ProfessionalPractice Why Cross-Training
S
OME currently popular models of health care delivery foster the notion of the economic paradigm of the patient and the nurse, in which the nurse is seen as a skilled taskmaster who possesses the interpersonal qualities of kindness and compassion. A result of this thinking is the belief that ancillary clinical personnel can be cross-trained to provide nursing care. It is our observation, however, that clinical nurses strongly reject this idea because they perceive themselves as owning a practice rather than simply performing a job. We have examined the work of philosopher Alasdair MacIntyre (198 1) and Dr Patricia Benner (1991) to understand why this is so. According to MacIntyre (198 1) one of the hallmarks of a practice, whether it be nursing or playing chess, is that “internal goods” are embedded in it. To become excellent in the practice of nursing, for example, one must achieve certain standards of skilled practical knowledge, moral judgment, and patient advocacy. agency, discretionary Practices may also have external goods, such as money, but what constitutes a practice is that excellence resides in realizing the internal goods inherent in that practice. Because caring is the foundation of the practice of nursing as well as its moral imperative, Benner (1991) posits that getting the practice “right” requires a response to the human concerns of the individual patient in a particular situation. Such goods as preserving dignity, control, and autonomy, or mobilizing hope in situations of fear, suffering, and breakdown cannot be taught by rules. These caring practices can be learned only within the rich tradition of nursing practice, which reflects how the human skill of caring has evolved over time in many concrete situations. It is in narrative accounts of these specific situations rather than in rules that we come closest to describing the situated practical knowledge that is continually being developed and lived out in the practice. The following exemplar by Elizabeth Davy, RN, illustrates how she brought her knowledge of the practice to ELOISEM. BALASCO, RN Vice President for Nursing THOMAS W. CATHCART Senior Vice President
Won’t Work bear on the situation vulnerability:
in a time of extreme
Peggy was having a colonoscopy because of rectal bleeding, pain, and an abnormal barium enema, and was extremely anxious upon arrival in the Endoscopy Room. Peggy was sure she had colon cancer and felt she couldn’t deal with any more problems. Her husband was recently diagnosed with lung cancer, for which he was being treated with radiation, but had still only been given six months to live. A large polyp was found in the sigmoid colon and when Peggy saw it on the video screen she began to so&for herself and for her husband. I was able to help her cry-something she really hadn’t done since her husband’s diagnosis and her subsequent care of him. The physician thought the polyp was too big to remove, and that surgery would be required. Peggy responded that surgery was out of the question, because she felt at this time she needed to care for her husband. I personally felt that the polyp could be removed safely. My experience with endoscopic polypectomies was extensive; I knew that this could be done and felt very secure in this decision. I voiced my opinion to the physician, and included Peggy in this discussion. Dr. M. agreed to try, and very successfully removed the polyp in two pieces, arduous as the task was. The next evening I received a phone call at home
from Peggy. She thanked me for letting her cry, for supporting her through the procedure, but mostly for helping the physician successfully and confidently remove the polyp! There are no rules that Elizabeth Davy could have consulted to define what good caring was in this situation. Her behavior comes out of the tradition of nursing, a complex, historical, still-evolving fabric of caring attitudes, skills, and practices that is not easily annexed by persons outside the tradition. She gave excellent nursing care to her patient because in both her professional education and her continued growth in the practice she has thought of herself as a nurse. and has learned by placing herself under the tutelage of the best standards of the practice of nursing as they have been handed down and reworked from one generation of nurses to another. This knowledge of nursing practice could, of course, be learned in the same way by persons of other disciplines, but such learning would be more than cross-training; it would be nursing education. References
Mercy Hospital
144 State St Portland, ME 04 10 1
Copyright 0 1992 by W.B.
of her patient
Saunders Company
8755-7223/92/0802-0001$03.00/0
Journal of Professional Nursing,
Vol 8, No 2 (March-April),
MacIntyre, A. (198 I). After virtur. Notre sity of Notre Dame Press. Benner, P. (199 1). The role of experience, munity. AdvanceJ in Nursing Science. 24(2).
1992:
p 69
Dame,
IN: Univer-
narrative
and com-
S
OME currently popular models of health care delivery foster the notion of the economic paradigm of the patient and the nurse, in which the nurse is seen as a skilled taskmaster who possesses the interpersonal qualities of kindness and compassion. A result of this thinking is the belief that ancillary clinical personnel can be cross-trained to provide nursing care. It is our observation, however, that clinical nurses strongly reject this idea because they perceive themselves as owning a practice rather than simply performing a job. We have examined the work of philosopher Alasdair MacIntyre (198 1) and Dr Patricia Benner (1991) to understand why this is so. According to MacIntyre (198 1) one of the hallmarks of a practice, whether it be nursing or playing chess, is that “internal goods” are embedded in it. To become excellent in the practice of nursing, for example, one must achieve certain standards of skilled practical knowledge, moral judgment, and patient advocacy. agency, discretionary Practices may also have external goods, such as money, but what constitutes a practice is that excellence resides in realizing the internal goods inherent in that practice. Because caring is the foundation of the practice of nursing as well as its moral imperative, Benner (1991) posits that getting the practice “right” requires a response to the human concerns of the individual patient in a particular situation. Such goods as preserving dignity, control, and autonomy, or mobilizing hope in situations of fear, suffering, and breakdown cannot be taught by rules. These caring practices can be learned only within the rich tradition of nursing practice, which reflects how the human skill of caring has evolved over time in many concrete situations. It is in narrative accounts of these specific situations rather than in rules that we come closest to describing the situated practical knowledge that is continually being developed and lived out in the practice. The following exemplar by Elizabeth Davy, RN, illustrates how she brought her knowledge of the practice to ELOISEM. BALASCO, RN Vice President for Nursing THOMAS W. CATHCART Senior Vice President
Won’t Work bear on the situation vulnerability:
in a time of extreme
Peggy was having a colonoscopy because of rectal bleeding, pain, and an abnormal barium enema, and was extremely anxious upon arrival in the Endoscopy Room. Peggy was sure she had colon cancer and felt she couldn’t deal with any more problems. Her husband was recently diagnosed with lung cancer, for which he was being treated with radiation, but had still only been given six months to live. A large polyp was found in the sigmoid colon and when Peggy saw it on the video screen she began to so&for herself and for her husband. I was able to help her cry-something she really hadn’t done since her husband’s diagnosis and her subsequent care of him. The physician thought the polyp was too big to remove, and that surgery would be required. Peggy responded that surgery was out of the question, because she felt at this time she needed to care for her husband. I personally felt that the polyp could be removed safely. My experience with endoscopic polypectomies was extensive; I knew that this could be done and felt very secure in this decision. I voiced my opinion to the physician, and included Peggy in this discussion. Dr. M. agreed to try, and very successfully removed the polyp in two pieces, arduous as the task was. The next evening I received a phone call at home
from Peggy. She thanked me for letting her cry, for supporting her through the procedure, but mostly for helping the physician successfully and confidently remove the polyp! There are no rules that Elizabeth Davy could have consulted to define what good caring was in this situation. Her behavior comes out of the tradition of nursing, a complex, historical, still-evolving fabric of caring attitudes, skills, and practices that is not easily annexed by persons outside the tradition. She gave excellent nursing care to her patient because in both her professional education and her continued growth in the practice she has thought of herself as a nurse. and has learned by placing herself under the tutelage of the best standards of the practice of nursing as they have been handed down and reworked from one generation of nurses to another. This knowledge of nursing practice could, of course, be learned in the same way by persons of other disciplines, but such learning would be more than cross-training; it would be nursing education. References
Mercy Hospital
144 State St Portland, ME 04 10 1
Copyright 0 1992 by W.B.
of her patient
Saunders Company
8755-7223/92/0802-0001$03.00/0
Journal of Professional Nursing,
Vol 8, No 2 (March-April),
MacIntyre, A. (198 I). After virtur. Notre sity of Notre Dame Press. Benner, P. (199 1). The role of experience, munity. AdvanceJ in Nursing Science. 24(2).
1992:
p 69
Dame,
IN: Univer-
narrative
and com-
