Nursing Practice in Pakistan: Holding aloft Professional Ideals through Thick and Thin
There is quite a bit of literature that critiques the profession of Nursing as a discipline essentially tied up with many other fields of study. It is widely considered that nursing knowledge is borrowed from other disciplines such as psychology, sociology and public health; and thus, the profession seemingly has little to show for its own unique identity. This argument may be all very well in its own right, but if I were to take nursing in a global context, it is its central ‘holistic approach’ that I appreciate most. To me, nurses’ varied role in providing need-based individualistic care is exactly what makes the profession stand a mile apart. Though countless writers have noted the very same point before, I would like to explore the issue drawing upon my own insights and experience.
For instance, in a patient with myocardial infarction (MI), many specialists would be engaged in providing health care. The nutritionist would plan the dietary regimen according to the patient’s needs, the psychologist would extend emotional care, and the physiotherapist would be called on to deliver need-based physical therapy to the patient… so on and so forth, all working for the patient’s well-being. Now the question arises: what is the role of nurses here in providing care to that MI patient? What is so special and unique about nursing care, particularly when other professionals are providing all the relevant care to the patient according to their specialty and expertise?
In my opinion, the nurse’s job is to coordinate all aspects of medical care:to ensure that well-planned, need-based holistic care finally reaches the patient. This individualistic and context bound approach is the essence of the nursing profession. The nurse must assess and address physical, spiritual and socioeconomic needs of their patients all at once.
Additionally,bear in mind the current scenario of healthcare in Pakistan, where poverty and illiteracy are added burdens, making quality healthcare inaccessible at grass root level. Often nurses are the only ones with the know-how and the liberty to channel limited financial resources to the patient’s best advantage. Many a times, it is the nurse who is the patient’s ambassador and advocate.
Let us return to the example of the MI patient. Now, the psychologist need not worry about the patient’s bed sores, but nurses do and so they take care to reposition patients frequently to prevent pressure sores. This is just one of the countless ways that nurses combine the fragmented care from all specialists under one umbrella, to promote the all-round well being of the patient. This ‘holistic approach’ threads through all of nursing practice and makes the discipline epistemologically unified. Its integration in real practice, however, remains a question mark.
Having examined the textbook role of nurses in healthcare, it is time to turn to the reality of nursing practice in Pakistan, and ask how that measures up against our professional ideals. Upon initially encountering the national nursing curriculum, and comparing it with the medical curriculum, the former seemed to me fairly comprehensive. However, I have been part of this system for quite some time now, and my impression has changed. Now I see a few major gaps in our curriculum.
For example, we have an approved course on Reproductive Health. When our students go for clinical rotations, the male students are invariably deprived of exposure to the labour room, as we nurses opt for providing culturally sensitive care. This excludes our male students from the antenatal, postnatal and prenatal care areas.
Since hands-on experience is part of the course objectives, it throws a real challenge to nursing faculty as well as to male students. There is no way but to come up with a compromised alternative to fulfill their clinical course objectives. I shall discuss this further in addressing the second question of gender epistemology.
My second point concerns nurses’ preparedness, whether the nursing curriculum is really flexible enough to address the current national needs, as it strives to be. To this end we have included a ‘care of the elderly’ course in our undergraduate nursing program. But when it comes to practice setting and even in the introduction of such courses in academia, there remain real challenges to be overcome. Have we paid enough attention to professional development of the faculty members in this specialty field?
Are we nurses really making a significant impact in terms of lowering morbidity and mortality of elderly community in our country? The answer is unfortunately, no. The issue of preparing nurses according to the specific needs of our population lingers on the periphery of our attention. Institutional commitment to this goal is of utmost importance.
The “person-centered care” is the unique focus of nurses; however work environment and work demands can change that if the importance of this focus is not understood by the non-nursing personnel one works for and reports to. Ask any hospital nurse if they are able to provide patient-centered care, and the answer will reveal the disconnect between the ‘ideal’ and ‘actual’ state of affairs.
Personally, I think the entire nursing curriculum needs to be revamped, seriously! And to do that, the workflow processes in hospital units, clinics, and community setting should be directly observed, and that insight should be used to design and develop the curriculum, content, and delivery modes. Ask a nurse how much of what she learned in nursing school she uses in her day to day work setting. What do we think her answer will be?
One solution is to emphasize the learning value of inter-professional classes; where various team members learn and practice in a class together. For a long time, nursing has isolated itself from the “care team.” Point to ponder is this: do we adequately train nurses how to influence other team members, how to communicate effectively with a team, how to truly listen to everyone on the team, how to coach and how to resolve a conflict?
As nursing is an intensely people-oriented profession, I believe only when no less than half our nursing education focuses on these behavioral, psychological, problem solving, critical thinking, and human interactive skills, (and the remaining half on human body, health and illness patterns), will our nurses succeed in achieving higher levels of personal satisfaction as well as patient and team satisfaction.
When we ask patients what they like best about their care, they do not say ‘I loved getting this or that diagnosis’, or ‘I am so happy that my doctor used so-and-so technology to treat my cancer’. Rather, what their care impresses upon them most deeply is whether the staff was helpful, whether the nurses answered their queries and if their doctor treated them as a human being or just a case. We have it all wrong in terms of what we emphasize in nursing education!
‘It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.’ – William Osler.
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