Primary health care is defined by the Canadian Nurses Association as "essential health care made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford" (Remkes & Sibbald, 1992). The primary health care model, adopted by the Canadian Nurses Association, represents a consumer-oriented health care system that has a preventive focus. A consumer approach places an additional responsibility on nurses to be broadminded in understanding the health needs of the public. Because consumers often have a diversity of mutually competing viewpoints about health, economic, social, and other needs, primary health care nurses must accept the challenge of ensuring that health care becomes integrated with social and economic sectors (Remkes Sc Sibbald, 1992). This author posits that the classroom debate is a teaching strategy for preparing student nurses, not only to accept the diversity of consumer opinion, but encourage the consumer to adopt a health promoting lifestyle despite social and economic constraints. After a thorough review of the literature, it is apparent that although debates are used frequently as a teaching and learning strategy, there is a paucity of literature available on the use of debates in nursing education. Moreover, there is an absence of nursing research to support the use of this strategy for assisting nursing students in understanding the salient concepts of primary health care. In this article, the components of a debate will be described and analyzed in relation to the guiding principles of primary health care, These principles reflect accessibility of services, public participation, health promotion, intersectorsl cooperation and the use of appropriate technology (Remkes Sibbald, 1992).
Identifying the Underlying Assumptions
When preparing for a debate students are presented with a clear resolution and must focus the debate by identifying the underlying assumptions of the resolution. These assumptions must be accurate and free of ambiguity. It is at this point that students' concerns regarding the relevancy of a debate become apparent. Some adult nursing students perceive their priority need to be "acquisition of skills such as physical assessment" (Wuest, 1989, p. 848). In a health care setting with a preventive focus, communication skills may be more relevant than psychomotor skills and therefore, it is necessary to reinforce the notion that debating enhances communication. However, students' enthusiasm may be heightened if the resolution is relevant to their clinical or community practice. By clarifying the assumptions, students are forced to isolate potentially contentious factors that are often entrenched in legislation such as the Ontario Health Insurance Plan (OHTP). The following debate resolution is used to illustrate the concepts described in this article: "Cosmetic surgery done to enhance self-concept should be covered by OHD?." Under this resolution, there is an underlying assumption that some cosmetic surgeries are not covered by premiums. Through an examination of OHIP legislation, students learn the facts regarding insurable and noninsurable benefits. Students are often surprised to learn that insured benefits vary from province to province (Ministry of Health, 1988). Another assumption stemming from this resolution is that Ontario residents have access to cosmetic surgery. The issue of accessibility is the first guiding principle of primary health care.
According to the Canadian Nurses Association (Remkes & Sibbald, 1992), accessibility "implies a continuing and organized supply of care that is geographically, financially, culturally and functionally within easy reach of the whole community" (p. 2). Primary health care nurses must be prepared to meet community defined needs. Before doing so, nurses need to be mindful of any legislation that may impact on their roles. Experience with classroom debates reinforces students' ability to understand and clearly describe legislation.
Taking a Stand
When the debate resolution is understood, the students must take an affirmative or negative stand on the issue. Attwood and Cheney-Stern (1983) maintain that debating helps allied health and nursing students develop "the ability to take a stand and risk being found on the losing side" (p. 82). The classroom environment is a relatively safe area in which to take such a risk, facilitating the valuable learning experience of risk taking. Alternatively, students may be encouraged to research and argue against their preferred side because it is more important to be able to explore both sides of an issue than to be on the winning side.
By taking a stand, students develop skill in "purposefully focusing attention on a single area" (Attwood & Cheney-Stern, 1983, p. 81). Focused attention is a leadership quality that primary health care nurses must possess. Attwood and CheneyStem (1983) define a leader as "one who is successful in influencing others to change their attitudes, beliefs, or actions* (p. 80). Under primary health care, client decisions are to be nurse-influenced and not imposed by bureaucracy. Moreover, nurses must demonstrate leadership skill to encourage community involvement in planning health care services (Remkes & Sibbald, 1992). Community involvement is the second guiding principle of primary health care.
If community involvement is to be effective, it is imperative that professionals be knowledgeable about community and family interrelationships and develop mechanisms to encourage eelf-care and self-reliant behaviors (Remkes & Sibbald, 1992). Nurses, having much contact with the public, must capture the opportunity to assume the leadership role and be able to clearly articulate their stand. Classroom debates help to prepare student nurses for practice in a nurse-influenced health care system.
Researching Affirmative and Negative Viewpoints
Once the students have chosen a stand on a resolution, a thorough review of current literature must be done to identify supporting facte. When planning their argument, it is important that students differentiate between cause and effect. In the aforementioned resolution, students using anecdotal data may find it difficult establishing that cosmetic surgery actually caused a change in the clients self-concept. In contrast, a stronger argument would be presented if research data are cited to support the viewpoints that cosmetic surgery had a positive effect on the client. By presenting research data appropriately, students learn to differentiate between fact and inference and in doing so, will enhance their cognitive skills and gain appreciation for the complexity of issues (Attwood & Cheney-Stern, 1983; Eletein & Harris, 1990). For example, although a person who has undergone cosmetic surgery may report an enhanced self-concept, students may question whether the reported change was intrinsically derived or one that was extrinsically derived by a societally imposed focus on beauty. Some students may argue that if cosmetic surgery resulted in a positive intrinsic change in self-concept, it may be health promoting. Health promotion is a fundamental concept of primary health care and is the third guiding principle.
According to the Canadian Nurses Association (Remkes & Sibbald, 1992), there must be an "increased emphasis on services that are preventive and promotive rather than curative only" (p. 5). Primary health care nurses who are knowledgeable about the facts on disease prevention may be able to convince the public that health promoting behaviors are worthwhile. It is well within the purview of nurses to share the researched facts with the persons who will be most affected by the health care model.
Students must also research data that contravenes their position so they can anticipate opposing arguments. This enables students to discover the vast amount of conflicting information, research and opinions that may result in conflict and lack of consensus (Huryn, 1986). Having such an appreciation prepares students for interactions with other health professions and paraprofessionals who have a vested, albeit divergent, interest in clients' wellbeing. Since collaborative action is crucial for eliminating duplication of services, primary health care nurses must be sensitive to the viewpoints of others so that intersectoral cooperation is achieved. Intersectoral cooperation represents the fourth guiding principle of primary health care.
Under a primary health care model, health development is integrated with social and economic development (Remkes & Sibbald, 1992). For example, healthy public policy on cosmetic surgery ensures that only research-supported surgical implants are used in cosmetic surgery and only skilled practitioners are licensed to perform procedures such as liposuction. Moreover, the decision to make the surgery an insurable benefit is examined in light of economic feasibility and the existence of a social need. To a certain extent, the intersectoral cooperation exists today, However, if clients' decisions are to be nurse-influenced, then primary health care nurses must understand how non-health sector decisions relate to health care. Sharing the facts with the public on how other sectors, such as housing and education, impact on health may motivate clients to assume an active role in total health development.
Presenting the Debate
Once a thorough review of the literature is completed, students are in a position to debate the resolution, thereby testing their arguments against peers. Organizational skills are crucial for planning how and when to introduce the data to achieve maximum effect. The students' ability to listen to the opponents' arguments and to verbally present a convincing contrary argument is measured by a shift in authence opinions from positions held before the debate to positions held following the debate (Attwood &. CheneyStern, 1983).
Debating assists students in sharpening their listening skills. Effective debaters are able to evaluate author bias and shallow reasoning and use these weaknesses to discredit the opponents' viewpoints during the rebuttal (BeU, 1991; Huryn, 1986).
Students who engage in debates may become proficient at analyzing problems and arriving at workable solutions. Where social issues are concerned, this may be a chaUenging task. Moreover, debating social issues assists students in modifying their opinions when exposed to sound opposing arguments. Primary health nurses are able to modify their opinions if they have developed skills in recognizing their biases and values, and presenting factual data. By effectively communicating facts, rather than advice, nurses educate and raise the consciousness of the public. An informed pubUc ultimately means decisions affecting them are nurse-influenced, not nurseimposed (Bemkes & Sibbald, 1992). Such information may promote self-help and self-reUant behaviors, both of which are fundamental to primary health care.
In a technologicaUy advanced world where options are numerous, the public needs to make informed decisions. Primary health care nurses, as part of a collaborative health care system, must assist the public in their decision-making. Decisions regarding the use of health technology represents a challenge for the public and is relevant to primary health care. The fifth and final guiding principle of primary health care addresses the use of appropriate technology.
Under this principle, there is a need to ensure that technology is adapted to the community's social, economic, and cultural development and can be maintained in an affordable way (Remkes & Sibbald, 1992). This places additional responsibility on primary health care nurses to be informed about non-health sector issues that impact on public health. By sharing with the public relevant facts on how the sectors relate to one another, primary health care nurses are in a position to encourage the public to become self-reliant in deciding if specific forms of technology are appropriate for them as individuals. By debating the merits of technology as students, primary health care nurses are prepared to address public concerns.
This article describes how a classroom debate may be an effective teaching strategy for preparing students for the role of a primary health care nurse. Through clarification of the underlying assumptions of the resolution, students gain an appreciation for legislation and availability of services. Acceseibility of services for the pubUc is the first guiding principle of primary health care. By taking a stand on the resolution, students develop leadership skills that help them influence the public, thereby encouraging the public's participation, the second guiding principle. To identify supporting data for both sides of the resolution, students must research current hterature and in doing so, they gain appreciation for two sidee of the issue and enhance their cognitive skills. Students must examine how decisions by other sectors of the community impact on health and if those decisions are health promoting. The concern for health promotion and intersectoral cooperation are two additional guiding principles. Finally, by presenting the debate, students develop their listening and verbal communication skills. In doing so, they develop greater recognition for their own biases and values, thus setting the stage for encouraging the pubhc to make their own decisions regarding health technology. Appropriate use of technology is the final guiding principle of primary health care.
In conclusion, the body of knowledge that student nurses require upon graduation appears voluminous. Effective primary health nurses have a broad base of knowledge that goes beyond the traditional nursing knowledge. In preparation for that role, students must be proficient at identifying issues of importance to the public's health; recognizing their own biases and values; coUecting current, ecientific data; and clearly articulating the facts. The classroom debate is one strategy that may assist students in preparing for the role of a primary health care nurse. To ensure this is an appropriate strategy, further research is needed to validate its effectiveness in nursing education.
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