Doctor of Education (Ed

Re-appraising Nurse Education Submitted for the Degree of Doctor of Education (Ed. D) Diane Cockayne September 2008 Department of Educational Studies Faculty of Social Science University of Sheffield Acknowledgements I would like to acknowledge the invaluable help and encouragement given to me by my supervisor Dr. Christine Winter and also that of Professor Paul Standish who supervised me during the early stages of my research before he left Sheffield. I would also like to thank Dr. Christine Ingleton, my manager in the University of Sheffield School of Nursing and Midwifery for supporting and facilitating my research. Finally, my thanks go to my children, Melanie and John, for encouraging me to begin and sustaining my motivation to continue my studies. Abstract The history of nurse education is one of conflicting claims regarding what it is a nurse needs to know. Perceived deficiencies in standards of nursing care, whether in the past or present, have often been attributed by medical doctors, those responsible for policy at governmental level, the media and the general public, as resulting from either a deficiency, or perhaps too great a proportion of 'theoretical', 'practical' and 'moral and spiritual' knowledge in nurse training curricula. This thesis is concerned with tracing the history of the debate through examining the evolution of nurse education policies and the discussions which have shaped them. The analysis is carried out within a framework constructed using all three 'types' of knowledge which are later analysed to determine what they might mean particularly in respect of nursing practice. As part of the assessment of the merit of the arguments regarding the weight to be given to these forms of knowledge in nurse education, the issue of what a contemporary nurse might be and therefore need to know is also addressed. Finally, and despite an initial tacit acceptance of the existence of these distinct 'types' of knowledge, this thesis raises questions about whether knowledge can be divided in this way. It argues that to do so is, at best, unhelpful and constraining in the designing of curricula for the education of nurses - indeed at worst, it is divisive of the profession and its educators and may have negative implications for the welfare of patients. Contents Chapter 1: Educating Nurses: Historical Perspectives Introduction I 1.1 Origins 1 1.2 The Influence of Christianity 6 1.3 The development of 'modern' nursing during the nineteenth century - the influence of Florence Nightingale 10 1.4 Nurse education policy at the beginning of the twentieth century 21 1.5 1921-1948 26 1.6 1949-1989 33 1.7 'Project 2000' to the present day 38 1.8 Conclusion 47 Chapter 2: The Nature of Nursing Knowledge Introduction 50 2.1 'Theoretical' knowledge 51 2.2 'Practical' knowledge (knowing how), Knowledge in the hands 60 2.3 Moral and spiritual knowledge 71 2.4 The nature of knowledge - key nursing texts 81 2.5 Conclusion 91 Chapter 3: What is a Nurse? Introduction 93 3.1 Media representations of the nurse 94 3.2 The views of nurses 111 3.3 The views of policy makers 120 3.4 Conclusion 125 Chapter 4: Re-appraisal Introduction 127 4.1 The (uneasy) relationship between theory and practice in nursing education 129 4.2 The problem of language 140 4.3 Theory and Practice -a re-appraisal 142 4.4 The place of moral and spiritual knowledge 149 4.5 Towards a more holistic approach to (nursing) education 153 4.6 Some implications of the study for contemporary policy and practice 159 4.7 Conclusion 166 References 169 Educating Nurses: Historical Perspectives Chapter 1: Educating Nurses: Historical Perspectives Introduction This thesis is concerned with the education and preparation of nurses for practice, something which has been the subject of debate and controversy from both within and outside nursing throughout its history. That controversy has largely centred on what it might be that nurses need to know and is, of course, inextricably linked with the question of what is a nurse - what is it that they do? What nurses need to know, both historically and at present, appears to have been framed in terms of three apparently competing 'types' of knowledge, theoretical knowledge, practical knowledge (including practical 'skill', an aspect of practical knowledge analysed in chapter 2), and moral and spiritual knowledge. The following chapters trace the history of this debate and its influence on nursing education (chapter 1); analyse further what these descriptions of knowledge might mean (chapter 2); and consider their value in the context of both images of nurses in popular culture and the contemporary reality (chapter 3). Finally, chapter 4 will articulate some of the implications of these findings for the future development of nurse education. 1.1 Origins Nursing is inextricably linked with ideas of caring, whether of children, older people or the sick. It conjures up an image of a warm, compassionate, and almost inevitably female person perhaps breastfeeding a baby ('nursing' in common parlance, even today), feeding a frail parent or grandparent, bathing, dressing and 'nurturing' sick relatives and perhaps even other members of the community. Jane Salvage (1985) notes that the idea of nurturing is central to the role of the nurse in that it reinforces a link between nursing and mothering and is aptly illustrated when, as she puts it "... we use the word 'nurse' metaphorically, such as in 'nursing a grievance' - nurturing feelings in the very core of our being" (p1). Educating Nurses: Historical Perspectives The vast majority of such 'nursing' activity was, and is, undertaken by people who have received no or very little instruction or education in respect of their nursing work, whether paid (as health care assistants) or unpaid. Indeed I will analyse what might constitute a 'nurse' in contemporary parlance later in this thesis. However, this first chapter is concerned with the history of the preparation of the trained nurse - the only person allowed in law to use the term 'nurse' to describe themselves (Nurses Registration Act 1919). (Nursery nurses require the prefix 'nursery' to remain within the law. ) In order to shed light on the development and role played by the three bodies of knowledge, i.e. theoretical knowledge, practical knowledge (including practical skill), and moral and spiritual knowledge, I will trace the development of nurse education policy paying particular attention to the arguments surrounding the weight given to them in nurse training programmes. It became increasing apparent when researching pre-Christian and even pre- Enlightenment 'health care' (to use a generic term) that the boundaries of what might today be regarded as 'nursing', 'medicine' and 'religious ritual' became increasingly blurred. As a result, I have had to adopt a wide interpretation, perhaps one wider than Florence Nightingale may have been comfortable with but certainly little wider than the contemporary nursing role. Although the link between the nature of knowledge needed to carry out these ancient practices and the nature of knowledge required by contemporary nurses may initially appear tenuous, I justify their inclusion on the grounds that the holistic nature of some of these healing practices will be more familiar to twenty first century nurses than those trained by Florence Nightingale. Moral and Spiritual Knowledge Perhaps unsurprisingly, the further back in time the analysis reaches and as the level of evidence-based knowledge of human physiology is identified as more rudimentary, the greater the emphasis writers and practitioners appear to place on the moral 2 Educating Nurses: Historical Perspectives probity and spiritual knowledge of healers. I am certainly not suggesting at this point that the link between scientifically generated knowledge and that of moral and spiritual training is one of a necessary inverse relationship, but that knowledge with a religious underpinning would appear from the literature reviewed to be pre-eminent until at least the 17t' century. It was then, for example, that William Harvey published the first description of the (hitherto speculative) role and function of the heart and blood vessels. His "An Anatomical study of the Motion of the Heart and of the Blood in Animals" was published in 1616. Guenter Risse (1999), in his history of the evolution of the modern hospital, traces the siting of healing practices and care in classical Greece and Rome to a framework of religious cults, rituals and institutions, and notes the pre-eminence of the 'spiritual dimension' in the healing process. He describes the cult of Ascelepius, the Greek 'healing god' and the inscription on the Ascelepieion (healing temple) at Lambaesis, "Enter a good man, leave a better one". Interestingly, some aspects of his narrative cited below may resonate with those familiar with the writings of Florence Nightingale, and indeed anyone with any recent experience of hospitals either as employee or patient: Every healing act is a mystery. The organisation of rituals in places such as the Ascelepia was in consonance with traditional temple routines guiding the interaction of the sacred and the profane. Access to the sanctuary was linked to notions of Greek piety and purity, with strict regimentation of dress and conduct. Ambulatory supplicants followed prescribed bathing and prayer formulas. A priestly caste of attendants followed a rigid set of daily scheduled be in the observances... .similar objectives could achieved military and perhaps slave valetudinarium... feeding, bathing, wound dressing, or drug prescribing routines, and perhaps even prayers followed. Language, symbols, music, and costume all worked together to establish and enforce social cohesion among the ill. In both venues, faith and emotion must have been critical factors facilitating recovery (Risse 1999, p58). Risse, a medical doctor, arguably appears to find it difficult to differentiate between the work of what he might term 'healers' and nursing practices, for which the majority 3 Educating Nurses: Historical Perspectives of his work he tends (at first sight) to ignore.

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