miscarriages, these women were left in Emergency Department waiting rooms and subsequently miscarried in the adjacent public toilets.
How is it that a first time Mum, after a complex pregnancy involving three visits a week from Hospital in the Home, daily IV fluids and a complex suite of medications, can have an emergency caesarean section at 37 weeks for a breech presentation and be discharged on day 3? Before her milk has come in let alone breastfeeding being established? Is this OK because that’s what the clinical pathway says for an uncomplicated, elective caesarean? How can this be individualised or person centered care?
So our question needs to be, “Are clinical pathways about ensuring quality, evidence based care or are they a sneaky way of reducing lengths of stay and the cost of providing health care”? And further more, have clinical pathways become a “cop out” for providing compassionate, dignified and creative nursing care? In fact are these two concepts mutually exclusive or can they exist quite happily together and improve what we do?
In terms of the efficacy of clinical pathways, there currently exists very little evidence that they do improve the quality of care. Certainly evaluative work done to date indicates that they can improve consistency in the type of care provided and when, but that doesn’t tell us about the quality. In fact, in a review completed in 2010 by Chan and Webster they concluded,
“Two systematic reviews report that clinical pathways enhance efficiency of care without adverse effects on outcomes amongst patients who undergo gastrointestinal surgery (Lemmens 2008) and show a significant length of stay reduction in patients who undergo invasive procedures (Rotter 2008). Both of these systematic reviews included evidence involving designs such as RCTs (randomised control trials) and other types of controlled studies.
In contrast, the findings from a Cochrane systematic review reported that there was no significant benefit in functional outcome and patient satisfaction and that quality of life might actually be made worse for patients following stroke care pathways (Kawn 2004). Therefore, clinical pathways seem to be beneficial for managing certain clinical problems, but not all.”
According to the Queensland Government, Patient Safety and Quality Improvement Service, “In reality, all patients follow a journey of care. It is recognised that Clinical Pathways generally best fit 70% of a particular diagnosis related group.”
In my specialty area of palliative care we should have an approximate client demographic split of 70% oncology patients and 30% non-oncology, (for instance patients with end stage cardiac, neurological, renal, respiratory and dementia). If we take on board the claim of the Queensland government and apply it in a palliative setting, we could translate that to mean that a Clinical pathway may well “fit” our cancer patients, but if you have a non-cancer diagnosis, a clinical pathway won’t meet your needs. But pathways are not applied selectively in clinical environments. You either follow pathways, or you don’t, there’s no “maybes”. Are we to deduce then, that it’s OK to impose clinical pathways on a whole diagnostic group, when the current evidence tells us that 30% of patients won’t receive the care they need?
We all know of the pressures on the health system internationally. The aging population, increases in chronic illness and high societal expectations of the healthcare system in terms of cure, access, technology and quality. These elements are all putting upward pressure on the cost of providing that care. We also know that we have an aging workforce and a skills shortage, so the system is under pressure on multiple fronts.
Clinical pathways are supposedly the product of a nursing evidence base. But what if there’s an underlying bias in the production of that evidence base?
Sarah Winch et al in a paper published in Nursing Inquiry in 2002, surmised “Evidence-based nursing has significant implications for nursing practice and research. Although much of the impetus for promoting evidence based nursing has come from the profession itself, the economic implications mesh well with the need for cost-containment in healthcare. In the United Kingdom, much of the support for evidence based practice and the funding of centres that conduct systematic reviews, comes from a government anxious to maximise the resources of its National Health Service”
How can we ensure that the art of nursing is not lost in this complex environment? Do we actually have a united understanding of what the ‘art” of nursing is? If it doesn’t exist in the scientific evidence base in which our practice is grounded, what is it?
Cathleen Jenner identified “the six most frequently cited attributes that reflect art across both nursing and aesthetics as creative, expressive, communal, interpretive, subjective and evocative.” All of these elements require the nurse to engage in a sensory fashion with patients, the team and the environment. They all relate to the psycho-social-spiritual domains of care. They are not able to be measured in terms of quantity.
Many years ago I looked after a lady let’s call her Elizabeth, who was slowly dying of pancreatic cancer. She’d been in and out of the palliative care unit on a number of occasions and was finally admitted for end of life care. I came on duty one Monday morning as the nurse in charge and at handover the staff said she had deteriorated over the weekend and was mostly unconscious. They were surprised she hadn’t died overnight. I did my round of the patients and when I looked in on her she was virtually moribund. Some time later, for no reason in particular, I went back in to see how she was going. As I stood by her bed, she opened her eyes and whispered something I didn’t quite understand, so I put my head down close to her and she said it again, “fish and chips………can I have fish and chips?”. “Of course you can Elizabeth, just give me a minute and I’ll nick down the street”. After telling my team where I was going I left the ward and went to the local fish and chip shop where I bought a piece of flake and some chips. When I returned to the ward, one of the staff said to me, “You’re crazy, Elizabeth hasn’t eaten in a week”.
I just smiled and walked down the corridor to her room. I put the white parcel on Elizabeth’s overbed table. I touched her shoulder and said “Elizabeth, your fish and chips are here”. I helped her sit up by adjusting her pillows and unwrapped the steaming white parcel. Under her own volition, Elizabeth sat forward, put her face over the steaming, salty fish and chips and took and enormous breath. She flopped back on her pillows. Before she closed her eyes, she smiled and mumbled, “thanks”. She died half an hour later.
Now I have no idea what “fish and chips” represented to Elizabeth, but as I watched her inhale the smell of the salt and feel the heat of the steam, I knew she was transported somewhere. Maybe to a childhood memory or to a time when she was happy and carefree. But whatever it was I could not have provided that experience for her, if I’d not taken her request seriously.
I wonder if Elizabeth had been on the LCP whether she would have been able to have that final, joyful experience or whether her request would have been regarded as an indicator of delirium and her sedation increased?
Which brings me to “Intentional Rounding”? Intentional rounding is a process that has been embraced internationally. It is said to make patients more comfortable, reassured and calm and to create a more orderly ward environment. In a study completed in the United States by the Alliance for Health Care Research in 2006 intentional rounding was found to reduce call bell use by 38%, reduce patient falls by 50% and reduce pressure areas by 14%. A 12 point mean increase in patient satisfaction was also noted by the study. These results have been replicated in the United Kingdom and intentional rounding is now being carried out in a number of Australian hospitals, including the one in which I work.
So what is “Intentional rounding”? It is a process that requires the nurse to visit the bedside of each patient, hourly and check on the “so called” 4P’s.
- Positioning (to ensure the patient is comfortable, dry and turned regularly, if required)
- Personal needs (including toileting)
- Pain (including pain rating, assessment and evaluating the efficacy of pain treatments, including analgesia)
- Proximity of personal items (such as the call bell, a drink of water, glasses etc, and a visual assessment of potential risks to safety)
At the completion of the rounding check, the nurse is to close the interaction with a question, such as “Mary, is there anything else I can do for you?” And of course, there’s the obligatory tick sheet to be completed at the end of the round to ensure that each patient has been seen, spoken to and their needs met.
Intentional rounding also requires the nurse at the commencement of their shift, to visit each patient, introduce themself and explain that they will be visiting every hour to check on the person’s care needs.
Now, call me a cynic, but I thought that was what we did? I thought this was what nursing was all about? I must say I think it’s a sad indictment on contemporary nursing when someone has to come up with a process that ensures nurses visit each of their patients regularly to care, nourish, nurture, empower and hold. How can you establish a trust relationship with your patients if you never see them? How can you empower patients to report pain and other symptoms if you depend on them using their call bell? We all know that patients don’t want to be any trouble. They know how busy we are and we reinforce this notion every time we rush into a room to answer a bell and send the very clear ‘non verbal’ messages that we have “more important things to do” than move their overbed table within reach.
So why should we be surprised that patients don’t report pain until they can tolerate it no more? Having been a patient on numerous occasions, as I’m sure many of you have been, I have memories of being in intense pain, knowing my analgesic was overdue, but still biting my lip, hoping someone would come. Finally in desperation, pressing the call bell, only, some time later, to get a frustrated nurse walk straight to the bell and switch it off, before even asking me why I had rung. That’s without the obligatory wait of up to an hour, to finally get the injection that had been 40 minutes overdue before I rang the bell. No wonder pain management and patient satisfaction improves with Intentional Rounding!
In an article on Intentional Rounding by Beverley Fitzsimons et. al, that appeared in Nursing Times in 2011, an interesting comment is made when addressing the concerns of those nurses who don’t like the supposedly “task oriented” nature of Intentional Rounding. “It is possible”…she says “that rounding may prove challenging for staff, because it leads them to encounter directly and personally some individuals’ painful circumstances via immediate, regular contact with patients as people.” Surely this is the very art of nursing? Meeting patients in that space of fear and uncertainty and being prepared to listen, support and empower them. Seeing them as people, not just patients.
So I’m certainly a fan of intentional rounding, though I feel sad that we’ve got to the place where a system has had to be developed to ensure it happens. I’m reminded of a story I recently saw on the ABC’s 7.30 Report. I’ve subsequently read the Coroners report, and must say it makes for grim reading.
Martha McKee (known to her family as “Bub”) was a resident in a RACF in Coraki, NSW and had celebrated her 91st birthday on July 25th 2010, with a party attended by family and friends. Mrs McKee was a frail, elderly lady with dementia. A resident in a 45 facility that was classed as low-care, though 20 of the residents were in fact high care, according to the Coronial report. On the night of the 28th of July, three days after her birthday, there were two staff on duty. An Enrolled Nurse, whose registration had lapsed and a 20 year old woman on her first night duty shift as a cleaner. The staff checked on Mrs McKee at 2.50am and told her to get some more sleep, because it was a long time till morning. Mrs McKee had bed poles in place, to help her pull herself up, even though she could do nothing for herself physically. Some time later Mrs McKee fell out of her bed, taking the mattress with her. Her neck was trapped by the bed pole. When the nurse returned to the room at 5am, she saw Mrs. McKee on the floor and described to the Coroner, “she was wax-work white. I turned the light on and it was absolutely horrific. I could tell she was dead.” But the nurse did not check her; she closed the door and telephoned the supervisor. Mrs McKee remained on the floor for another hour before a nurse checked to see if she was dead. The Coroner was unable to determine her time of death or how long she may have suffered. “What I can say is that, had she been alive, she may have been able to have been resuscitated,” Magistrate Denes said.
Now there are a number of contributing factors to the death of Mrs McKee and certainly the skill mix and level of staffing in Residential Aged Care Facilities can be considered a primary contributor and was identified as such by the Coroner. I can’t help but wonder, would Intentional Rounding have altered the fact that Mrs McKee fell out of her bed? Would rounding have identified earlier that she in fact had fallen out of bed and if found then, would she have been able to be resuscitated? Would rounding during the day shift, when more staff were on hand, have identified the fact that the bed poles were inappropriately placed and may well have constituted a hazard? Of course all of this is conjecture but this tragedy should provide us with a wakeup call. How could something like this happen? The take home message for me, was a powerful and heart rending statement made by Mrs McKee’s daughter at the close of the 7.30 Report interview, “She’s not a number- she’s my Mum”
Canadian academic, Danielle Blondeau in an article in Nursing Philosophy said “when nursing is conceived as a practical art, ethical considerations enter into the carrying out of all activities.”
To me this means ensuring the care we provide is of a quality we’d want for ourselves or someone we love. Asking the question, “What if this was MY Mum?”
The art of nursing requires us to use our imagination in how we think about our work. It requires us to perform, just as a musician or a dancer does, in that everything we do is expressive of our values, our feelings, our mood and our nursing philosophy and we perform our role as the physical manifestation of this. The art of nursing is sensory, in that it influences the sights, smells, tastes, touch and sounds we create in the environment in which we work and it is communal in that all of these elements are shared with every patient with whom we have contact. Rose and Parker in the Journal of Advanced Nursing, cited Lumby’s depiction of the communal nature of nursing,
“I see this art every time I walk into an environment where a nurse is busy “creating” the day for another person. They are busy using light, space, sound, words, movement and touch to deliver the message of care. And like true artists they are willing, indeed they see it as essential, to share their performance with others.”
The art of nursing, in my view is also reliant on our ability to trust our clinical intuition. The intuition that comes from nursing knowledge and experience. The intuition that prods us to act and question the visual clinical picture. There is no place for this on a clinical pathway. How can you document that despite a patient being conscious, articulate, eating and drinking, all of those things that would make you tick the box marked “stable” on a clinical pathway, you somehow have a nagging feeling that this person is imminently dying? And what do you do with this information? Do you ignore it because you can’t validate it on paper OR do you act on it? Despite the clinical picture, do you stay with that patient just a little longer so they don’t die alone? Do you allow yourself to be vulnerable, ring their family and say, “I could be wrong, but I just think if you want to see Mum before she dies you should come in.” And yet it is these very elements that constitute the art of nursing that are often discredited. Janet Barker claims,
“Perhaps part of the problem related to nursing developing an EBP ethos is that nursing is often considered as more of an art than a science and as such certain types of evidence are valued above others, such as expert opinion and practice experience”
By definition, expert opinion and practical experience should inform the evidence base. Clinical intuition born of contemporary knowledge and life long learning should not be discarded as irrelevant, nor should the art of what we do. The quantity measures of ALOS, falls and infection rates, pain and symptom control and clinical outcomes are all important measures of efficacy, however if we don’t value or consider the quality measures of individual patient experiences, effective and empathetic communication and therapeutic relationships, we may as well be motor mechanics.
As stated by Sally Penz and colleagues,
“The unique nursing knowledge gained through nursing research (qualitative and quantitative) must be the primary guide for practice. Intuition, clinical judgment, and experience cannot be dismissed as valid sources, but quality research evidence must work in partnership with these sources of knowledge.”
So it is in the marriage of art and science where contemporary nursing practice should reside. One is no more important than the other and yet as I stated at the outset, my fear is that we have jumped head first into the metaphorical swimming pool of science, without our “artistic” bathers on. And now find ourselves divested of the one thing that will allow us to swim in that pool comfortably and proudly.
To quote Jenner once more, her literature review caused her to surmise that “the art of nursing is the intentional creative use of oneself, based on skill and expertise, to transmit emotion and meaning to another. It is a process that is subjective and requires interpretation, sensitivity, imagination and active participation.”
To me the art of nursing is what allows us to think outside the square (or the conventional pathway, if you like), it’s about having a sense of grace and confidence in our shared humanity, being prepared to look for creative and innovative solutions to complex problems and when there appears to be no solution to the problem, being prepared to sit in a space of often intense discomfort in order to just “be” with someone as they struggle to create a sense of meaning about their experience.
Integral to the art of nursing is also our ability to retain a sense of adventure and joy in the work we do. This sense of personal and professional satisfaction is what enables us to become resilient. It is not to be found in the application of technology and treatment interventions alone, it resides in our human interaction with patients.
But does reclaiming the art of nursing add one more impost on us to be the supermen and women of the caring professions? Does finding the creativity in our practice mean just another task we have to find time for in our already busy days or can reclaiming the art of nursing have a positive impact on us personally and professionally as well as improving the outcomes for patients and families in our care?
We all became nurses for a reason, for each of us, those reasons will be different. It’s not what makes us become nurses in the first place that matters, it’s what keeps us nursing that’s important.
Whether we work at the bedside, in the classroom, in administration or in the bureaucracy, to stay happy and healthy in nursing, to be a mentor and role model for those who follow us, we need to be able to walk away at the end of each day and say “YES” I made a difference today!
THAT’S the art of nursing, that elusive element that creates a point of balance between the science and the aesthetic, between the head and the heart. That intangible aspect that enables us to transcend the limitations of the system in which we work and create, innovate and inspire. That mysterious quality that exists within every nurse, if only we knew how to define it.
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