Journal of Advanced Nursing 1979, 4, 3-8
Mobilizing nursing skiiis* . Robertmffany S.R.N. R.C.N.T. Director of Nursing, Royal Marsden Hospital, London and Surrey Accepted for publication 20 June 1978
TIFFANY R . (1979) Journal of Advanced Nursing 4, 3-8
Mobilizing Nursing Skills The author argues that the practice of nursing should be based on the 'nursing model' related to care, not the 'medical model' related to cure. Using the nursing model entails making an assessment of the patient's needs and an individualized nursing care plan to meet them. It is conceded that the historical development of nursing practice as a series of stereotyped, ritualized activities within a hierarchical profession militates against implementing the nursing model; but the author illustrates how the Royal Marsden Hospital, a specialist hospital for the treatment of cancer patients, has innovated and developed the concept, as well as creating specialist roles for nurses who maintain continuity of patient care from the first appointment in the hospital's outpatients' clinic through to his after-care following his discharge home.
INTRODUCTION The title of this paper immediately poses two questions. Firstly, what kind of solutions are nurses seeking and what is the underlying prohlem that requires a solution; and secondly, what skills do nurses have or need to acquire to enahle these solutions to be within their grasp. In attempting to answer these questions it is necessary to define the particular and unique contribution of the nurse and to review nursing practice in its historical context, present day setting and future development. Nursing has been defined as a caring process and perhaps it is helpful to use Virginia Henderson's (1966) definition of nursing as a basis for discussion, and then to compare the role and function of the nurse with that of her medical colleagues: 'The unique function of the nurse is to assist the individual sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that they would perform unaided if they had the necessary strength, will or knowledge. It is likewise the unique contribution of nursing to help people be independent of such assistance as soon as possible.' * Based on a paper read at the ioth Annual Symposium of the Marie Curie Memorial Foundaiion, London, 16 May 1978. 0309-2402/79/oioo-ooo3$02.oo ©1979 Blackwell Scientific Publications 3
4
Robert Tiffany
Based on this definition. Professor Jean McFarlane (1975) compared the medical approach to disease prohlems with the nursing approach, viz: Medical Model: Diagnosis -> Treatment -^ Cure Nursing Model: Assessment -^ Help and assistance -> Self care The medical model begins with diagnosis based upon symptoms and investigation and progresses to treatment by a variety of modahties in an attempt to achieve a cure and, where cure is not possible, the remission of symptoms and the alleviation of distress. It is within this philosophical framework that Medicine directs its resources, both human and financial: better diagnostic machinery and the search for new diagnostic methods; improved methods of treatment increasingly based upon a multi-disciplinary or rather interdisciplinary approach; and research into the nature of the disease, its diagnosis, its treatment and the differential cure rates for the different modalities of treatment. THE N U R S I N G M O D E L The nursing model begins with assessment. First of all into the deficiency of selfcare, brought about by the disease, its treatment and the patient's reaction to both. In addition sociological and psychological factors have to be considered. One cannot consider disease as an isolated physical entity. It takes place within a context and that context is the total environment of the patient. In assessing the emotional needs of patients with cancer it must be remembered that each patient will react to his diagnosis, treatment and prognosis in a different way. The elderly grandmother living alone and the young husband with a family and a mortage might be expected to react very differently to life threatening illness. Failure to assess the social and emotional status of the patient will not result in the problems disappearing. But failure to recognise the importance of those aspects along with the physical needs of the patient can result in heightened anxiety, which in turn will affect the physical recovery of the patient, in addition to creating overt and covert psychological problems. Having assessed the needs, a nursing assessment can be made. This nursing assessment is dynamic and requires frequent review and modification unlike the medical diagnosis which is usually constant throughout a course of treatment. Following the assessment of patient needs it is necessary to make an individuaUzed nursing plan that will offer help and assistance to the patient according to his particular needs. This differs from the historical concept of nursing in which a series of stereotyped activities, based upon tradition and imputed preferences, were ritually performed by nurses following the pronouncement of a medical diagnosis. The aim and objective of this individualized care is to promote independence as soon as possible so that self-care can be achieved. By allowing the patient and
Mobilizing nursing skills
5
his family to participate in the planning it should be possible to set short and long term goals that can be measured and monitored together, to see if progress is being made. Where self-care cannot be achieved, maximum independence within the community, utihzing the support of domicihary agencies should be considered. Where continued hospitalization is required it is an essential nursing function to maintain the patients' dignity and as much independence as the patients' condition will allow, so that patients can feel that they are still in control of their own destiny.
Nursing solutions In comparing the nursing and medical models, it must be stressed that nursing solutions are not synonymous with medical solutions. Care is required at all stages during a patient's illness and it is not dependent upon cure for a successful outcome. In fact in many situations it may be after cure has been achieved that the real process of caring begins. Furthermore, where there is failure to achieve a cure, successful nursing intervention can offer a solution. It is essential that nurses caring for the patient with cancer must understand the effects the disease and its treatment has upon the patient and his family. They must also possess human relationship skills necessary to offer support and assistance during this difficult period; practical skills to make effective nursing intervention to prevent, minimize and treat problems that come within their sphere of authority; and the technical knowledge and skills that are required in caring for patients undergoing increasingly sophisticated and complex forms of therapy. If the nursing profession is to continue to make an eflfective contribution in the increasingly complex field of care of cancer patients, it must examine its role and function in depth and be prepared to make the necessary changes that are required. There have already been great changes in British nursing education. No one can doubt that nursing management has expanded and developed its role significantly in the past io years as co-equals in multi-disciplinary teams with a consensus decision making process related to the health care planning and administration. But what of nursing practice e There has been a great deal of publicity and controversy recently about nurses extending their clinical role. Perhaps expanding is a better word, for it suggests professional growth in depth as well as width and offers heights that can he achieved.
A dilemma in the nursing profession One of the difficulties in the nursing profession is a behef that all nurses are the same and that they are generalists. The distinction of competence and the authority to perform certain functions is often based on a system of seniority that does not take into account individual differences, preferences or abilities of particular nurses. British nurses have become so attached to this concept that it is often thought right and possible to move nurses from one nursing area to another without lowering standards of care, provided adequate numbers are maintained.
6
Robert Tiffany
RosemaryWhite (1977) has accurately outlined the problem: every registered nurse is expected to know about the complexities of modern drugs throughout the whole spectrum of the pharmacopoeia, to know how to perform a whole battery of complex technical procedures, console grieving relatives, care for children and old people, go into patients' homes to care for patients with a variety of illnesses and to be an educator for relatives caring for their famiUes. Furthermore, nurses do not yet seem to be sufficiently secure to be able to go to nursing colleagues for advice even though it is quite acceptable for the doctor to refer his patient to a specialist for a second opinion. The consultant physician feels free to refer his patient to a surgeon (and vice-versa). Unfortunately this convention is taking time to be generally accepted in the nursing profession. But if the nursing profession does not avail itself of the in-depth knowledge of specialist nurses and continues to beHeve that the general nurse must know it all, it will continue to be a profession broadly based in knowledge but sadly lacking in depth. Dr Charlotte Kratz (1976) has made the interesting suggestion that two kinds of specialist nurse are required. One with a small 's', which is the nurse who has developed special skills in a specialty such as oncology, and one with a capital'S', who has in-depth skills in a particular aspect of the specialty and who can act as consultant to other nurses working within the specialty. An example of the latter could be the stoma care nurse. THE C O M M I T M E N T NEEDED The philosophy and concepts outlined above and which I beheve are necessary in order to mobilize nursing skills, to offer solutions to the problems of patients with cancer, can be summarized as follows: 1 It is necessary to defme the unique and particular role of the nurse caring for the patient with cancer and to examine those areas of care to which she makes a contribution with members of other health care professions. 2 There is a need for more individuahzed care. This is more than just aboHshing task lists and allocating individual nurses to individual patients. It means the dismantling of stereotyped and ritualized care and substituting specific nursing activities tailored to meet the particular requirements and varied needs of individual patients. This can only be achieved by assessing patient needs, the identification of a nursing diagnosis and the implementation of a specific care plan to meet the particular needs of individual patients. 3 There is a need for more specialization in nursing so that a base of in-depth knowledge can be estabhshed upon which to base nursing practices and procedures. This specialization is probably required at two levels and obviously requires considerable educational and research input. Experiences at The Royal Marsden Hospital The philosophy outlined above has been adopted in The Royal Marsden Hospital
Mobilizing nursing skills
7
and the effects that this has had on nursing practice and patient care have been revolutionary and exciting. As progress has been made towards personalizing patient care a greater professional awareness has developed. Nurses are discovering that clinical work can be as rewarding and often more stimulating than opting for administrative or educational roles, which previously appeared to be the only avenues open to nurses who wished to use their initiative and decision-making skills. Many 'routine' tasks that were rituaUy performed but of dubious therapeutic value have been aboHshed. New skills have been acquired; skills in dealing with the emotional aspects of care and also new skills in the technical sphere where new developments are almost constant. As clinical knowledge and competence have developed a more multidisciplinary approach to care has been fostered where the parameters of care are not clearly defined between the health care professionals, and where blurring the edges of professional roles allows the more appropriate practitioner to utilize their skills for the optimal benefit of the patient. The introduction of clinical nurse speciahsts into a variety of areas has provided clinical leadership, helped to defme nursing needs, helped to identify and analyze problems, assisted in the seeking of solutions and, what is more important, helped to demonstrate and provide effective care for patients. The results of the introduction of clinical nurse specialists has been an increase in awareness amongst nursing staff of their own worth and the unique contribution to patient care that they are able to make. Nursing knowledge is being built up, and the dissemination of this has already improved the overall care of the patients. As nursing knowledge and skills have been developed to such a level that the expertise is easily recognizable, it has been possible to establish nursing clinics that run parallel to and are complementary to those of medical colleagues. One example of such a development is the care now offered to mastectomy patients. It has to be recognized that although a great deal of effort has been put into the curative element of care, the results today are hardly better than 20 years ago. Perhaps the advent of adjuvant chemotherapy may change this, but only time will tell. Coupled vdth this fact is the knowledge of considerable psychological trauma and altered daily living patterns of those cured of the disease.
Continuity of Care A service has now been estabhshed at The Royal Marsden Hospital where a nurse begins to estabhsh a relationship with the patient in the outpatient department, follows the patient through all the stages of treatment, offering support to the patient and expertise to other nurses caring for the patient, fits the most appropriate prosthesis and, with the community liaison nurse and the ward sister, makes plans for discharge. At her own non-medical mastectomy clinic the nurse can follow up on problems that need help and support and thus provide a continuity of nursing care from diagnosis to after-care. It is hoped that such nursing action will greatly improve the quahty of life for mastectomy patients which should be
8
Robert Tiffany
measured as success, even if there is a failure to cure. Where cure has been achieved it is hoped that the psychological trauma accompanying this particular surgical procedure will have been removed completely, or at least minimized. The Royal Marsden Hospital is not unique in developing speciahst roles for nurses, although as a specialist centre it has played a major role in encouraging nursing developments in oncology. Nurses have and are continuing to develop skills that can be mobilized to provide effective care for patient with cancer. The solutions to many problems are certainly within the grasp of nurses, provided they have the necessary vision, maturity and courage to stretch out their hands and take them.
References HENDERSON V. (1966) The Nature of Nursing: A Definition and its Implications for Practice, Research
and Education. Macmillan, New York. MCFARLANE J.K. (1975) What Do We Mean By Care. Nursing Mirror 141, No. 14, 47. WHITE R. (1977) Mature or Matutinal. Nursing Mirror 144, No. 16, 41. KRATZ C . (1976) The Clinical Nurse Consultant. Nursing Times 72, No. 46, 1792-3.
Mobilizing nursing skiiis* . Robertmffany S.R.N. R.C.N.T. Director of Nursing, Royal Marsden Hospital, London and Surrey Accepted for publication 20 June 1978
TIFFANY R . (1979) Journal of Advanced Nursing 4, 3-8
Mobilizing Nursing Skills The author argues that the practice of nursing should be based on the 'nursing model' related to care, not the 'medical model' related to cure. Using the nursing model entails making an assessment of the patient's needs and an individualized nursing care plan to meet them. It is conceded that the historical development of nursing practice as a series of stereotyped, ritualized activities within a hierarchical profession militates against implementing the nursing model; but the author illustrates how the Royal Marsden Hospital, a specialist hospital for the treatment of cancer patients, has innovated and developed the concept, as well as creating specialist roles for nurses who maintain continuity of patient care from the first appointment in the hospital's outpatients' clinic through to his after-care following his discharge home.
INTRODUCTION The title of this paper immediately poses two questions. Firstly, what kind of solutions are nurses seeking and what is the underlying prohlem that requires a solution; and secondly, what skills do nurses have or need to acquire to enahle these solutions to be within their grasp. In attempting to answer these questions it is necessary to define the particular and unique contribution of the nurse and to review nursing practice in its historical context, present day setting and future development. Nursing has been defined as a caring process and perhaps it is helpful to use Virginia Henderson's (1966) definition of nursing as a basis for discussion, and then to compare the role and function of the nurse with that of her medical colleagues: 'The unique function of the nurse is to assist the individual sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that they would perform unaided if they had the necessary strength, will or knowledge. It is likewise the unique contribution of nursing to help people be independent of such assistance as soon as possible.' * Based on a paper read at the ioth Annual Symposium of the Marie Curie Memorial Foundaiion, London, 16 May 1978. 0309-2402/79/oioo-ooo3$02.oo ©1979 Blackwell Scientific Publications 3
4
Robert Tiffany
Based on this definition. Professor Jean McFarlane (1975) compared the medical approach to disease prohlems with the nursing approach, viz: Medical Model: Diagnosis -> Treatment -^ Cure Nursing Model: Assessment -^ Help and assistance -> Self care The medical model begins with diagnosis based upon symptoms and investigation and progresses to treatment by a variety of modahties in an attempt to achieve a cure and, where cure is not possible, the remission of symptoms and the alleviation of distress. It is within this philosophical framework that Medicine directs its resources, both human and financial: better diagnostic machinery and the search for new diagnostic methods; improved methods of treatment increasingly based upon a multi-disciplinary or rather interdisciplinary approach; and research into the nature of the disease, its diagnosis, its treatment and the differential cure rates for the different modalities of treatment. THE N U R S I N G M O D E L The nursing model begins with assessment. First of all into the deficiency of selfcare, brought about by the disease, its treatment and the patient's reaction to both. In addition sociological and psychological factors have to be considered. One cannot consider disease as an isolated physical entity. It takes place within a context and that context is the total environment of the patient. In assessing the emotional needs of patients with cancer it must be remembered that each patient will react to his diagnosis, treatment and prognosis in a different way. The elderly grandmother living alone and the young husband with a family and a mortage might be expected to react very differently to life threatening illness. Failure to assess the social and emotional status of the patient will not result in the problems disappearing. But failure to recognise the importance of those aspects along with the physical needs of the patient can result in heightened anxiety, which in turn will affect the physical recovery of the patient, in addition to creating overt and covert psychological problems. Having assessed the needs, a nursing assessment can be made. This nursing assessment is dynamic and requires frequent review and modification unlike the medical diagnosis which is usually constant throughout a course of treatment. Following the assessment of patient needs it is necessary to make an individuaUzed nursing plan that will offer help and assistance to the patient according to his particular needs. This differs from the historical concept of nursing in which a series of stereotyped activities, based upon tradition and imputed preferences, were ritually performed by nurses following the pronouncement of a medical diagnosis. The aim and objective of this individualized care is to promote independence as soon as possible so that self-care can be achieved. By allowing the patient and
Mobilizing nursing skills
5
his family to participate in the planning it should be possible to set short and long term goals that can be measured and monitored together, to see if progress is being made. Where self-care cannot be achieved, maximum independence within the community, utihzing the support of domicihary agencies should be considered. Where continued hospitalization is required it is an essential nursing function to maintain the patients' dignity and as much independence as the patients' condition will allow, so that patients can feel that they are still in control of their own destiny.
Nursing solutions In comparing the nursing and medical models, it must be stressed that nursing solutions are not synonymous with medical solutions. Care is required at all stages during a patient's illness and it is not dependent upon cure for a successful outcome. In fact in many situations it may be after cure has been achieved that the real process of caring begins. Furthermore, where there is failure to achieve a cure, successful nursing intervention can offer a solution. It is essential that nurses caring for the patient with cancer must understand the effects the disease and its treatment has upon the patient and his family. They must also possess human relationship skills necessary to offer support and assistance during this difficult period; practical skills to make effective nursing intervention to prevent, minimize and treat problems that come within their sphere of authority; and the technical knowledge and skills that are required in caring for patients undergoing increasingly sophisticated and complex forms of therapy. If the nursing profession is to continue to make an eflfective contribution in the increasingly complex field of care of cancer patients, it must examine its role and function in depth and be prepared to make the necessary changes that are required. There have already been great changes in British nursing education. No one can doubt that nursing management has expanded and developed its role significantly in the past io years as co-equals in multi-disciplinary teams with a consensus decision making process related to the health care planning and administration. But what of nursing practice e There has been a great deal of publicity and controversy recently about nurses extending their clinical role. Perhaps expanding is a better word, for it suggests professional growth in depth as well as width and offers heights that can he achieved.
A dilemma in the nursing profession One of the difficulties in the nursing profession is a behef that all nurses are the same and that they are generalists. The distinction of competence and the authority to perform certain functions is often based on a system of seniority that does not take into account individual differences, preferences or abilities of particular nurses. British nurses have become so attached to this concept that it is often thought right and possible to move nurses from one nursing area to another without lowering standards of care, provided adequate numbers are maintained.
6
Robert Tiffany
RosemaryWhite (1977) has accurately outlined the problem: every registered nurse is expected to know about the complexities of modern drugs throughout the whole spectrum of the pharmacopoeia, to know how to perform a whole battery of complex technical procedures, console grieving relatives, care for children and old people, go into patients' homes to care for patients with a variety of illnesses and to be an educator for relatives caring for their famiUes. Furthermore, nurses do not yet seem to be sufficiently secure to be able to go to nursing colleagues for advice even though it is quite acceptable for the doctor to refer his patient to a specialist for a second opinion. The consultant physician feels free to refer his patient to a surgeon (and vice-versa). Unfortunately this convention is taking time to be generally accepted in the nursing profession. But if the nursing profession does not avail itself of the in-depth knowledge of specialist nurses and continues to beHeve that the general nurse must know it all, it will continue to be a profession broadly based in knowledge but sadly lacking in depth. Dr Charlotte Kratz (1976) has made the interesting suggestion that two kinds of specialist nurse are required. One with a small 's', which is the nurse who has developed special skills in a specialty such as oncology, and one with a capital'S', who has in-depth skills in a particular aspect of the specialty and who can act as consultant to other nurses working within the specialty. An example of the latter could be the stoma care nurse. THE C O M M I T M E N T NEEDED The philosophy and concepts outlined above and which I beheve are necessary in order to mobilize nursing skills, to offer solutions to the problems of patients with cancer, can be summarized as follows: 1 It is necessary to defme the unique and particular role of the nurse caring for the patient with cancer and to examine those areas of care to which she makes a contribution with members of other health care professions. 2 There is a need for more individuahzed care. This is more than just aboHshing task lists and allocating individual nurses to individual patients. It means the dismantling of stereotyped and ritualized care and substituting specific nursing activities tailored to meet the particular requirements and varied needs of individual patients. This can only be achieved by assessing patient needs, the identification of a nursing diagnosis and the implementation of a specific care plan to meet the particular needs of individual patients. 3 There is a need for more specialization in nursing so that a base of in-depth knowledge can be estabhshed upon which to base nursing practices and procedures. This specialization is probably required at two levels and obviously requires considerable educational and research input. Experiences at The Royal Marsden Hospital The philosophy outlined above has been adopted in The Royal Marsden Hospital
Mobilizing nursing skills
7
and the effects that this has had on nursing practice and patient care have been revolutionary and exciting. As progress has been made towards personalizing patient care a greater professional awareness has developed. Nurses are discovering that clinical work can be as rewarding and often more stimulating than opting for administrative or educational roles, which previously appeared to be the only avenues open to nurses who wished to use their initiative and decision-making skills. Many 'routine' tasks that were rituaUy performed but of dubious therapeutic value have been aboHshed. New skills have been acquired; skills in dealing with the emotional aspects of care and also new skills in the technical sphere where new developments are almost constant. As clinical knowledge and competence have developed a more multidisciplinary approach to care has been fostered where the parameters of care are not clearly defined between the health care professionals, and where blurring the edges of professional roles allows the more appropriate practitioner to utilize their skills for the optimal benefit of the patient. The introduction of clinical nurse speciahsts into a variety of areas has provided clinical leadership, helped to defme nursing needs, helped to identify and analyze problems, assisted in the seeking of solutions and, what is more important, helped to demonstrate and provide effective care for patients. The results of the introduction of clinical nurse specialists has been an increase in awareness amongst nursing staff of their own worth and the unique contribution to patient care that they are able to make. Nursing knowledge is being built up, and the dissemination of this has already improved the overall care of the patients. As nursing knowledge and skills have been developed to such a level that the expertise is easily recognizable, it has been possible to establish nursing clinics that run parallel to and are complementary to those of medical colleagues. One example of such a development is the care now offered to mastectomy patients. It has to be recognized that although a great deal of effort has been put into the curative element of care, the results today are hardly better than 20 years ago. Perhaps the advent of adjuvant chemotherapy may change this, but only time will tell. Coupled vdth this fact is the knowledge of considerable psychological trauma and altered daily living patterns of those cured of the disease.
Continuity of Care A service has now been estabhshed at The Royal Marsden Hospital where a nurse begins to estabhsh a relationship with the patient in the outpatient department, follows the patient through all the stages of treatment, offering support to the patient and expertise to other nurses caring for the patient, fits the most appropriate prosthesis and, with the community liaison nurse and the ward sister, makes plans for discharge. At her own non-medical mastectomy clinic the nurse can follow up on problems that need help and support and thus provide a continuity of nursing care from diagnosis to after-care. It is hoped that such nursing action will greatly improve the quahty of life for mastectomy patients which should be
8
Robert Tiffany
measured as success, even if there is a failure to cure. Where cure has been achieved it is hoped that the psychological trauma accompanying this particular surgical procedure will have been removed completely, or at least minimized. The Royal Marsden Hospital is not unique in developing speciahst roles for nurses, although as a specialist centre it has played a major role in encouraging nursing developments in oncology. Nurses have and are continuing to develop skills that can be mobilized to provide effective care for patient with cancer. The solutions to many problems are certainly within the grasp of nurses, provided they have the necessary vision, maturity and courage to stretch out their hands and take them.
References HENDERSON V. (1966) The Nature of Nursing: A Definition and its Implications for Practice, Research
and Education. Macmillan, New York. MCFARLANE J.K. (1975) What Do We Mean By Care. Nursing Mirror 141, No. 14, 47. WHITE R. (1977) Mature or Matutinal. Nursing Mirror 144, No. 16, 41. KRATZ C . (1976) The Clinical Nurse Consultant. Nursing Times 72, No. 46, 1792-3.
