There is a debate in nursing: is it an art or a science? Most people claim it’s both, but to varying degrees. I think of it this way: if you are an artist who paints portraits in oils, then science – knowing what paints to use, how to use them, your technical ability and skill – is what you use to express your art. Your artistic ability is what guides you to use your technical skills; the technical skills allow you to express your art. The two go hand in hand.
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If you know how to make decisions, and how to think like a nurse, then you will be well on the road to being the nurse you need to be.
WHAT DO NURSES DO?
According to Henderson (1966):
Nursing is primarily assisting the individual in their performance of those activities contributing to health, or its recovery that they would perform unaided if they had the necessary strength, will, or knowledge.
Recently, the Royal College of Nursing (RCN, 2003) defined nursing as:
The use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death.
To really understand these, we first need to look at what ‘health’ is. A search for ‘health’ on the internet leads to some diverse opinions:
So, what is health? If it is an ability to survive then a baby isn’t healthy because it relies on someone else to meet its needs. Is it the absence of disease or illness? Well, that definition would make it impossible for anyone with a chronic disease to ever aspire to health. What about the ability to cope? I can cope with some things well and other things (like approaching book deadlines …) a little less well. I don’t know about you, but for me coping is relative.
• being free from disease or illness
• the ability to cope with everyday activities
• a state of balance
• ability to survive
• a social situation with rewarding relationships
• being financially solvent
• being without stress or worry
• complete physical, mental and social well-being
• free from abnormality
• free from abuse or exploitation
• being able to enjoy and participate in activities.
If you were a 90-year-old woman with arthritis, high blood pressure and diabetes, would you be ‘healthy’? What if you were still able to get out and do your shopping, you were able to live with your arthritis because of appropriate medication, your diabetes and blood pressure were diet controlled and you still had social activities that you enjoyed?
Would you, as that woman, be less or more healthy than a 40-year-old man who is stressed by working too many hours, smokes, drinks and is a little overweight, even though he doesn’t have high blood pressure, arthritis or diabetes?
Health is relative. As a nurse, it’s your job to help improve individuals’ potential health and bring their actual state closer to their potential state. If the best a patient can have for a healthy life is to be cared for around the clock and enjoy social interaction by watching television, then that’s health, for that person.
Your nursing assessment needs to identify your patient’s actual and potential states of psychological, physical and social health. Your assessment is the foundation of holistic care: looking not just at the body, or the mind, but at the life of the individual.
By understanding health, being able to assess health potentials and acting to promote, maintain and restore the individual’s health potential, you are nursing. It’s not something you can do with a written model, a document, a pill or a blood-pressure cuff. Nursing is using what you know and – to some extent – who you are, to help patients and their carers find and remain in the place they need to be.
NURSING INTUITION
What is nursing intuition:
• A strange psychic ability?
• Lucky guessing?
• What you get from your nursing tutor?
• Awareness developed as a result of reflection, experience and education?
Intuition is that feeling you get without knowing why you get it. It happens to every nurse at every level: it’s that little voice inside you:
I only just qualified as a children’s nurse, but I have had four children of my own and now even a grandchild. When I was working one night, I couldn’t help but think there was something wrong with this one little lad. His obs were fine, nothing seemed obvious, but this little voice kept telling me to pay attention. I checked him far more frequently than I would usually. On one check I realised he was sweating. I took his temperature – his skin was hot – and found it very high. To make a long story short, he had a serious infection but we were able to treat him quickly. I don’t know how I knew; I just did.
This story is not unique: you hear it all the time:
• ‘I just knew’
• ‘I had this funny feeling’
• ‘Something just told me’.
Sometimes, it’s about simple things:
I just decided to swab the wound; it didn’t look really infected, just a bit inflamed, but I just thought it was a good idea. Turned out to be infected with MRSA.
Sometimes, more complicated things:
How do nurses know? Where does that ‘funny feeling’ come from? Some people say it’s an instinct with some kind of psychic basis, but most people agree that intuition in nursing is the result of cues that the nurse isn’t consciously aware of. Looking at the examples above, how could the nurses have known?
The night nurse called the family and suggested they come in. Their mother was dying but the doctors thought it was still a matter of at least a week. The night nurse just felt that it would be a good idea for them to come in. The patient passed away an hour or so after they got here.
The nurse who swabbed the wound and found MRSA: perhaps there was a certain odour or appearance that the nurse had seen many times before that always turned out to be MRSA or some other infection. The nurse probably realised unconsciously that:
This smell + that appearance = MRSA.
As a result of this conclusion, the nurse decided to swab the wound.
The nurse who knew, without knowing why, that the family should come in had worked nights for years. How many dying patients had she cared for? She probably recognised, unconsciously, the cues and signals that meant the patient was going to die soon.
Think about some of the skills and knowledge you bring:
• You have had relationships and interactions with many different people.
• You have been a partner/spouse/child.
• You have been a student.
• You have had experiences in different working environments.
• You have had personal and family health worries.
• You have had good days and bad days.
• You have been filled with grief, joy, worry, pain and fear.
• You have been lazy and motivated.
Each of us brings different experiences to nursing and these experiences, as they integrate into practice, will influence the nurse we become.
Think for a moment about a jigsaw puzzle. When you first begin, you identify the edge pieces and you group the colours together. As you start to work the puzzle, you might notice that certain subtle tones (for an example, let’s use the colour blue) are more common in one place than another. Using nothing more than that, you start to further separate blue pieces from other blue pieces. Someone with less experience in puzzles might not realise that this is a useful strategy; he or she might use more trial and error.
The more experience you have, the less you need to use trial and error and the more quickly, and accurately, you can put the puzzle pieces together. It’s the same in nursing.
As you reflect (see Chapter 6), you start to integrate who you are as a person – your beliefs, feelings, knowledge and past experience – into your nursing practice. As you begin to reflect ‘in action’ rather than just ‘on action’ this integration of experience and knowledge will start to become more unconscious. This is where you will start to really develop your intuition. As you read research, learn more about evidence-based practice and add to your knowledge, skill and experience base, the resources for your unconscious decision-making will grow.
With further reflection, you learn to hear that ‘little voice’ from your unconscious awareness. You will probably find, as most experienced nurses have, that you often regret not listening to that inner voice.
In The student nurse handbook (Siviter 2004) I explain a little about ‘Nurse Brain’, how being a nurse affects the way you think for the rest of your life. You don’t see things the same any more: you notice when someone looks unwell, you think more about health and health-related issues, you can’t help but relate to the world as a nurse. ‘Nurse Brain’ is really when you allow reflection and intuition to be tools you use every day: you can be a nurse without reflection and intuition but these elements make you a better nurse than you could ever be without them.
There is much more to being a nurse than just providing hands-on care. Nursing is a profession in which nurses themselves use their nursing knowledge and skill to make decisions: they use their highly tuned ‘Nurse Brain’ to guide what they do and how they do it. Nurses who develop and listen to their intuition are more sensitive to patients, families and their needs. They are more likely to solve a problem before it gets out of control, and less likely to make mistakes.
In From novice to expert, Benner (2001) gives a very concrete path for the development of expertise in nursing, and recognises that the development of intuition is not just an element of development but a hallmark of nursing expertise. Personally, I don’t think the development is as concrete as Benner relates but I do believe that, to become expert, you need to be an intuitive and reflective practitioner.
This intuition is why experienced nurses can use their expertise as evidence for evidence-based practice. Sometimes, an experienced nurse says ‘I just know, that’s why’. If you don’t develop that inner voice, then a huge area of nursing practice and expertise will be closed to you.
BOUNDARIES AND LIMITS
There are two parts to boundaries and limits: respecting them and making sure other people respect yours. In Chapter 5 we will talk about assertiveness; in this chapter we will talk about how you respect the boundaries and limits of your own practice.
Boundaries
Poor boundaries in nursing often result when we are more concerned about getting our own needs met than meeting our patient’s needs. The Nursing and Midwifery Council’s (NMC’s) Code of professional conduct tells us that we must have good boundaries, that we must not abuse the power our position gives us and that we must work to protect the public, not be someone they need protection from. These are key principles to being professional and are at the very core of professional behaviour: it’s these boundaries that help us behave in a professional way.
What are good boundaries?
• Not overstepping the line between professional and personal relationships.
• Being able to say ‘No’ when it’s appropriate.
• Always putting the patient and the patient’s needs before your own.
• Making certain that you act in a way that maintains trust and upholds the reputation and image of nursing and nurses.
Some simple ways to keep good boundaries
• Don’t give patients your personal contact details.
• Don’t ever keep a ‘secret’: as a professional, you must work with the team. Don’t flatter yourself into thinking that you have a ‘special’ relationship with a patient. If the patient speaks to you it can’t be a secret because it’s part of your professional role to communicate with others in the team. Secrets are something you tell friends, not healthcare professionals.
• Do your job: you have to know what things are your responsibility to take care of and what things aren’t. If your patient is in a domestic abuse situation but you are not her counsellor or social worker, then you shouldn’t try to do the counsellor’s or social worker’s job. Focus on doing your job and supporting others in theirs, not trying to do their job for them.
• Don’t tell too much about yourself: it is not appropriate to focus your interactions on yourself. Let me give you an example: I have an obvious American accent and patients often ask where I am from. I can’t really say ‘Let’s not talk about me …’ it would seem rude. So, I tell them where I am from and ask them where they are from. I try to move the conversation around to get them talking about themselves. Would I love to stand there and chat non-stop about America? Probably. But that’s not what I am there for.
Boundaries are also very important to your co-workers
The things you do will set a precedent for other staff. Your behaviour can teach your patients what to expect from nurses and other staff. If you always bring them a chocolate bar from home they might start to wonder why others don’t.
If you find yourself doing ‘extras’ for patients, you need to look closely at your behaviour:
• Are there certain kinds of patients for whom you do extras and some for whom you don’t?
• Are you setting up unfair expectations that other staff might have to cope with?
• Are you treating the patient with dignity and respect?
• What are your motives? Be really honest with yourself: is this about the patient or about trying to look good?
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