While on tour of the Soviet Union, one of our group members was hospitalized. Being fluent in Russian, it was requested the I stay with her during her hospitalization. Having studied the Soviet health-care system and having visited Soviet healthcare facilities on previous visits, the opportunity to spend time in a Soviet hospital was welcomed with mixed feelings. Although my experience with Soviet hospital nursing is based on one hospital, new insight was gained into the application of Orem's self-care theory.
Nursing within the Soviet Union consists largely of following prescribed orders given by physicians. As stated by a Soviet head nurse, "A nurse must follow the doctor's prescriptions to the letter and carry out the minimum work assigned here - such is her duty" (Lotareva, 1982, p. 52). The education of nurses within the Soviet Union reflects the subservient role of nurses to physicians. Nurses are trained at medical technical schools where physicians direct, organize, and teach the major portion of didactic content. Practical nursing experience within the curriculum begins at a hospital the first year of nurses' training (Hancock, 1982).
Two tracks for nurses' training exist. One consists of three years of nurses' training, following eight years of basic education. The second track consists of two years of nurses' training, following 10 years of basic education. Tb specialize in a particular area of nursing (i.e., pediatrics), Soviet nurses must take additional coursework that lasts from one to six months. All nurses are required to take state re-examinations every two years (Fahley, 1987). Although strict adherence to physicians' orders is the norm, some Soviet nurses are beginning to see the need for independent thinking and action, especially in emergencies and when physicians are unavailable (Lotareva, 1982).
Soviet society's view of nursing likewise reflects a subservient role. Nurses are considered "middle level medical personnel," as are laboratory and x-ray technicians. Physicians, however, are viewed as "high level medical personnel" (Dennis, 1985).
The subservient role of nurses in the Soviet Union and their strict adherence to physicians' orders was clearly evident in their nursing actions within the hospital visited. The implementation of their nursing actions was noted to have definite implications on the self-care abilities of clients. A review of Orem's theory of self-care will assist in understanding nursing care and client self-care within Soviet hospitals.
Orem defines self-care as "the practice of activities that individuals personally initiate and perform on their own behalf to maintain life, health, and well-being ... It is an adult's personal, continuous contribution to his own health and well-being" (Foster & Janssens, 1980, pp. 92-93). Self-care is viewed as having a practical and therapeutic approach. According to Orem, nursing is defined as assisting clients in achieving maximum self-care (Griffith & Christensen, 1982). Three nursing care systems exist to assist clients in achieving self-care. The first is the "Wholly Compensatory System." Within this nursing care system clients are unable to care for themselves and are totally dependent upon nurses. In the "Partly Compensatory System" some nursing care is needed to assist clients in achieving self-care; however, it is less than in the previous nursing care system. Clients have more control in that they can verbalize their need for nursing care. The last nursing care system is the "Supportive-Educative System." Nursing action within this system consists of assisting clients who are ready for self-care by means of teaching and supportive activities.
The group member was diagnosed with transient ischemic attack (T.I.A.) and hospitalized on a neurological wing. She was admitted to a ward with four clients. The diagnoses of the clients ranged from cerebral vascular attack (C. VA.) to metastatic brain cancer. The treatment for clients with C. V. A. and T.I.A. was similar. It included a regimen of medications, some of which were similar to those used in Western medicine. Strict bed rest for 10 days followed by a slow increase in activity was also part of the treatment plan. The usual length of hospitalization for clients with C. V. A was three weeks, with most clients discharged without evidence of paralysis.
Hospital personnel included a physician administrator and one day and one evening physician for the entire wing. Additional hospital personnel working on the 80- to 100bed floor included three dietary personnel who were also responsible for housekeeping, one orderly, and one nurse. Hospital nurses typically work a 24-hour shift with three days off followed by another 24-hour shift, etc. Nurses wore lab coats over street clothes, with white scarfs/caps that held their hair up off their shoulders.
Most of the hospital floor was divided into wards with four to five beds in each ward and one adjoining bathroom with a shower. Each ward had one small refrigerator. CIients were allowed to have food brought for them and kept in the refrigerator. No medical or nursing staff checked the food. Clients freely ate the food and shared it with each other. Street clothes and gowns from home were worn. No hospital gowns were provided. Once clients felt well enough to leave the floor or hospital premises they did so without passes or permission from hospital personnel.
Clients readily assisted each other. Most teaching and supportive measures were performed by clients rather than nurses. If a bedpan was needed, clients assisted each other with the bedpan. When a client needed to be ambulated, again clients assisted each other. Teaching bedridden clients dangling was also performed by clients rather than nurses. Bedridden clients on occasion received meals brought by dietary personnel. However, it usually was clients that brought food from the kitchen, fed other clients, and removed soiled dishes.
It was obvious that the major portion of nursing action was to carry out physicians' prescription orders. For example, the nurse on duty would bring all medications for the day at 8:00 a.m. She would briefly explain when they should be taken (i.e., after breakfast, at bedtime). She would then give all medications for the day to each client. Only if clients requested information regarding a medication was any explanation given. Frequently, the 8:00 a.m. encounter with the nurse was the only one for the day. If there was a problem or question that clients were unable to answer for each other, a physician was usually called. We were informed that nurses assisted clients with their exercise regimen when ordered by a physician. This, however, was not observed with any clients on the floor.
During and after our visit to the Soviet hospital, I spent much time contemplating the scope of Soviet nursing practice and its impact on clients' self-care abilities. It was evident that their scope of practice is very limited. It was also evident that clients assumed the major portion of their care whether it was supportive or educative. Furthermore, it was evident that clients were discharged in a state of self-care, regardless of limited nursing actions, in assisting clients to achieve self-care. What, then, are the dynamics between nursing action and self-care?
Within Orem's nursing systems it is assumed that clients move from a state of dependency on nurses to a state of independence or self-care. Nursing actions are gauged according to a client's ability to assume self-care. Thus, Orem's three nursing systems indicate a stage-type progression toward self-care with the assistance of nursing actions.
Soviet nursing actions appear to remain constant (i.e., fulfill physicians' prescription orders) rather than change with clients' self-care abilities. Clients on their own tend to assume appropriate actions to achieve self-care. This is done either independently or collectively with other clients. Thus, a dependency upon nursing actions to achieve self-care is not present. Rather, nursing actions as defined in each of Orem's nursing systems are assumed by clients in Soviet hospitals. In spite of this, clients were discharged from Soviet hospitals in a state of self-care.
I left the Soviet Union realizing the need for nurses in the United States to re-evaluate the definitions of self-care and nursing actions. Especially needed is an evaluation of nursing actions, considering the possibility of nursing actions maintaining clients in a state of dependency longer than necessary. Although our present definitions of self-care and nursing actions assume clients are responsible for a major portion of their care, we must begin to question the degree to which nursing actions are focused on meeting the needs of nurses rather than clients' needs for self-care.
- Dennis, L.I. (1985). Nursing within the Soviet health care system. Int Nurs Rev, 35(5), 149-153.
- Fahley, W.S. (1987). Recollections of nursing and health care in the Soviet Union. Public Health Nurs, 4(2), 120-122.
- Foster, P.C. & Janssens, N.P. (1980). Dorothea E. Orem. In George, J.B. & The Nursing Theories Conference Group (Ed.), Nursing Theories: The Base for Professional Practice (pp 90-106). Englewood Cliffs, N.J: PrenticeHall, Inc.
- Griffith, J.W. & Christensen, P.J (Eds.) (1982). Nursing Process: Application of Theories, Frameworks, and Models. St. Louis, Toronto, London: CV. Mosby Company.
- Hancock, C. (1978). Nursing behind the Iron Curtain. Nurse Mirror 20(15 ). Joint Report by the Director General of the WHO and the Executive Director of the United Nations Children's Fund, Primary Health Care. International Conference on Primary Health Care, Alma-Alta, U.S.S.R.
- Lotareva, V. (1982). The nurses' council in a Soviet clinic. Imprint, 5, pp 51-53.