Notes on
The Impact of Nursing by University of Liverpool, via FutureLearn
The lecturers, tutors, and hosts for the course were
Denis Parkinson,
Matt O’Rourke,
Rob Lindsay,
Vaiva Adamonyte
The course uses Liverpool as its anchoring context for a historical perspective on the growth and development of nursing through to its current state. The course reviews the profession and identifies its early traces and relates them to the present day. A critical stance on nursing's accepted creation myth, its origin in Florence Nightingale's project, reveals its nascent origins in social action, hygene movements, the growing scientific basis of medicine. As a profession, perhaps hampered to some extent by its domination by women, it is marked by a continuously increasing and formalised body of knowledge, practices and beliefs contributing in turn to its vibrance and professional evolution. As its members were and are predominantly female, Nursing education, and its expansion internationally into broader societal contexts, has facilitated female emancipation, moves to equality, and independence.
Images of Nursing
Exercise: Critical Historical Discourse Analysis of an image:
Postcard. Artist: Giovanni Battista Carpanetto (1863–1928). Publisher: Committee of Turin, ItalyAngel Nurse Man Nation. [Signature] G. Carpanetto. 1915. [
Alternate source link]
This image is beautifully constructed, asymmetric. Unsure if watercolour charcoal sketch. A naked wounded/dying soldier, grasping a rifle and draped in the flag of Regno d'Italia (Kingdom of Italy). The flag contains the only coloured element. A winged woman-angel, possibly naked, comforting the man, kissing forehead, hands near but not touching appearing to cradle the man's head. Man looking above focusing beyond the angel's face, as if he knows someone is there but he cannot see her. Possible scene of battleground or destruction in the background. The angel-soldier juxtaposition seems to have been a prevalent theme in the Italian postcard collection. Having seen other examples I'm unsure if all the female figures are intended to be nurses as such.
I also really liked this studio photo of a trio of male nurses/orderlies. Very confident neutral expressions.
Health History
Looking at the links between scientific health knowledge, industrialisation, epidemics and infection, social conditions, social change, urbanisation, health care and health policy.
The "Oral History of Nursing on Merseyside" (
link) is (I believe) a very important study because it was designed to capture and interpret participants (Nurses) own perceptions of the work, its demands, its rewards, reflecting on their careers and motivation. This kind of data is really important as it presents the opportunity to divulge alternate accounts either in contrast to or in addition to the conventional "Nightingalian" narratives of "Nurse as Angel", "Nurse as female aspect of man's war" etc. The article sets out the background, conditions, research objective, research method, and disposition of the data gathered. A possible template for our own research.
The interactive timeline (
link). I was most impressed by the story of Kitty Wilkinson and the time of the Cholera Epidemic (~1829). The link between disease and sanitation may or may not have been scientifically proven at that stage but as it says "she encouraged the washing of clothes with chloride of lime which destroyed the bacteria" and set up public washing and bathing facilities, crucial in a city of the day in which common domestic dwellings had inadequate (an understatement) hygienic facilities.
p.s. The timeline page is a very effective communication tool. I want to make my own.
19th century Liverpool was at the centre of hard-won knowledge on how the Cholera disease spreads. As one of the worlds foremost and important city-conurbations of the day those in Liverpool faced and discovered the necessity to address healthcare as a social concern thus needing a systematic response. Epidemics produced crises and great suffering that fortunately we, human society, have thankfully studied and learnt from such that we now have not just solutions but a scientific approach to understanding and addressing the problems posed by disease conditions, agents, vectors etc. All of these various developments come together to produce a whole system of knowledge, a sum greater than the parts. Epidemiology, sanitation, transmission/vector theory, ideas of bacterial agents.
By 1832 the Cholera epidemic had hit Liverpool. The 1832 outbreak was the culmination of its having progressed from China, through India, gradually reached Europe. The gradual movement of the Cholera epidemic was followed closely by the press. Typical treatment was by quarantine in a fever hospital. However relatives of infected individuals feared that the bodies of family members would be taken by members of the medical profession for anatomical dissection, an activity despised by the general public.
Cholera attacks the lining of the intestine and causes diarrhoea leading to rapid dehydration. People's clothing becomes soiled and can spread contamination to others. Poor people had a dire need but little opportunity to clean soiled and potentially infective clothes. Kitty Wilkinson volunteered her home to allow poor to wash and clean. There was a growing "sanitation movement" raising awareness of the link between disease and cleanliness and building facilities to deal with the problem. Wilkinson "encouraged the washing of clothes with chloride of lime which destroyed the bacteria" and went on to establish public washing and bathing facilities for the poor.
Living conditions were harsh for the poor and less well off. A wave of pauperism, destitution and poverty surrounded and flooded Liverpool throughout this period,as it did in other towns and cities in Britain and Ireland. The early 19th century saw drastic changes in social demographics. Population composition had altered partially as a consequence of the Napoleonic Wars (1803–1815) an other military adventures in which upwards of 600,000 of the British military died. Social change was also taking place as the population shifted from rural to urban communities in consequence of the burgeoning Industrial Revolution. The growth of cities and concentration of humanity therein became focal points of sporadic cholera epidemics and pandemics in the 19th century. Liverpool's 1832 outbreak was just one of many comprising the second great pandemic sweeping through Europe. To these conditions were added the impacts of death, starvation and disease from sporadic crop failures and famines in Ireland and Britain, culminating in the Irish Potato Famine (the Great Famine 1845–1852). (Hunstman et al. 2002).
There are few records available of the short-lived training School for nurses established in 1829 in Liverpool by Messrs. Hornby and Hodgson, Bickersteth and others, however its legacy influenced subsequent endeavours, as recorded by the Rev. Howson in 1859. (Hunstman et al. 2002). A leaflet set out early principles and values by which its nurses would be trained. Aside from religious and pious standards the nurse would be trained (and evaluated) to provide skilful support for medical care, to administer remedies and alleviate pain.
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| Long's nursing lectures 1878 (Jones, 2007) |
The early syllabus for nursing education (above) is notable for four aspects: 1. the history of nursing and its context, 2. practical techniques, 3. focus on factual knowledge, and 4. diagnostic or problem solving. In the introduction James Long opens by reflecting "On Nursing" and "Miss Nightingale" which we presume establish the need for nursing's professional foundation, its history, in turn informing the values and ethical aspects of nursing as a profession.
The section devoted to "What is Health" covers "Symptoms" and "Modes of Dying" deal with challenging areas by addressing them in an up-front manner. Running to over 273 pages it must have been an expensive book or sequence of lectures, one that very few nurses would have had the wherewithal to own themselves.
Conclusion of week 1
The long arduous project to define nursing as a valued professional occupation commences in earnest at the beginning of the 19th century. The evolution of nursing into a profession takes place falteringly at times, in parallel with social changes that saw healthcare becoming more and more a public necessity and a public good. The development of public knowledge of the need for sanitation, hygiene, the growing acceptance of the germ theory of disease and disease transmission, the development of the concept of community health care and health as a public good is also closely related to social conditions, the establishment of community and social structure.
Nurses and nursing were at the heart of these changes in society, at the heart of social transformation, and played a role in forming part of the very essence of modern, caring, civil society. The values of nursing arise from and concentrate some very distinctive aspects of the human condition: caring, feeling, empathy, healing, life cycle and health. I argue that the concentration of these qualities in the discipline of nursing may be seen to filter back into society, possibly engendering shifting social norms of society at large, gradually becoming more caring and compassionate. At the very least it is clear that the growing importance of nursing in society coincides with nurses defining their role as paramedical professionals linking care in the community, and in hospitals, along with an aspiration to improve the human condition.
The profession of modern nursing
A 'modern' nurse? The overarching ethos of a nurse is to assess, confer, and based on their professional judgement offer compassionate appropriate care for anyone regardless of condition, ability, status.
The NHS leaflet offers a definition of modern nursing, referring to the 6 Cs: care, compassion, competence, communication, courage, commitment. They also mandate 6 areas for action for nursing, midwives, and care staff paraphrased as follows: 1) helping people stay independent. 2) provide a positive experience of care. 3) delivery high quality care and measure impact. 4) progress and leadership. 5) right staff + right skills + right place. 6) provide a positive experience.
Education pathways into nursing traditionally followed the apprenticeship model. The profession offers extremely diverse career paths and specialisms; surgical, midwifery, general, pediatric, intensive care, psychiatry, disability, developmental, care of elderly, palliative, diabetic, bariatric, accident & emergency, military, teaching, ward management.
District and community nursing has always been part of the scene. Some argue that nursing's original vision or remit was as an outreach activity, a service in the community rather than confined within the concentrated medical environment of hospitals.
Mental health specialism
Nurses are involved in supporting people living at the margins of society and of people who are marginalised due to learning disabilities, disabilities more broadly and many others who have little or no voice. Nursing as a profession has a long association with outreach in the community; identifying, communicating and addressing medical need and the social impacts of inequality, deprivation and injustice.
Psychiatric nursing is one of the key specialisms. One of the most challenging aspects of nursing is psychiatric care, essentially "nursing the brain"; to coin a paraphrase from
Ruby Wax discussing her experiences of mental health issues in a TED talk. (Gee, tough audience Ruby. Well I loved every syllable (and the drawings and the model of the brain especially). If time allows, follow up with the University of Liverpool
online mental health course.
Exercise:
Depression Quest is an online (serious) game built using
Twine (see here for
instructions for creating new interactive stories). It presents a series of everyday life events for you, as a person living with depression, have to attempt to deal with and manage. Depression as depicted here occurs in completely unexceptional situations and circumstances with no singular defining trigger initiating an episode or its passing. This is a really difficult area but the (serious) game handles it very sensitively, believably, and compassionately. It is a very good tool for raising awareness about the attitude and thought processes of someone experiencing depression.
A mix of art and science
The profession transmits its skills and traditions from one generation to the next, however the evolving body of knowledge, its rationale and the science behind nursing is equally important. Care and compassion require nurses to draw on their innate humanity but also their experience, judgement and knowledge in order to work effectively as healthcare professionals.
Diabetes
Diabetes (type 1 - often affecting young people, a chronic condition where the body does not produce insulin) (type 2 - often affecting older people, usually linked to lifestyle, diet and activity). (see
NHS pages on diabetes)
BariatricsBariatrics is the branch of medicine that specialises in the study and treatment of obesity. The word bariatric is derived from the Greek words 'baros' meaning 'weight', e.g. barometer, and 'iatros', for physician. While obesity is itself a growing problem, patients in the obese range pose particular challenges for health professionals regardless of entry point into the health system. The bariatric specialist employs his or her training, techniques, specialised devices and machinery to help manage heavy patients. The knowledge, skills, experience and equipment may not be as readily available in other parts of the health system, thus presenting challenges and risks to patients and caregivers. It is commonly accepted that incidents involving patient handling are one of the largest contributors to workplace injury in healthcare. Researchers highlight the challenges posed to nurses, for example, "during a typical 8-hour shift, a nurse lifts a cumulative weight of about 1.8 tons" (duBose & Donahue, 2006). Consequently patient handling is an increasingly important competence for nurses and healthcare professionals generally. Proper patient handling depends on specialised attitude and knowledge, needs assessment and procedural support, assistive equipment, practical skills and healthy, capable healthcare professionals.
As in nearly all areas of healthcare, professionals encountering patients must overcome the common tendency to associate patient conditions with life choices and make personal judgements. The 6 Cs as defined in the literature are intended to help us retain our sensitivity and awareness to such thinking.
- Care: "the provision of what is necessary for the health, welfare, maintenance, and protection of someone" (New Oxford American Dictionary, 2013)
- Compassion: Concern for others
- Competence: Skill and ability to successfully act and take action in work.
- Communication: To convey and articulate but also to perceive, be aware and interpret the other.
- Commitment: Being dedicated to courses of action, to belief, values, and professional standards.
- Courage: The inner strength to cope and persist in our actions in the face of fear, horror, discomfort, etc, to overcome the discomforting, the uncomfortable and extreme difficulties encountered.
The six perspectives are interrelated and interdependent, but more importantly are mutually reinforcing if consciously developed. The 6 Cs are evident and applied in all of the nursing specialisms however the challenges of bariatric care may present greater demands on the areas of compassion, commitment and competence.
Compassion is an inner feeling and existential phenomenon of the individual. It may be difficult to experience and therefore to convey genuine compassion if we attribute the usually chronic condition of a bariatric patient with their life choices. Essentially, it is easy to be judgemental, but it is less easy to walk in another’s shoes.
Commitment in bariatric care is essential in order to deliver appropriate necessary care. Postoperative pain, rehabilitation, exercise and supporting patients adopting new regimes requires commitment and belief in the veracity of treatments.
Competence is particularly important both for the treatment of the patient for the patient's own sake, but perhaps more significantly for the healthcare professional's own well-being. The nurse therefore needs proper and effective training in the physical handling of bariatric patients using techniques, specialised devices and machinery to assist movement. The most significant competence however is that of judging if and when situations require such supports.
Changing perceptions of nursing: Identity in public discourse 1700-1800 Ireland
The following instances of the word "nurse" appearing in notes, announcements and advertisements in newspapers in Ireland over the period 1700-1820 indicate a gradual shift in the meaning and connotations of the term over that time. In nearly all cases the term relates to a role fulfilled by women, from posts as wet nurses through to nursing in fever hospitals.
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| Advertisement for "The New Practice of Physic, by Thomas Marryat, M.D.": Freemans Journal, Tuesday, December 18, 1764; Page: 4 |
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| A wry poem: Freemans Journal 1763-1924, Tuesday, September 10, 1765; Page 2 |
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| Advertisement seeking a wet nurse: Freemans Journal, Saturday, April 29, 1775; Page: 3 |
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| Front page advertisement: from "The Public Register, or, Freeman's Journal." Vol XXIII. "From Thursday, April the 13th, to Saturday, April the 15th, 1786" |
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| Front page beside other articles announcing Summer concerts in the Rotunda "for the Benefit of a very useful and liberal Charity": from "The Public Register, or, Freeman's Journal. Vol XXIII. "From Thursday, April the 13th, to Saturday, April the 15th, 1786" |
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| Advertisement: Belfast Newsletter, Friday, September 05, 1806; Page: 3 |
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| Advertisement: Belfast Newsletter, Friday, February 24, 1809; Page: 3 |
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| Advertisement on front page: Freemans Journal Thursday, June 29, 1809; Section: Front page |
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| Report of the House of Industry: Freemans Journal, Wednesday, February 07, 1816 |
How does the concept of Innovation inform the discipline of Nursing?
The shift towards nursing as a university taught degree (BSc or BN) was contentious when first mooted and then actualised through the 1970s and later. However university centred nursing qualifications remain controversial, predominantly it may seem, among former nurses whose own formation in the 50s and 60s was based on the traditional apprenticeship model.
Not all countries made the move to university-sited nurse education, nor have countries adopted the model contemporaneously; some still lag behind this trend. However the increasing use of advanced technologies, therapeutics, specialised and advanced procedures in healthcare generally suggest that the increasing specialisation and technical character of nursing has become a permanent shift.
The structure of BSc Nursing in Ireland retains a lot of what was good about the old RN/RGN training. Unlike many other University degrees nursing retains that practical component, up to 50% of first year timetable for student nurses in Ireland is practical placements, assignments at the various University Hospitals. It is really crucial that that first year nursing students get that on-the-job exposure early to give them practical experience of the real, often emotionally challenging, messy and difficult work of nursing in real situations dealing with real patients. In that way I feel the student is given practical unglorified experience, and is able to decide early on if the career is for them or not.
In the broader environment it is helpful to look at the structures and resources employed in primary, secondary (and tertiary?) health care. The UK has a well developed ecosystem of primary and secondary care settings. This angle may be a useful way to analyse the differences between countries in terms of how developed and linked the primary and secondary systems are.
The importance of nursing in primary and secondary care of citizens is highlighted by the
World Health Organisation's (WHO) six international nutrition targets for 2025. Each of these targets has implications for governmental priorities, the allocation of resources, and the operational focus of agencies operating in the health sector.
- 40% reduction in the number of children under-5 who are stunted
- 50% reduction of anaemia in women of reproductive age
- 30% reduction in low birth weight
- no increase in childhood overweight
- increase in the rate of exclusive breastfeeding in the first 6 months up to at least 50%
- reduce and maintain childhood wasting to less than 5%
Nurses are at the front line in these initiatives; assessing patients, reliably reporting information to authorities, communicating with patients and citizens, as health educators teaching and advising patients, as trusted members of society providing resources at point of need (medicines, medical devices, dietary supplements).
The profession of nursing has become a global community of shared values and training, in which Nurses share learning and practices. Using the example of the
Ponseti method, Andrea Spyropoulos (President of the Royal College of Nursing 2010-2014) highlights how therapeutic innovations may trace unexpected paths, originating in one setting, perhaps ignored until recognised in another setting and developed further before returning and being adopted in the first. The Ponseti method is a manual therapy for reversing the occurrence of talipes (the technical term for clubfoot) in newborns. Its originator, Ignacio Ponseti (from Majorca) developed the technique in the United States but it was neglected due to the prevailing tradition of surgical intervention. However developing countries recognised the value of therapy over the cost and complications of surgery. In Malawi the technique was adopted and expertise developed further, producing excellent outcomes for patients. The Ponseti method, proven in Malawi, is now recognised and a modified version used in the UK for the treatment of
talipes equinovarus. Importantly this and other innovations couldn't have taken place without community, communication, and individuals working and moving in different international healthcare systems.
Research and Innovation
Research databases like CINAHL (
Cumulative Index for Nursing and Allied Health Literature) are rich resources for reviewing prior knowledge. Nursing research, like other role centred contexts in healthcare and professions like engineering, computing, etc. addresses the whole spectrum of concerns, innovations and developments impacting the work of nursing. Research questions are usually formulated according to the scientific model. The PICO model (population, intervention, comparator and outcome) is a popular way of approaching research in a systematic manner. The CASP approach (critical, appraisal, skills programme) helps to structure the systematic review of research papers identified as relevant to a research question.
However while the PICO and CASP models are useful paradigms for classical action/reaction physical sciences style of studies, they tend to be based on the experimental sciences. We should equally be aware that many other research paradigms may be applicable, suitable, or even more appropriate for some kinds of nursing research. For example one might wish to understand sociological aspects of nursing, or develop a historical analysis, or apply critical theory to interpret workplace culture and power etc.
Genetics is an example of the kind of systemic specialised scientific knowledge that has become embedded in and constitutive of, our understanding of modern healthcare and by implication the profession of nursing (see
www.nhs.uk/ for information). Nurses often act as translators or interpreters for patients and their families seeking to understand how or why outcomes occur or why particular interventions are necessary. People may become patients because of genetic conditions or environmental changes that trigger a genetic response. For example greater understanding of autoimmune diseases has resulted in more and more people being diagnosed as susceptible to dietary allergens. Nurses provide a supporting role to patients, explaining diagnoses, helping them to understand the causes and teaching patients how to adapt to or change their dietary regimes.
E-Health care and Health Information Technology (HIT) is a trend with potentially large impacts on the profession of nursing (
link to RCN explanatory leaflet on e-Health). E-Health is a catch-all title applied to the use of information technology in the healthcare professions. It covers the application of databases, sensors, computing devices, records systems etc. The use of tablet computers for observations at the patient bedside is increasingly replacing paper observation charts and for capturing patient data.
One risk with new technologies is that the patient may become less visible, less engaged with, that technology becomes substitutes for engagement at a personal and human level. Healthcare must still be based on the values and principles of the medical profession, like the hippocratic oath or nursing's 6 Cs. There are also unexpected aspects of new technology that have moved beyond the control of healthcare professionals. Many more patients are attempting to solve problems themselves, from self-diagnosis via internet search to participation in internet communities focused on particular conditions and diseases. However many of sources of information are unregulated and unmoderated, and the information and advice on offer may be erroneous or at variance with the actual patient's needs. It is important therefore that medical advice and intervention is given by qualified professionals interacting with and caring for the individual.
Another challenge with new technologies is they offer corporations in the healthcare industry, greater access to valuable patient data but also risks surrounding patient identity and privacy. The ready access to more detailed demographic and epidemiological information is certainly 'of value' in terms of assessing the efficacy of medication and treatments, perhaps improving the effects of follow-on treatment and follow-up. But it is not always the patient (or future patients) that benefit from this data. Patient data is of great value or significance to other industries and agencies, but who owns the data, who should have access to it, when should it be given, how long for, how (if at all) should patients be identified? These and many more questions arise.
Ethics
Ethics deals with concepts of right and wrong. The 6 Cs encapsulate the ethical substance and obligations of nursing. To respect the individual, treat them with dignity. To ensure good communication, both to and from the patient as a fundamental concern, to gain consent, to assess understanding, to understand the patient's need and the patient's trust.
For nurses, along with other healthcare professionals, ethics is a central concern. Equally importantly the professions are regulated by law and by their governing bodies which in turn establish and govern their members under published codes of practice and professional standards.
