Tracey McDonald
I am sure many of you have wondered, as have I, what becomes of the graduates that we come to know during the years of undergraduate career preparation. Is the knowledge and skill repertoire gained during their degree adequate in the world beyond the university? Are they merely surviving out there, or are they able to make and take opportunities that go well beyond the basics learned as undergraduates? These questions are increasingly pertinent for nursing in Australia. Rapid change and development within our socio-political environment has altered the traditional territorial stereotypes of health personnel as the focus increasingly shifts to a more utilitarian approach to individual and population health.
There remain certain disciplinary fundamentals to be imparted to all neophytes along with certain generic qualities and skills that are expected of university graduates but what of the less tangible resources that enhance the confidence and enthusiasm of qualified people in their field of expertise? Feelings of power and confidence in one's ability to influence work environments in order to achieve personal and professional goals are hallmarks of all true professionals. In the health arena, graduates of nursing enter a world in which potential and actual human tragedies become the focus of several disciplines that operate in a collaborative yet competitive way to provide health-related services to the public. (McDonald 1994) The economic and human imperatives in health services at times compete for priority and cause less experienced nurses to deal with the dilemmas that arise from increasing demands for shrinking resources. Professional practice in such an environment is not for the faint-hearted. Sub-standard and out-moded care results in hardship for patients and their families and this places pressure on students to become proficient in intellectual as well as psychomotor skills. To do this, students need relevant and timely learning experiences delivered within a supportive context, without fostering student complacency. Content must be current, pitched at the leading edge of the discipline and take into account developments in associated industries and disciplines. This is by no means an easy task to achieve in an environment of rapid technological development coupled with stereotypical expectations of nurses held by the general public, other health workers and managers and often, nurses themselves.
Constrained opportunity for role developments in nursing stem from its vocation-based origins. The development of nursing as an academic discipline in the university sector has been met with scattered support, and some resistance from those health services where fears persist that graduates will, in some way, be less skilled in the technical aspects of acute care than hospital-trained nurses.
The needs of the health care system are in a state of turbulence with greater reliance being placed on all professionals to perform both collaboratively and autonomously in meeting the needs of clients or patients in ways that are efficient and appropriate. In this environment, a practitioner who has been taught to deal only with past technologies and situations becomes a liability to the employing organisation and to their profession. What is needed in a turbulent environment, is a practitioner who is confident in knowledge-based practice and who is able to think critically and creatively about themselves as resources to be further developed and wisely allocated. Under these rules, it is more likely that the needs of the health care system will be better met by graduate nurses with critical analytical abilities than by those trained under the old system who may have neglected their own professional development (McDonald 1994).
Autonomy, though a major attribute of a profession, has not been linked in any true sense with the practice of nursing in hospitals. The acute hospital context in which nurses have traditionally practised using delegated medical authority to treat medical conditions, can be easily confused with real professional autonomy.
Autonomy for nurses means the initiation, assessment, diagnosis and treatment of patients without authorization from another and without the legal or policy requirement of reporting the details to another authority for approval beyond that required of any other professional. This aspect of nursing practice has recently enjoyed a resurgence with the industrial interest in nurse practitioner and consultant roles as well as an increased professional interest in private practice (NSW Department of Health, 1992). This raises questions as to the comprehensive nature of nursing undergraduate curricula and indeed, the adequacy of a degree limited to three years. While it is true that the majority of graduates will seek employment in the acute hospital sector as they have traditionally done, we must ask whether this continued trend is a result of a curricular over-emphasis on acute care skills and collaborative practice concepts thus limiting the students' perceptions of themselves as potential autonomous practitioners. The undergraduate nursing degree is basic preparation for registration, and therefore must be geared to satisfying the minimum requirements of the Department of Health.
One advantage of being in the tertiary education system is the possibility of doing so much more than satisfying minimum requirements and as Chaska (1990:269) observed, we teachers are charged with a responsibility to remove traditional role constraints so that graduates of nursing courses are able to perceive themselves as having a mandate for autonomous as well as collaborative roles in practice.
The expectations of competency for all tertiary-prepared professionals are spelt out quite clearly in the Australian Standards Framework Descriptors that came into force on July 1, 1994. While debate continues on the appropriateness and utility of applying competency measures to professional performance, in a practice-based discipline such as nursing this framework provides a tangible starting point in terms of attitudes, values, knowledge and skill. Of the eight levels of the national competency grid, levels seven and eight are the professional levels. Level seven is expected of beginning tertiary graduates and level eight of those who are more qualified or experienced.
Level seven reads as follows:
Competency at this level involves the self-directed development and mastery of broad and/or specialised areas of knowledge with a range of skills. Application is to major, broad, or specialised functions in highly varied and/or highly specialised contexts.
Competencies are normally used independently and are non-routine. Significant high level judgement is required in planning, design, operational, technical and/or management functions.
The competencies are likely to be applied in accordance with a broad plan, budget or strategy. Responsibility and broad ranging accountability for the structure, management and output of the work of others and/or functions may be involved.
The implications of this description for the teaching and learning approaches utilised by academics are obvious. More effort must be given to empowering students to confidently perform in their chosen field upon graduation. They must be capable to at least level seven.
Professional nurses have identified gaps in their undergraduate preparation for which they had to compensate in order to perform autonomously in their present practice. (McDonald 1993) The major areas identified were:
This Community Development Nursing subject explores the factors involved in facilitating changes in behaviour to optimise health in line with the Ottawa Charter. Traditionally the nursing role in community development has involved community assessment, health promotion and education program development, implementation and evaluation. The generally accepted goal of community development is to find ways to maximise opportunities for people who are disempowered from whatever cause, and enable them to make healthy choices and to influence their health options. The clients of community development nurses range from individuals and families to groups such as schools and industry. This type of nursing practice epitomises primary health care and is becoming more prominent as changes in health care systems move towards fast turnover and early discharge goals. (Healthcover 1994)
Combining all of these expectations into a learning experience called upon both teachers and students to think 'outside the square' and approach the subject as if it was a project that had to be managed in real-world contexts. Each tutorial team became a project committee with a goal and time constraints within which they had to work. Formal committee structure gave students their first introduction to this mode of organisation and after two years at university this came as quite a shock to some who preferred a more laissez-faire approach.
In these health promotion projects students interacted directly with their target population (in this instance several local primary schools) and were encouraged to perceive the projects as being real in terms of providing a valuable service to the pupils, teachers and parents. Community development projects for each committee had a set structure and time frame; and a requirement that they, and not the lecturer, deal with the public in setting up the project. It was up to the students to negotiate the topics to be covered in the health promotion exercise, to research the topics chosen and to develop a health education program appropriate to the earning level of the participants. It was also a requirement that they locate and secure resources and support from local and state businesses and government and to evaluate the committee's functioning and the value of the final health promotion or health education presentation. For each school the presentation took a different form, dictated by resources and the topics negotiated with the school principals.
Advertising and marketing to the various target groups was also under student control. In all of this, students directed the content, process and recording of the activity with guidance and support being given by lecturers only as requested by students.
The strategy of having the students work within a committee structure with formal documentation and defined leadership roles and responsibilities achieved more than just the presentations in the schools. Rotation of chairman and secretary positions enabled most of the students to experience the responsibility and power of leadership and the experience of addressing the entire student assembly at weekly forums. For many students the experience of leadership roles was something they had avoided until it was thrust upon them in this subject, even so, all reported that they had gained a valuable experience and greater insight into their capacity to take on such roles.
As teachers, we provide educational opportunities for students that inculcate values of personal responsibility, professional commitment and determination, among other essential professional values. This process was enhanced by having students document the process of development of these values and the impact this change was having on their attitudes. Students in the community development nursing course were asked to keep handwritten journals of the processes involved in their course project. From the feedback received it became apparent that reflection using the technique of journalling had the effect of enhancing student insight into the learning of values. The decision to require handwritten journals was based on the knowledge that journalling can occur anywhere and to restrict entries to times of access to a computer would detract from the spontaneity of the journals. Having the journals in a bound exercise book also allowed for observation of the processes of development and insight in the order in which they occurred rather than having students subsequently correct or hide their original feelings or observations about events. Another reason for the handwriting exercise relates to the need for legible handwriting in patient records which are regarded as legal documents.
In terms of teaching goals, the strategies used to teach this subject were chosen to address the need to break down the entrenched 'niceness' of the students - a characteristic that seems to pervade nursing subjects. From the journals it is apparent that this pervasive need for affiliation caused many students to be reluctant in asserting their own ideas in competition with their colleagues. There was also an entrenched entering behaviour concept of 'team' which invariably resulted in a few members doing most or all of the work while other students were carried along by their momentum.
It was apparent that over the previous five sessions of study, students had found their own comfort levels and had achieved personal and group reputations as leaders or followers. If students were to be encouraged to take on new challenges and to try new roles, a scheme of assessment that rewarded individual effort and competition needed to be developed. The assessment devised fell into three categories that will be discussed in more detail below:
The journal entries of 140 students are currently being qualitatively analyzed. It is hoped that the process of developing a sense of professional autonomy and responsibility during the process of initiating, developing, setting up and evaluating a unique education program designed for a primary school as a client, can be explicated. Preliminary findings indicate that students progressed through a sequential, multi-step process beginning with apprehension, revelationary experiences, self-doubt, insecurity, frustration (and sometimes aggression), and terminating with satisfaction and a sense of accomplishment.
Students appear to have developed personal constructs in the form of maxims to guide them through the experience. While initial impressions of the task set were negative and stereotypical, later journal descriptions were qualified by their understanding of the circumstances of the public need for health promotion and health education; and a development of an appreciation of the different perspectives and insights of their student colleagues, lecturers and potential clients.
The most important contribution to students' cognitive understanding and development of leadership skills was the requirement that they compete for grades by taking on leadership roles from which they might otherwise have retreated. Assessment for this section revolved around their personal visibility in meetings and in the records of committee activities. Guidance was given in terms of format, but the committee was able to decide on its own procedures and presentation of the group folder at the end of the subject.
Each of these folders was read by the assessor and note taken of the frequency of appearance within the formal record of each of the students. The highest scoring student for each particular committee was allocated 30% and all other students were graded below that score. This assessment method was made clear to all students at the outset of the subject.
The effect on students of this marking method was the subject of considerable comment in the journals. Particular mention was given by many of the students to the effect of competition on friendships and the effect of friendships on competition. Most of the students were able, by the later stages of the subject, to separate professional responsibilities from personal attachments. The initial competitiveness based on personal achievement also had a tendency to be replaced by a more goal-directed individual effort as the date for the public presentation of the project neared.
The inevitable feelings of being managed and controlled by others are difficult to overcome as part of the student experience of gaining clinical experience in controlled settings. Their responsibility under these circumstances is limited to the performance of tasks required in the course objectives and reliance on clinical teachers to ensure that they have an opportunity to attempt prescribed procedures under supervision. Such approaches are of course essential but do little to expose students to the rigours of time management, bureaucratic skills, public relations and marketing skills that nurses in autonomous roles claim to be essential for future nursing practice. The strategy described here went some way towards giving these final year students real experience in project management and direct dealings with the public.
Analysis of the student journals indicates that within this time and context pressure, bureaucratic, management and public relations tasks were all required so that all members of the committees performed their required roles in preparing for and presenting on the day. Insights gained into unexpected human frailty and strengths abound in the journals and reflection-in-action in many of the entries resulted in emancipatory strategies that led to feelings of empowerment.
My own reactions to the process included an early nervousness about delegating so much responsibility to the students, but this abated as the students became more individually assertive and as goal-directedness replaced personal competitiveness within each of the groups. Students struggled courageously through meeting management, coalition development, peer evaluation and competition, and once they realised that while I would act as mentor, I would not act as arbiter or direct them to a solution, they began to develop their own innovative problem framing and problem solving strategies.
One of the great strengths of nursing is the ability we have to adapt and thrive in an ever increasing variety of contexts. Nurses are no different from other people in that we are most likely to experience feelings of powerlessness in situations in which interpersonal conflict with colleagues exists. Traditional nurse education approaches have not prepared graduates to thrive or even survive, in a competitive environment where political rather than rational decisions abound. The history of nursing is well supplied with evidence of both oppressed group behaviour and administrative and medical oppression but there is very little evidence of nurses seeking to empower themselves as a group.
Current trends in nursing towards focused practice and an expansion into the community development or primary health care field support efforts by nurses to increase their expertise in areas of project management, political and bureaucratic strategies involved in the provision of health care services such as community development. Educational strategies geared to the future of nursing will be those that reconceptualize power so that it is no longer a culturally negative concept in nursing; and those that increase student awareness of social, economic and political forces that constrain nurses in their practice, and so limit their power to control their own disciplinary direction. Opportunities to experience such influences are found within the university campus environment as well as in the health care system.
When Rafael (1993) asked nurses to identify the dimensions of an empowering organizational climate, value was given to controlling one's own work and strong and credible leadership from supervisors. It is entirely possible that similar responses would be obtained from other professional groups. At the completion of this initial examination of teaching strategies geared to empowerment of graduates, I am encouraged that students of nursing can be given opportunities to experience these two dimensions while preparing to take on their own professional identities. The process of teaching in this way can be taxing but the rewards are worthwhile in terms of the observation made by Paulo Friere (1965:24) that education, if it is true education, liberates. Education that constrains is oppression.
Feedback from the recipients of these health education programs, all teachers and principals, businesses and government bodies involved as well as the media, local personalities and the general public has all been very positive. The impression given by the final year students of the Bachelor of Nursing course at the University of Wollongong 1993, was that of a capable, professional and health-oriented group who gave something valuable to the community, and challenged the stereotype of 'hospital nurses'. I would like also to extend an invitation to any readers interested in looking at the project folders submitted by the students. I can be contacted on E-mail (t.mcdonald@uow.edu.au) or on (042) 213227.
A version of this paper was presented at the 6th National Nursing Education Conference in Canberra, October 1994. This paper draws on the material presented at that forum.
Friere, P. 1965 Pedagogy of the Oppressed
Pelican Books, Great Britain
Health Cover 1994 Care and Treatment April-May issue No 19.
Healthdata Service Publishers, Sydney
McDonald, T. 1993 Gaps in Professional Nursing Preparation for Autonomous Practice in the UK Unpublished research of study tour project
McDonald, T. 1994 System-Wise Graduates: the end of political naivete in Nursing 6th National Nursing Education Conference, Australian National University, Canberra
Rafael A.F. 1993 Content Analysis of Public Health Nurses' Perceptions of Power and Powerlessness Unpublished paper. First International Conference on Community Health Nursing Research, September. Edmonton, Canada.
4 August 1995
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