Freshman nursing students continue to enter baccalaureate nursing programs with many misconceived ideas regarding professional nursing. Among these misconceptions are the traditional views of the health care hierarchy, specifically in regard to the concept of the health care team and the functions of its members. Having been involved in the Introduction to Professional Nursing course for the past few years, we continue to find that freshman students visualize "health" care solely taking place in a restorative setting as ordered by the physician and implemented by the nurse. This previous socialization certainly limits their perceptions of the scope of todays professional nursing practice.
To verify our perceptions, we asked approximately 75 freshmen nursing students to list at least three members of the health care team. The majority of students were only able to identify two members - the doctor and the nurse; no student included the patient. This informal survey demonstrated the need to identify those individuals who constitute the health team, and to explore various roles and interrelationships among these team members. The most significant finding indicated the need for students to recognize the patient as an active participant on the team. These results supported our initial premise that freshman students should be socialized to the broader realm of health cafe at an introductory level of the curriculum.
The health care team concept was initially introduced through class discussion and readings. To further illustrate and clarify the concept we developed a model diagram. Our specific strategy was to provide introductory health care models, have the freshman students review them, and then ask them to construct alternate models based on their critical evaluation of other models and their personal values system. To implement our strategy, we invited another member of the health care team to present his view of the health care team. In using this approach, we believed that students would have sufficient exposure to various points of view.
A PRESENTED MODEL
A Presented Model
The guest speaker, a physician, utilized the analogy to a baseball team in his illustration of the health care team Figure 1). He placed the physician on the pitcher's mound and the nurse behind the plate as the catcher. He then assigned various members of the interdisciplinary team which included the dietician, physical therapist, clergyman, social worker, x-ray technician, dentist, and psychologist to the bases and the outfield,
When describing the roles of the allied health professionals, the physician alluded to the fact that any one of them, at any particular time, may be the most valuable player. For instance, if the left fielder, the psychologist, makes a spectacular catch that wins the game, that is his intervention assists the patient back to health, then he is considered the star of the game.
By stressing the interdependence of each team member, he also emphasized the collaboration that is necessary for a team effort to exist. The primary goal of this team effort, then, is to work for the benefit of the patient, who was placed as a fan in the stands.
As we anticipated, this model stimulated student response and class discussion. The students first reacted to the poeition of the patient. Their reaction was one of confusion and controversy since previous class discussions identified the patient as an actively participating member of the health care team. In contrast, the freshmen viewed the physician's model as excluding the patient from the team and positioning him in the stands as a spectator. This led the students to question the purpose and goals of the health team. In addition to the position of the patient, they recognized that the concept of the family was completely omitted from the model.
Another student reaction focused on the assigned positions of the physician and the nurse. Interestingly, the freshmen expressed traditional values concerning who controls patient care. Most class members believed that placement of the physician as the pitcher suggested that the physician was in control of the team. The students' interpretation was based on the fact that baseball is a pitcher's game. Similarly, a few students viewed the nurse as the direct recipient of the physician's orders implying that, traditionally, nursing care was totally directed by the physicians. Even though one member reminded the group that it is the catcher who gives the "signal" to the pitcher, the majority still believed that the pitcher ultimately determined the pitch. A final reaction focused on the placement of the allied health professionals on the team. The students unanimously agreed that there was a need for collaboration and cooperation among all team members.
Based on these reactions, the class attempted to construct an alternate model (Figure 2).
The primary focus of the alternate model was placement of the patient and his family on the team. This priority evolved from the students' belief that the purpose of the entire health care system or "ball game" is to assist and support the patient or family to meet health care needs. Again, using the analogy to baseball, we asked the students, "What specific position will the patient play?"
Since the first objective of the Introductory Nursing Course was to discuss the Philosophy of the College of Nursing, the students were now specifically referred back to the definition of Man as stated in the philosophy. This definition describes Man as having "the potential to direct, integrate and/or adapt to his total environment in order to meet his needs" (Philosophy, 1979, p. 1). Based on this statement, we emphasized the free will and independent decision making that a patient should exercise when maintaining, restoring, and promoting his health care. Thus, the students realized the key position the patient should play on this team.
Having already determined that the pitcher's position was one of control and leadership, they then decided to place the patient on the pitcher's mound. To insure family participation, the students assigned the family to the bullpen to be utilized as relief pitchers.
In this key position as pitcher, the patient would receive signals from the catcher - the catcher being any member of the health care team who assists the patient to identify his needs. Viewing this function as analogous to the role of a patient advocate, we again referred the students back to the definition of Nursing in our philosophy. This definition states that "nurses will serve as change agents and emerge as full partners with other health disciplines in leading and shaping health policy and in functioning as an advocate for the health care consumer" (Philosophy, 1979, p. 1). We then determined through class discussion that the nurse most often assumes the role of patient advocate, based on the close contact and continued assessment of the patient. However, it is vital for all health team members to recognize that they may also serve in the advocacy role depending on the patient's specific needs at a particular time. We concluded that the role of the patient advocate is to assist the patient and his family in identifying and clarifying their health care needs and encouraging active participation in their own self-care.
When the pitcher identifies his needs with the assistance of the catcher, he expresses these needs to his primary health care provider. The patient expresses his need by throwing the pitch to the primary care provider who is the batter and receives the need. The primary care provider then is any member of the health care team who is functioning as the coordinator of health care. Having identified the members who constitute the health care team during previous class discussion, the students also recognized the need for a coordinator of the team effort. However, they again believed that this position is most often played by the nurse or physician. It is important to point out that the batter is not an opponent, but a co-force necessary to implement the health care process.
Having received the need from the patient, the coordinator evaluates the need and directs it to the appropriate health team member. In the student generated model the health team members are identified as allied health professionals who are stationed on the bases and in the outfield. Similar to the physician's model, these interdisciplinary health team members included the dietician, physical therapist, clergyman, social worker, x-ray technician, dentist, and psychologist. However, in the alternate model, it is important to note that all health team members could rotate to the catcher and batter positions serving as patient advocates and health care coordinators.
The student generated model illustrated the equality and cooperative effort necessary for the team to function effectively. The model also suggested that no one member is solely responsible for patient care, and that at any given point in time, one member must take responsibility for coordinating efforts. Using this approach, the students were able to identify the multifaceted nature of responsibility and coordination in the health care team.
We believe that positive outcomes eventually resulted from the physician's initial presentation of a different viewpoint of the patient's position on the team. The students were able to take his viewpoint, compare it to previous nursing class discussions in the attempt to clarify and identify the role of the patient. From this discussion, we were also able to introduce several new concepts that would be critical elements in the process of socializing young students. For example, in their alternate model, the students identified the concept of the health care team and the members who constitute the team. By determining positions players could assume on the field, the students were able to clarify the various roles of the team members. The freshmen also recognized the flexibility and interchangeability of these roles.
The students identified the patients as active participants of the health care team. They viewed the patients as having the responsibility to identify their own health care needs to another member of the health care team if unable to meet them without assistance. The students viewed patients as controlling forces which actually provided for the introduction of the self-care concept into class discussion.
The introduction of the self-care concept stimulated us to briefly orient the class to the development of conceptual frameworks. By critiquing the models and formulating an alternate model, we were pleased and assured that the students demonstrated beginning abilities to conceptualize thoughts and ideas. This orientation also helped us to introduce another objective of the freshman curriculum which is, "Compare selected conceptual models of Nursing" (Introduction, 1980, p. 2).
Values clarification techniques were utilized throughout the development of the students' model. When attempting to describe specific roles of the team members, we were not surprised to find that freshmen frequently expressed traditional views of the general public regarding the controlling role of physicians and the subservient role of nurses. A problem that the students identified was the different perspectives health care professionals have about the team of which they are a part. The students realized that two contradicting roles of the patient were expressed, leading them to the conclusion that health care providers must join together and clarify each team member's role. They also recognized the need for collaboration and cooperation, specifically between physicians and nurses in meeting patients' needs.
Throughout the exercise we consistently encouraged students to express their beliefs irrespective of how traditional we might have judged them to be. We also stressed the necessity of continually identifying and clarifying their own individual values and perceptions as they participate in the educational process and are exposed to new ideas regarding nursing and health care.
By using the teaching strategy as described, we believe we were able to effectively assist freshmen students in identifying and analyzing the roles of nurses and others in health care, and most importantly, the significance of the patient in determining and participating in his own health care.
- Introduction to professional nursing, syllabus. (1980). Villanova, PA: College of Nursing, Villanova University.
- Philosophy of nursing (Rev.). (1979). Villanova, PA: College of Nursing, Villanova University.