11
BEING A NURSE
FORMATION, AS NOTED EARLIER, occurs as students develop knowledge, skilled capacities, and insights into the notions of the good that are central to nursing practice. Thus it cannot be restricted to prespecified locations or even course objectives. In formation, personal and professional transformation are central. This chapter focuses primarily on experiential learning in clinical and informal learning settings.
Theories of socialization typically do not account for the profound development that many nursing students experience in sensory perception, skilled know-how, and capacities for engaging in relationships with patients and families. Nor do socialization theories adequately account for the sense of wholesale personal transformation that many nursing students describe—the point at which they feel as though they are nurses—and how participation in nursing practice creates a meaningful existence that, for many students, is markedly different from their life as lay persons or beginning students. The lay student moves from acting like a nurse to being a nurse.
As the example of Sarah Shannon’s classroom suggests, learning in a practice discipline such as nursing requires more than socialization into prescribed roles and adoption of a prescribed set of beliefs. The process of formation—developing and using situated knowledge and skilled know-how, and learning ways of perceiving and acting ethically—is arduous. As Dunne (1997) observes, “A practice is not just a surface on which one can display instant virtuosity. It grounds one in a tradition that has been formed through an elaborate development and that exists at any juncture only in the dispositions (slowly and perhaps painfully acquired) of its recognized practitioners” (p. 378).
In both interviews and survey responses, advanced-level students and beginning nurses frequently described how their sense of mission, or calling, made it possible for them to withstand the rigors of learning for practice and gave them the courage to enter high-stakes situations, where the consequence of a mistake can be enormous. The students claim that this understanding of the significance of their work and their identification with nursing practice were what kept them focused through terrifying clinical situations, heavy or conflicting academic demands, and competing family and work responsibilities—any of which might have led them to drop out. They cite classmates who were performing well but who did not identify themselves with the significance and relevance of nursing practice and consequently chose to drop out of the program. Students describe finding what Taylor (2007) calls a “moral source”: “Coming to clarity about [our motivations] why we are doing this can help identify and neutralize other extraneous motives…which may muddy action and lead us away from our goals. And it [moral sources] will characteristically also inspire us to strengthen our resolve. A motivation which has this kind of potential to empower I want to call a ‘moral source’” (p. 673).
Doing, Knowing, Being
Nurses enact their knowledge of the natural and human sciences, technology, and ethics and are able to transform this knowledge into the capacity to perceive and act in a given situation. Students’ descriptions of how they learn in clinical situations to perceive, think, and act like a nurse are consistent with accounts of learning to use knowledge (Eraut, 1994; Lave & Wenger, 1991). Bourdieu (1990) uses the term habitus to describe the situated, tacit knowledge of inhabitants of a culture or practitioners of a complex practice. As the practitioner develops a habitus, incorporating taken-for-granted meanings, knowledge, and skill, it recedes to the background, becoming part of a complex web of the practitioner’s assumptions, expectations, understanding, and skilled capacities. As a result of developing new perceptual capacities, a sense of salience, and skilled know-how, a habitus is formed and available to the practitioner. The practitioner develops the capacity to become attuned to each familiar situation (Benner et al., 1999; Lave & Wenger, 1991).
As nursing students develop habitus, instructors formally recognize them as nurses. An instructor in a BSN program observed: “In the second semester of the junior year, everyone begins typically calling the students ‘Nurse.’ You might ask them to do a patient assessment, and at first, they say, ‘I’ll go get the nurse and she will do it.’ ‘Wait a minute, you are the nurse.’ And I think it’s that realization, coupled with either [sic] the complexity of the pathophysiology and the medications that the patient is on, and also recognizing, ‘I have to be organized. I just can’t run around in circles any more. I have to focus myself, get organized, have a plan.’”
As students progress from caring for one or two patients to larger patient assignments, the situation shifts dramatically; complex, busy clinical assignments call for learning new ways of organizing and planning. The students must learn “styles of practice” (Merleau-Ponty, 1962) that attend to the demands and priorities of patients in diverse situations. Even though styles of practice, or performance, bear a family resemblance to one another, the student must learn to respond to the salient clinical and human issues of each unique situation.
Style of practice is not limited to performing technical skills or learning to cope with inflicting discomfort on patients. Skillful and helpful ways of being with patients who are suffering vary according to the severity and intrusiveness of therapies, and on the patient’s own coping responses. Although they may not use the term formation, many nurse educators deliberately foster the student’s movement from a lay person’s understanding of what nurses do to an insider’s professional understanding of being a nurse and thinking like a nurse. Characteristic of this process is a shift in focus from mastering technique—producing replicable and predictable outcomes—to exercising flexible judgment and taking astute, context-dependent action in an underdetermined situation.
A faculty member describes how she encourages this shift from the start, even in skills lab:
The skills lab really lays out a lot of those fundamental things for nursing, and that’s what the students are totally focused on when they get there. They think if they can learn how to give a shot, they’re a nurse. We explain to them that is not the be-all and end-all in nursing. I think a lot of lay people think nurses give shots and put in IVs and make beds . . . and these students are comparable to lay people when they first start. They don’t always know what nursing is all about. So I think that’s where we start to get the ball rolling . . . you have to spend a lot of time on those fundamental skills so that they become rote, and the students don’t have to think step by step how to do a blood pressure and how to give a shot and how to put in a catheter, because then that frees them up for the higher-level skills . . . thinking and decision making and applying knowledge to taking care of patients. So, that’s definitely a big piece of starting to help them think like a nurse. And we really do try to start to explain that to the students: “Yes, this is very important to your learning, but skills are a very small part of what nurses do.”
Such messages in skills lab and elsewhere are important, but making the transformation to practice also depends on experiences that change the student’s capacity to use and act on knowledge in a complex situation. The temptation is to reduce the notion of moral agency to a possession of skill and strategic capacities. However, strategic skillfulness and knowledge ignores the relational issues involved in good nursing care. The merely strategically skilled nurse would not need a good “bedside manner.” However, the relationship between a patient and nurse depends on trust. Taylor (1985c) counters the attribution of strategic prowess as the essential characteristic of human agency with this: “Agents are beings for whom things matter, who are subjects of significance” (p. 104). By this he means that taking a stance on the kind of person one wants to be shapes human agency even though strategic powers and possibilities might permit disparate choices and actions.
Re-Forming the Senses
Nurses work daily with sights, sounds, odors, and tactile sensations that in other parts of their lives they might find repugnant. Whereas seasoned nurses and nurse educators often forget how or when they learned to cope with the sights, sounds, smells, and discomforts of patient care, student nurses new to the environment find it challenging to encounter bodily odors, for example, and the often-noxious odors of the hospital. Students must re-form their interpretation of bodily odors as common, not repugnant or even socially taboo. We noted that the important process of retraining the senses, so necessary for assessment and acceptance of patients in vulnerable circumstances, is rarely given significant attention in nursing education. It is easy to overlook something so subtle in a packed curriculum. However, by giving attention to students’ reactions to the sensory challenges of nursing, educators and staff nurses can offer strategies for retraining the senses and also teach students strategies for using the senses in assessment.
Some educators do focus on the sensory. For example, one nurse educator who prepares new students for the sights, sounds, and smells they will encounter in clinical situations notes how it contributes to their transformation. She offered the example of preparing her students for the odors they will encounter when caring for a patient with a new colostomy:
I’m talking with the sophomores about the smells. So yesterday, one of my students asked a question about tomorrow’s patient assignment in postclinical conference, and I said, “This person is going to be incontinent, they’re going to sneeze, they may vomit. What are you going to do?” They all sat there. Then someone said, “I can’t stand it when someone vomits.” So I think it’s this clinical world that’s a major confrontation for them. And as a faculty member who takes them for the very first day, I literally walk across that bridge with them. And here we are, and they do such an incredible job. I’m going to cry, they do such an incredible job that by the fourth day they’re nurses. They are different people.
Student nurses must also learn new ways to touch that comfort the patient while also producing important assessment data (Weiss, 1992). For example, a student might touch a patient in order to listen to heart sounds or palpate the abdomen. Touching patients in this new capacity requires that the student develop a professional demeanor and style of comportment that conveys concern and instills confidence in the patient while also demonstrating the student’s technical competence. This is extremely difficult for most students, especially when they are not yet sure of what they are “palpating” or how the patient will respond to their touch.
For example, an educator in maternal-child nursing describes the difficulty students have when learning to feel the location and firmness of the fundus (upper portion of the uterus) after a woman has given birth:
Our students tend to be so frightened of checking the fundus and actually putting their hands on the patient, because it’s the first time they’ve done an extensive assessment of a patient. They’ve done a history and physical on an elderly patient in a nursing home in the previous course and then, of course, practiced on each other. But as far as a patient in a hospital who’s just had any kind of procedure or being around body fluids, this is their first experience with that. And so when they feel the fundus they say in postclinical conference, “I found it, I really touched the fundus, I couldn’t believe I could really feel it,” like they don’t believe us when we tell them, “Of course you can feel it.”
Re-Forming Social Sensibilities
Developing habitus and styles of performance enable the practitioner to be engaged with varying forms or degrees of involvement according to the situation. Students must quickly come to grips with the amount of suffering they will witness as nurses and the full extent of the manifestations of human illness and injury and their treatments. As one educator commented, “Even in pediatrics, students confront the difficulty of seeing kids who are badly injured or have multiple surgeries. A lot of students come in to be pediatric nurses and then they work with kids who are sick. And so they realize, ‘This isn’t going to be exactly what I thought it was going to be. I’m going to see some tough things’ and it’s hard. It’s hard.”
Not only must students learn to face people every day in situations and conditions that the lay person does not typically see; they must also learn to respond helpfully to people who have unusual or antisocial behavior. A nurse educator who teaches psychiatric nursing explains: “We deal in areas with patients that nobody else wants to know about too much. People don’t want to talk about sexual areas; depression, drug and alcohol abuse in our society are hidden. And we’re the ones who have to get in there and ask those questions. It’s hard for the students to be able to talk with somebody who has schizophrenia or someone who’s delusional or has a drug and alcohol problem that’s pretty severe, so we role-model how to talk with patients.”
As this educator points out, students face difficult work in re-forming how they relate to others, even down to the questions they might ask a patient. In effect, nursing students must learn to change the boundaries of their social access. For example, students develop relational attunement as they learn to read facial and bodily expressions in a given situation.
Sometimes the patient is compromised by dementia and difficult to meet as a person who has a history, likes, and dislikes. One student gave a moving account of caring for a confused elderly woman who thought the student was her own daughter. The student tried to correct the patient but gave in to the patient’s recognition response when the student’s corrections did not stick. The student gave the woman a bed bath, brushed her teeth, and brushed her hair while the woman continued to believe it was her own daughter providing the care. By meeting the patient as a person, she felt her care revealed the woman in a different light.
Re-Forming Skills of Personal Involvement
A student learning to insert a nasogastric tube will focus on the task, thinking out the steps of the procedure and preparing for the outflow of gastric juices. Yet, as Minnie Woods’s experience related in Chapter Nine suggests, to incorporate fully the skills of the procedure into caring for the “person at the end of the bed” students must quickly progress from practical knowledge, or skilled know-how, to insight and understanding of the patient’s fears, and how and why procedures are needed for the patient’s recovery or comfort.
Student nurses talk readily about the interpersonal challenges they face in nursing. The process of learning some of the important lessons in the skills of involvement can be pleasantly surprising. A student nurse describes her initial pediatric experience:
I like kids. I just don’t want to take care of them. I don’t like the crying and the screaming, the, “You’re going to take your meds” and they’re, like, “No!” And I just don’t like the fighting. So I had a seven-year-old boy who had compartment syndrome. He had broken his arm earlier in the summer and now had an infection. They had to open the wound and it was horrible, and he was in a bed for weeks and weeks. He was three hours from home, and his mom could only come in for a couple of days out of the whole week, and so his grandmother was there sometimes and sometimes his aunt. He was just really, really miserable, the poor kid. He would get really agitated.
Somehow I ended up bonding with him.. . . It had been raining for a week, and the sun came out. Being an idiot, I asked, “Have you been outside recently, have you looked out the window?” And he said, “No.” (He could not see out the window and could not go outside.) So I asked, “What do you think you could see outside that window?” (I was trying to correct my mistake.) He started drawing, and that’s how the window drawings started. I started drawing on the windows with dry-erase marker…and I would draw landscapes and I would ask him to imagine whatever he would see outside. It ranged from cowboys and Indians to army men in tents. I filled whole windows up with pictures for him.
After that, any time I asked him to do anything, he would just say, “OK.” I let him wrap my arm in a towel and pretend it was a cast so that he could do neuro[logical] checks on me. I started to actually enjoy pediatrics. That was dangerous!
In studies of skill acquisition, it was found that nurses who did not learn effective skills of involvement with the problem or situation at hand, or as it related to interpersonal relationships with patients, families, and team members, did not go on to become expert nurses (Benner et al., 1999; Benner, Tanner, & Chesla, 2009; Rubin, 2009). In our study, we noted that very often skillful involvement with the interpersonal aspects and the specific situation occur in direct patient care or are located in the hidden curriculum, and recognition of interpersonal concerns and attunement to those concerns become visible only when things go wrong. For example, a student gave an account of being in a situation where her skills of involvement were not yet sufficient for the patient’s needs:
I remember the second quarter, we took Effective Communication, and we talked about communication and about what you should do in different situations. I found myself in a situation in a room where a woman was very upset because she had cancer . . . she just had surgery and she was worried how her husband would feel about the disfigurement to her body. She thought he was really upset. It was such a surreal experience because I found myself sitting in there thinking, “All right, now I’m supposed to be an active listener and supposed to reflect the questions.” So I felt like I was doing it by textbook. And I’m thinking, “This is someone’s life, and I’m sitting here and I’m doing this and no one’s watching me.” I felt really over my head . . . but that’s what we do. We’re in people’s lives and our job and our role is affecting people’s lives. I still remember that experience, and now in my practice it comes a lot more naturally, but I remember that very clearly; I remember thinking, “What do I do? What action do I take?”
I remember the side of the bed I was sitting on. She was just really sad and really depressed, and she was just crying. We learned you’re supposed to say, “Are you feeling sad?” And it came out of my mouth. I thought, “Oh, it seems like the right thing to say, because that’s what I’m supposed to do.” And I said that thing, but it was kind of awkward . . . but I was the only one there; I was the only one talking to her. So I think it did help to some extent, but I still felt very awkward doing it, and she was definitely more caught up in her emotions and really sad and was crying and she probably didn’t notice my ineptitude.… She responded. She said, “Yes, I am feeling sad,” and she kind of elaborated. I don’t know if I was anticipating her emotions, but I sensed that she started to sense that I didn’t know what I was doing. [laughs] And she started to withdraw.… I remember feeling like she was starting to close up, not open up, but she had this big open-up and then stopped. She kind of sensed that I was in over my head.
Students must learn to distinguish when communication techniques are useful and when presence and compassion are the most one can offer. The student recalls the feeling of being “in over my head” and sensing a patient withdraw because she was not comfortable in the situation. This is a moment of insight and experiential learning that has an impact on the student as she reflects on it.
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