Nursing and Education

Introduction

Nurses and physicians come from two distinctly different programs. In the neurocritical care unit (NCCU) they work side by side but may not have been provided with the opportunity to understand each other’s roles. The purpose of this chapter is to provide a common ground of understanding for nurses and physicians to help improve multimodal monitoring systems by exploring the role of nursing in patient monitoring and how nursing education influences that role.

Historical Perspective of Nursing and Monitoring

Almost a century ago George Santayana wrote, “Those who cannot remember the past are condemned to repeat it.” The history of nursing parallels the development of patient monitoring and equally affords an insight to predict some of the future directions in patient monitoring. Today nurses view the terms multitasking and multimodal monitoring not as new terms, but as evolving paradigms. In this chapter the historical influence of medicine on the current role of the nurse serves as a mechanism to understand how nursing can optimally contribute to emerging trends in neurologic monitoring.

Ancient Past

In ancient times nursing and medicine were intertwined, and there were healers who brewed medicinal teas and tended to injuries with a combination of mysticism, herbalism, and remedies handed down through oral history. After each cup of “medicine” and after each broken bone was set, the healers monitored their patients and observed their successes and failures that they shared with other healers. When human societies settled down and towns were established, medical care was regimented and evolved into a discipline.

As the base of medical knowledge expanded, humankind began to document the effect of various treatments. Oral history or direct observation no longer could adequately transfer medical knowledge that now was shared across time and distance in written form. Although physical evidence exists to support splinting of bones, herbal remedies, and even trepanation, much of known early medical history is attributed to Egyptian papyrus writings. Several key writings provide clues to the role of nursing in emerging societies. Except for midwifery, nursing was predominantly a male profession. Wreszinski translated the Ebbers papyrus such that future English versions report “wet nurse” as the figure who provides milk to a child. Historians find no female versions of a nurse’s role as an attendant or assistant to the physician. The nosocomii were men who were educated by physicians and taught how to run a hospital; the role of the nosocomii (from which we derive nosocomial) is not fully described but is thought to be the first ancestor of modern nursing.

More modern times provide a few clues to the emerging role of nursing. The physician’s role evolved over time and was symbolized through Asclepius, the god of medicine and healing. The rod of Asclepius often is shown with a coiled snake. Of the five daughters of Asclepius, it is Hygeia, goddess of health, from whom many believe the modern nurse descends ( Fig. 5.1 ). Drawings and sculptures of Hygeia often depict her holding a snake, cup, or both. Further symbolism of the rod of Asclepius is the caduceus. This symbol, which has come to represent medicine, shows twin snakes (or a two-headed snake) coiled about the rod of Asclepius. The caduceus was adopted in the early 1900s to represent medicine and often is confused with the twin snakes and winged staff of Hermes (a symbol of commerce). Controversy exists whether the snake represents the twin battles of life and death, or more directly the practice of removing worms from open wounds by winding them about a small staff.

Immediate Past

During the middle ages the role of God in health care expanded and in times of plague, men and women devoted to God began to house and care for the sick. Most historical scholars believe that the nun’s habit of the 15th and 16th centuries is the forerunner to the nurses’ cap of the mid-20th century. Nursing care was a separated workforce, both by sex and time. Male nurses associated with religious brotherhoods and female nurses associated with sisterhoods often were separated by distances that were not easily crossed.

The end of the Middle Ages marked the onset of modern history and a further evolution in the healing arts. In particular global commerce, increasing life span, growing population centers, and war created new opportunities and challenges for the medical team. During this time it was realized that a physician alone could not attend to the sick and wounded. Instead, nurses around the world took on this role. Florence Nightingale provides one of the earliest and most resilient personifications of the nursing profession and the role of nursing care in patient outcome. She had been educated in mathematics and through careful observation was able to demonstrate a significant change in outcomes by modifying the postoperative care and environment of soldiers during the Crimean War. By war’s end she had penned texts on care and conduct in both military and civilian hospitals and helped to establish a center for nursing training. After the war she wrote Notes on Nursing, which provided details on how nurses should care for and monitor patients in their wards. In this book her words provide a glimpse of the future:

“What you want are facts, not opinion—for what can have any opinion of any value as to whether the patient is better or worse, excepting the constant medical attendant, or the really observing nurse?” F. Nightingale (1860)

This insight forecasts two needs in the establishment of fact and a foundation of monitoring in neurocritical care. First, the phrase “constant medical attendant” implies a need to obtain data without gaps across time. Second is the use of the word “observing” as a method to obtain facts about the patient rather than provide opinions.

Recent History

In the last century nursing and medicine have witnessed an astounding evolution in the ability to acquire and store data. Although nothing has replaced the utility of direct observation, new tools have been developed to enhance observational skills and provide for continuous assessment. Feeling for the threadiness of a pulse was replaced with blood pressure auscultation, then noninvasive blood pressure cuffs and subsequently with continuous intra-arterial blood pressure monitoring and now an effort to use noninvasive blood flow monitoring.

Just as the tools to find facts have evolved, so have the methods to communicate and record these facts. Oral histories and verbal reports of facts were replaced with short notes. Notes become cumbersome and were placed in charts, which became disorganized and were replaced with tab-separated sections. Physicians wrote orders for nurses to follow (being careful to press down hard enough to ensure that their notes filtered through multiple layers of carbon-copy paper. Electronic medical records (EMRs) now dominate the field and provide the opportunity to think of data acquisition beyond traditional boundaries.

Changes in how we observe and record data have paralleled the changes in who records and observes data. After the U.S. Civil War, nursing became a primarily female occupation. The “Angels of the Battlefield” became famous leaders. Dorothea Dix became the first female superintendent of the Union Army, Mary Todd Lincoln advocated for nursing before and after her husband’s assassination, and Clara Barton became the founder of the American Red Cross. With each new war the face of nursing changed again. By the end of World War II, nearly 60,000 women joined the military nurse corps. With the advantage of rapid transport, medical evacuation, and mobile army surgical hospital (MASH) technology, men became trained as corpsmen in subsequent wars. Many of those corpsmen turned to nursing as a postwar profession.

Education of nurses has evolved quickly to meet the growing demand for what Nightingale predicted: “a really observing nurse.” In 1873 Linda Richards became the first nurse to graduate as a Nurse with a Diploma in the United States. Thirty years later, North Carolina became the first state to require nursing licensure. By 1956 Columbia University became the first school to award a master’s degree in nursing, and in 1965, the University of Colorado established the first nurse practitioner position. Although nurse educators and nurse scientists began entering academia with doctoral degrees in affiliated areas (e.g., biology, education, psychology), the first PhD programs specifically in nursing were established in 1954.

Currently nurses have a wide range of programs and career paths that include certification and specialization that range from the licensed practical nurse (LPN) to the doctorally prepared nurse. Table 5.1 provides a list of titles and descriptions for professional nurses with advanced education to give a general understanding of the primary role designated to each discipline.

Table 5.1

A Short Description of Common Nursing Titles

	Registered Nurse (RN)	Clinical Nurse Specialist (CNS) *	Nurse Practitioner (NP) *	Certified Registered Nurse Anesthetist (CRNA)	Doctorate in Nursing Practice (DNP)	Doctor of Philosophy (PhD)
Career focus	Diploma, associate or baccalaureate degree in nursing	Expert in clinical nursing, master’s degree	Midlevel provider of direct care, master’s degree	Midlevel provider of anesthesia care, master’s degree	Leadership roles as an advanced-practice nurse	Nursing research
Degree objectives	Entry to practice as a nursing professional	A CNS is an advanced-practice nurse familiar with the theory and research related to a nursing specialty area, such as critical care. Traditionally, a CNS influences patient outcomes through direct clinical practice, collaboration, education, research, consultation and system leadership. CNSs are uniquely prepared, by experience and education, to manage the complexities of negotiating complex health care delivery systems.	An advanced-practice nurse who diagnoses and manages common acute and stable chronic health problems. NPs perform comprehensive physical exams, order and interpret diagnostic tests, obtain specialty consults, and perform and prescribe therapeutic measures, including most classes of medications. NPs, individually accountable for their practice and decisions, collaborate closely with physicians.	Advanced-practice nursing. CRNAs provide anesthetics to patients in every practice setting, and for every type of surgery or procedure. They are the sole anesthesia providers in two thirds of all rural hospitals, and the main provider of anesthesia to expectant mothers and to men and women serving in the U.S. Armed Forces.	Nursing leaders in interdisciplinary health care teams. Using the tools and skills specific to translating evidence gained through nursing research into practice, they improve systems of care, and measure outcomes of patient groups, populations, and communities.	To prepare nurse scientists to develop new knowledge for the science and practice of nursing. Graduates will lead interdisciplinary research teams, design, and conduct research studies, and disseminate knowledge for nursing and related disciplines, particularly addressing trajectories of chronic illness and care systems.
Curriculum focus	Basic nursing care	Improve outcomes for patients by influencing systems level, team, and patient change	Direct care provider with prescriptive authority	Direct care provider with prescriptive authority	Translation of evidence to practice at the systems level	Independent researcher
Core courses †	Nursing assessment, nutrition, pharmacology, human growth and development, psychology, maternal/child, microbiology, communication, anatomy and physiology, and mental health nursing	Applied statistics, research design and methodology. Graduate-level pharmacology, assessment, and pathophysiology. CNS students are required to take specialty focus courses and advanced health assessment.	Applied statistics. Graduate-level pharmacology, assessment, and pathophysiology, and courses in an elected specialty (e.g., management of critically ill patients, for the acute care NP, versus child health in family care, for the family NP)	Neurobiology, spinal and epidural anesthesia, and advanced airway management. Graduate-level pharmacology. CRNAs are required to achieve a number of clinical internship hours (varies by state).	Evidence-based practice, applied statistics data driven health care improvement, financial management and budget planning, effective leadership, health systems transformation	Philosophy of science and theory development, advanced research design, statistics and data analysis longitudinal and qualitative research methods. PhD students are required to take courses related to their intended area of research.
Prescriptive authority	No	No ‡	Yes	Yes	No ‡	No
Point of entry	High school diploma	BSN	BSN	BSN	BSN or MSN	BSN or MSN
Program length §	2-4 years	2-3 years	2-3 years	2-3 years	2-3 years	4-7 years

* There are a variety of subspecialties (i.e., family practice, acute care).

† Course requirements vary by state and university. The core requirements are provided here only as a sample of general requirements.

‡ May have prescriptive authority.

§ Full-time student.

Nursing Theory—Practice and Process

The discipline of nursing is a unique blend of art and science that evolved over many years even before nursing education became compulsory. The various views on epistemology in nursing are summarized by Walker and Avant. Empirical knowing is guided by practice and observation. In the empirical realm, knowledge is created from an extension of the senses; it arises from experiment. The need for nursing knowledge as a separate discipline was a major catalyst in the evolutionary process of nursing. As nurses became educated they contributed to the fundamental knowledge base of nursing; nursing theory emerged as the driving force to test and explain nursing practice.

The advantages to this approach are well described. Nursing science provides the best evidence for nursing care of patients. Caring, although not solely in the domain of nursing, requires a theoretical basis, just as curing, not solely in the domain of medicine, requires a theoretical basis. Theory provides a foundation of knowledge about a problem or situation; what is known, what are the components, mediators, moderators, and co-variables. Importantly, theory provides the platform from which new hypotheses may be generated and tested. Nursing knowledge is not limited to academic research or rigid theories. Theories that are not supported by scientific testing give way to those that hold up to such scrutiny.

Nurses at all levels are responsible for generating and testing theories, and for participating in research. Most recently, the push for evidence-based practice (EBP) has emerged as a dominant paradigm in nursing care. Understanding the role of nursing theory in nursing education and bedside care provides insight for members of other disciplines that interact with nurses. One of the most widely explored theories in critical care setting is Benner’s Novice to Expert Theory.

The Novice to Expert Theory

Benner’s Novice to Expert theory of nursing care is often cited in the critical care setting and describes five stages of professional development: (1) novice, (2) advanced beginner, (3) competent, (4) proficient, and (5) expert. At first appearance the NCCU is a chaotic environment filled with sights, sounds, and even smells that rarely are encountered in daily life. In the midst of this chaos, nurses are focused on the task of patient care. When nurses first come to the intensive care unit (ICU) they enter at the novice level. When novices, nurses often may be unsuccessful in recognizing and interpreting key data. The focus is on task completion, and novices are governed by rules (medical orders) such as “record B/P q1h, notify medical doctor if SBP<180 mm Hg.” The novice has yet to gain the experience required to understand how the context of one situation varies from another situation.

Through a carefully orchestrated orientation most novices are prepared to move to the stage of advanced beginner within 1 year. Advanced beginners have developed the ability to quickly and accurately interpret much of the data, most of the time. The competent nurse is one who has been working in the ICU for 3 to 5 years and has begun to link incoming data to long-term outcomes. This stage is embodied by the nurse who consciously plans a strategy to provide care but may lack the skills of more advanced professionals to quickly respond to change.

The nurse who can understand the holism of patient care and quickly recognize how to acquire and interpret needed data is considered proficient. Proficiency is not garnered by the number of years a nurse has worked or by his or her level of education. Proficiency is demonstrated in actions that move the patient forward along a continuum of care. The proficient nurse relies on years of experience to provide care guided by maxims with subtle nuances for patient-specific situations.

Critical thinking skills have been directly linked to nurses advancing from novice to expert. At the expert level nurses have accomplished performance aspects that have allowed them to progress to higher levels of professionalism. The expert nurse is one who has become an active participant in the care of ICU patients, relies on experience as a foundation for action, and is able to recognize the entirety of the situation. To accomplish these performance aspects, the nurse must possess critical thinking skills and have acquired new schema. The progress from novice nurse to expert nurse typically occurs over many years. As nurses gain experience they develop enhanced critical thinking skills, which leads to the development of new schema and they become more adept at recognizing and interpreting information.

A clinical example provides additional meaning to these five stages. It is 2 pm and the nurse prepares to turn her patient in bed. The novice states, “It is 2 pm ; we turn patients at 2 pm ,” but does not recognize the implications of the patient’s heart rate. The advanced beginner recognizes the patient’s heart rate as she turns the patient, and then (having seen results in the past) administers analgesia. The competent nurse notes the heart rate before she turns her patient; she plans to administer analgesia and wait for a more normal heart rate before turning the patient. The proficient nurse accepts the holism of the situation noting that the patient was recently given a diuretic; she acquires additional data (blood pressure, oxygen saturation) and follows the maxim that “fluid is the answer” before seeking a new medical order. Finally, the expert nurse is one who can step out of maxims, rules, and guidelines. Intuitively, the expert talks soothingly to the patient, touching gently, planning her approach to turn the patient with assistance only after allowing family to visit and turning down the radio that inadvertently had been left playing.

Care Models

Nursing theory leads to the development of care models. An information-inclusive model of nursing knowledge is preferred to a model in which knowledge is limited by its point of origin. Jacobs-Kramer and Chinn modify Carper’s model of nursing knowledge only to the extent of suggesting that the model become an active template to synthesize groups of knowledge from multiple disciplines. Nursing models that embrace both empirical and nonempirical approaches to grow and develop the knowledge base provide the greatest potential to advance the contributions of nursing toward improving patient outcomes. The American Association of Critical-Care Nurses (AACN) embraces the synergy model for care of critically ill patients. Additionally, many hospitals and universities have adopted various evidence-based nursing practice (EBNP) models.

Evidence-Based Practice

A sharp distinction exists between EBP and practice supported by evidence. As the term implies, EBP is that which is rooted in research. The implementation of EBP requires that the practitioner begin with a question and then evaluate all the available evidence that surrounds the clinical question; practice is thus driven from the results of this process. Practice supported by evidence is a significantly less rigorous process in which the practitioner has a practice pattern or paradigm and then seeks evidence to support that paradigm. Many health care systems have adopted the principles of EBP and created more individualized models. The Iowa model is one such example that has been successfully adopted by different health care systems.

Synergy Model

The synergy model focuses on the needs of the patients but describes a dyadic relationship between nurses’ competencies and patients’ characteristics. The model identifies eight patient characteristics and eight dimensions of nursing practice. Levels for the characteristics and dimensions are described in detail elsewhere. The nursing competencies are clinical judgment, advocacy and moral agency, caring practices, collaboration, systems thinking, response to diversity, facilitator of learning, and clinical inquiry. The patient characteristics are resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision making, and predictability. The health care environment is a vital element in the synergy model and can either promote or hinder outcomes. For optimal synergy the environment needs to be one in which the nurse-patient dyad is supported.

In the neurocritical care setting, nursing provides an optimum contribution only through thoughtful collaborations. Nursing is a vital component of any care delivery model, and it is primarily tasked with bedside decision making within the context of primarily physician-derived parameters. Nurses benefit from an understanding of the history of the medical model, and physicians benefit from an understanding of the history and development of nursing theory and care delivery models.

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