Art and Science of Nursing (Nursing Knowledge I)

Introduction

Should nursing be an art or science or, both art and science? Is the dual nature of the profession overburdening the nurses, or complementing each other in restoring, maintaining and advancing the health of the people?  These are the issues this Paper attempts to seek answers for, in the Bhutanese context.  It argues that Bhutanese nurses in theory, tread the scientific path more than the art one, though in reality, the care provided by the Bhutanese nurses exceeds professional services, being steeped in Buddhist values of compassion and selflessness.  

It is a difficult task to assess the knowledge level of nursing colleagues in a small, transparent and patriarchal society like Bhutan where age is often associated with wisdom and experience. Arguments with and queries to the seniors are not always welcomed. There is no yardstick to assess the knowledge of nurses objectively, since there is no authoritative literature and studies done in this area in the country. Thus, this Paper makes deductive analysis from author’s critical observation, the first hand experience in the profession and the random survey carried out by designing a questionnaire.  The Paper, however, concludes that, given its short institutional history, knowledge and efficiency of the Bhutanese nurses is commendable and suggests ways to improve it.

I. Nursing Knowledge

Nursing is as old as the modern health care system in Bhutan. It was nurtured by expatriate doctors from the neighboring countries, who primarily staffed the Bhutanese hospitals until recently.  Initially, there was emphasis on quantitative or curative services in order to combat common diseases and take the services closer to the scattered population in the rugged terrains (Royal Institute of Health Sciences - 25 Years of Service, 1999). Lately, attention is increasingly given to preventive and qualitative services though the country is still grappling with resource constraints.  

Present system affords little room for the nurses to contemplate over what they do or know.  They implement ‘daily chores’ or the doctors’ orders, almost mechanically and ritualistically and, the patients almost never doubt or question the efficacy of the care provided. Medical quality, safety, and negligence are new concepts.  There is little time, avenue and motivation for the nurses to upgrade their knowledge and skills. Nursing is just another bread-earning profession and, a nurse, just another public servant with no special skills or incentive; almost none analyze whether nursing is an art or science, or both.  Until recently, there was lack of competition, innovation, excellence and rewards in nursing.

However, this ‘who cares attitude’ is fast changing. Not only that the entry level of the nurses has been enhanced, but a quality assurance and standardization unit has been set up and, a patient safety unit is in the offing. This has induced a need for the nurses to maintain or update their competencies.  Moreover, the Medical Council Act 2002 and the Medicine Act 2003 require more than transplanting into the system of the experiences and wisdom gathered by our western counter-parts. Above all, recipients of our services are demanding more – quality services from competent and caring professionals.   

II. Assessing Knowledge Level of Nurses

There are 21 nurses working at the Samtse District Hospital (where the author is a staff nurse) of which 6 are GNMs (General Nurse Midewife), 2 ANMs (Auxillary Nurse Midwife) and rest 12 are ANs (Assistant Nurses). The 2 ANMs staff the Community Health Units. The rest of the nurses are placed in different wards and the operation theatre. The knowledge level of the nurses may be mainly assessed from three aspects such as, academic qualification, work experience and professional attitude.

a. Academic Qualification

Number of years one spent in the class rooms and training institutes make difference in the knowledge level of nurses, especially in clinical practice, decision-making and leadership.  It comes handy in explaining or justifying the processes one performs.  A GNM, for instance, is better than an AN. This is more relevant in our context since most of the senior nurses were trained in the institute which lacked adequate or proper equipment and teaching aids; a major portion of the training involved informal theoretical lectures and committing lessons to memory. This is accentuated by the lack of refresher courses once the nurses are dispersed in remote areas.

The author carried out a random survey by designing a questionnaire (see appendix I) to assess the knowledge level of the nurses, as well as analyze the perception of fellow-nurses on whether nursing is an art and science. Most of the GNMs perceive nursing as a combination of both science and art; where as, the ANs are indifferent to the two aspects of nursing, or exhibit its science aspect more than the art one.

 b. Work Experience  

Practice and experience reinforce knowledge. Experiences often mask deficiency of qualification or knowledge since errors are eliminated by trial and error over the years (Arbon, 2004).  It is observed that ANs which comprise more than 50% of the total nurses having work experience of more than 15 years do as well as or even better than newly trained GNMs or B.Sc. nurses.  While conducting a delivery, for instance, a new and a qualified nurse becomes little nervous; where as an experienced AN remains cool and composed; he/she apprehends complication and informs doctors on time. Similarly, an experienced nurse stitches wounds better than a qualified nurse and, many a times, an experienced nurse repairs episiotomy better than a gynecologist or an obstetrician.

The experienced nurses exhibit the ‘five Cs’ of nursing in their duties - compassion, competence, confidence, conscience and commitment (Roach, 1987 cited in Paley, J. 2001).  However, most new and qualified nurses pick up the tricks of the trade fast and catch on with or leave behind the lethargic and indifferent senior ones.

c. Professional Attitude

Many Bhutanese nurses are more inclined towards the science aspect of nursing.  Due to their limited knowledge and appreciation of the art of nursing, they have been criticized as being not very polite in dealing with patients and the public,  as well as failing to respond to the patient’s needs on time (Bhutan Times, 2007, July 29).  They have also been alleged to be sleeping during the night duties, tending to personal works, engaging on the telephone and inter net.  Thus, nurses have to accept that a complete nursing service includes dealing with the patients and public in an effective, ethical and professional manner.

However, nurses are not to be blamed alone. There is acute shortage of nurses in all the hospitals. There are little or no tours, trainings, workshops or studies. Their morale is low since there are no perks and privileges commensurate with their works and sacrifices. This is taking toll of their personal and family lives and affects their efficiency.  Obviously, knowledge is bound to take back seat in the profession in such circumstances.

III. Nursing – Art or Science?

According to the College of Nurses of Ontario (CNO), nursing is a science as well as an art. “The science is the application of nursing knowledge and the technical aspects of practice; the art is the establishment of a caring relationship through which nurses apply nursing knowledge, skills and judgment in a compassionate manner” (http://www.cno.org/docs/general/student intro.pdf).

More than 50% of the nurses the author interviewed during the random survey believed that nursing is more of a science than an art, though some of them can not tell the technical difference between the two (see appendix I). Consequently, they tend to take nursing as routine and ritualistic execution of doctors’ orders which  lacks human touch, compassion, counseling and encouragement of the patients to fight the diseases and rekindle hope to be reclaimed as productive human beings. 

On the other hand, since nursing is a very physical and strenuous profession it is best treated purely as science without overburdening the nurses and affecting their efficiency.   Secondly, while multi-skilling has its advantages, this is an era of specialization.  It may be better to be specialist nurses by concentrating on one of its aspects than multi-skilled average or general ones by embracing art as well as the science aspects of nursing. Secondly, contrary to the opinion that nursing devoid of art aspect lacks in quality of services, nurses can give adequate time and prompt care to the patients and concentrate on the scientific or medical treatment of the diseases (Benner and Tanner, 1997). Yet, on the other hand, in country like ours where we face acute manpower shortage, nursing needs to encapsulate both the art and the science of nursing.

However, Florence Nightingale thought that nursing was different from medicine, psychology or social work (Fawcett, 1992; Chinn and Kramer, 1995 cited in Potter and Perry, 2001). Stressing on its art aspect she said that:   

                                             

“Nursing is an art if it is to be made an art, it requires as exclusive a devotion, as hard a preparation, as any painter’s or sculptor’s work, for what is having to do with the living body- the temple of the God’s spirit? It is one of the fine Arts; I had almost said the finest of the fine Arts” (Donahue 1996 cited in http:// www.nursing.gr/Artnursing.pdf).

If nursing evolved purely as an art as the pioneer herself desired,   nurses would not be stereotyped as ‘baby nurses’ or people who are ‘tender to sick and wounded’ (Daly, J., Speedy, S., and Jackson, D., 2000, p. 40).  Nursing yielded to the influence of science and technology in the post - Nightingale era which believed that both have the same goal.  As a result, nursing has lost its own artistic identity and its growth was retarded. It has almost become subservient to the medicine. In other words, nursing should have been nurtured, as desired by Florence Nightingale, purely as an art, as alternative or supplement to medical services. On the other hand, medicine has consolidated nursing and nurses have developed professional identity and ways to work with doctors productively (Blue and Fitzgerald, 2002).  

IV. Changes in Nurses’ Knowledge

There is increasing pressure on the nurses to satiate the ever-increasing demands of the patients and public for better and efficient services. This is mainly due to advancement in medical sciences which has made detection, diagnosis and treatment of diseases easier. This requires the nurses to constantly update their knowledge and skills. In order to ensure uniform, consistent and competent medical services throughout the country continued medical education is a must. Nurses should be engaged in academic and literary activities, participate in workshops, seminars, conferences and refresher courses on a  regular basis to cope with  the rapidly changing healthcare environment. In keeping with the different roles (clinical practitioner, administrator, teacher, researcher, etc.) the nurses are required to assume, they should be educated and trained properly, including in areas of clinical practice, decision-making, critical thinking, leadership and resource management. Nurses should also be encouraged to conduct researches on pertinent issues and specialize in different nursing areas for improved and specialized services. Nursing should be treated as a special profession; they should be paid well and their services acknowledged and respected.

Conclusion

Medicine cure diseases but art may save lives. Nursing should be a delicate blend of art and science.  A complete care may not be possible if it is purely art or science. Hence, nursing may be ‘lame’ without the art aspect, but it may be ‘blind’ without the science aspect.  Though nursing with one of its aspects may be preferable to the individual nurses in terms of workload, but it may be incomplete service without the other. Bhutanese nurses in general, display both the science and art of nursing in their practices.  They are beginning to ‘walk the extra mile’, connect to the patients and earn their respects, rather then induce fear and contempt.  The nursing education must accordingly be restructured to include a balance of the art and science of nursing.

 Reference

Arbon, P. (2004) Understanding experience in nursing. Journal of Clinical Nursing, 13, 150-157 in Study Guide, Nursing Knowledge, La Trobe University ; Victoria.

Benner, P., & Tanner, C. (1997, January). Clinical judgement: How expert nurse use intuition. American Journal of Nursing, pp. 23-31 in Study Guide, Nursing Knowledge, La Trobe University; Victoria.

Bhutan times (2007, July 29). Row over a still born. 2(14), 1.

Blue, I., & Fitzgerald, M. (2002). Interprofessional relations: Case studies of working relationships between registered nurses and general practitioners in rural Austraila. Journal of Clinical Nursing, 11, 314-321. Study Guide, Nursing Knowledge, La Trobe University ; Victoria.

Daly, J., Speedy, S., & Jackson, D. (2000). Context of Nursing: An Introduction. Australia: MacLennan & Petty Pty Limited.

Paley, J. (2001). An archeology of caring knowledge. Journal of advanced Nursing, 36(2), 188-198 in Study Guide, Nursing Knowledge, La Trobe University ; Victoria.

Potter,A.Patrica and Perry,G.Anne,(2001), Fundamentals of Nursing. Harcourt, Australlia.

Royal Institute of Health Sciences, (1999), 25 years of service; To our King, People and Country. Thimphu; Bhutan.

Wilson, M., & MacDonald, H., (2007). Nursing Knowledge; Study Guide. La Trobe University ; Victoria.

Electronic Sources

College of Nurses of Ontario, (2007). The Standard of Care. http://www.cno.org/docs/general/student intro.pdf   Retrieved on 6/11/07.

Michalis, R., (2002). Nursing as an Art. http://www.nursing.gr/Artnursing. Pdf  Retrieved on 26/10/07.