As nurse practitioners (NPs) and nurse educators prepare for the challenges of the 21st century, what health care trials will the future hold? How will nurse educators prepare humane, ecologically aware, technically competent, proactive practitioners? Dickens' opening lines, "It was the best of times, it was the worst of times" (1859, p. 13) is as apt a description of the societal conditions- the times- now as it was then. Nurse practitioners are currently experiencing the best of times in terms of the resurgence of primary care and the concurrent valuing of their expertise in the marketplace. They are better educated and more uniformly credentialed than in the past, and numerous scientific studies agree that the quality of care provided by nurse practitioners is exemplary (Brown & Grimes, 1993; Hill, Bird, Harner, Wright, & Lawton, 1994; Kassirer, 1994; Kearnes, 1994; Office of Technology Assessment, 1986).
It is the worst of times in that providers are expected to diagnose and treat patients at an increasingly fast pace. Large health care alliances measure success by the number of patients seen each day and variables such as the use of laboratory and radiology procedures in fee-forservice practices or the lack of their use in capitated practices. The role of practice in many employment settings is circumscribed, disease-related, organ-specific care with the bottom line being to preserve or generate revenue (Jones & Jones, 1995). This is not meant to malign managed care, but to define the barriers to providing user-friendly health care services. Because the "humanness/humaneness" of health care delivery continues to be reduced, how can nurse practitioner educators strengthen the human life link focus so central to pedagogy and practice?
Nurse practitioner programs are designed to incorporate the necessary elements of a technical/diagnostic model which requires that large numbers of facts or information be delivered in an efficacious manner. Also needed, however, is commitment to the infusion of meaning into the educational endeavor. A way to accomplish this is to embrace the phenomenological perspective which incorporates the experiences of individuals and families with whom NPs work. Integrating these experiences involves eliciting the meanings of wellness and illness from the patient. As Merleau-Ponty pointed out, The world is not what I think, but what I live through" (1964, p. 16). Valuing the personal perspective of the patient should be a theme reiterated throughout a student's education.
A student's program of study is an educational journey and, in the authors* view, an indoctrinating experience. With this understanding, education becomes a moral endeavor. Faculty interactions with students during their journey are reflected in how students interact and connect with their patients while engaged in providing health care. The manner in which students and faculty wish to be treated and acknowledged are the ways in which patients wish to be treated and acknowledged. The meaning of being human/humane is borne out in the congruency between human expectations and humane actions. The concept of the journey is discussed within the framework of attending to the biotechnical, the realms of meaning, and the connections.
Attending to the Biotechnical
Assimilating the biotechnical aspects of nursing science with meanings embedded in human existence is critical to the evolution of student awakening to the idea of the "person as significant'' (Berman, Hultgren, Lee, Revkin, & Roderiek, 1991, p. 7). The difficulties encountered and fueled by the necessity of providing the biomedical facts perhaps fosters linear thinking and the idea that health care deals in absolutes. Students want the facts and formulas, which facilitates patterns of thinking in which patient care activities are slotted into the domain of databases, dichotomies, logic problems, algorithms, and SOAP formats. The SOAP format is a way of organizing data collection. It is an acronym for subjective data (what clients say about their health), objective data (information detected by the practitioner), assessment (conclusions drawn by the practitioner as a result of subjective and objective data collection), and plan (actions the practitioner will discuss with clients to alleviate the identified health problems). While these approaches to patterns of thinking are efficient ways of managing data, they may also separate the health state from the individual experiencing that state. This is depicted dehumanization. Promoting these patterns of thinking in the name of science and rigor poses the following question: How is science and rigor promoted within the context of humaneness?
Turning to applications of this idea, the following vignettes are posited. The health state used as an exemplar throughout the discussion is tuberculosis (TB). Classic algorithms or flow diagrams that depict TB as a pathophysiological state are traditionally presented in a mode which encourages students to think linearly and place the disease process into little boxes. The following Wallace Stevens (1964) poem exemplifies the authors' thoughts regarding this method.
Rationalists, wearing square hats.
Think in square rooms.
Looking at the floor,
Looking at the ceiling.
They confine themselves
To right-angled triangles.
If they tried rhomboids,
Cones, waving linea, ellipses
As, for example, the ellipse of the
half-moon- Rationalists would
wear sombreros (p. 75).
The linear method of thinking is an effective mind-organizing process. The goal is not to totally discount a "rationalist" approach but to bring to the learner other ways of being/knowing. Inherent in this nursing educational approach is the realization that the disease process coexists in the context of humanness.
Attending to the Realms of Meaning
Captaring the patient's sense of being in the world and understanding the meanings embedded in the experiences in which the NP interconnects with them is paramount to the authors' pedagogy. As shared by Benner and Wrubel, "The symptom can never be experienced in isolation, it will always be experienced in terms of past and present life" (1989, p. 204). In addition, the idea of meanings enmeshed in "planned futures'' or in what Greene terms "realms of possibility" (1978, p. 182) is included.
The authors envision the role of the NP as an eliciting one, one that serves to uncover the meanings of wellness and illness for the patient and family. In the initial clinical course. The Culture of Primary Health Care, students are mentored to encourage self-help and self-hope by believing in the patient's and family's abilities to make choices. The role of the NP is not only to assess, diagnose, and co-plan care but to offer feedback that increases patients' awareness of the implications of their choices. Truly listening and hearing patients is essential to embracing their humanness. This is a cognitive shift from a traditional medical "Greyhound" model with a credo of "leave the driving to us."
Critical to this role for the NP is the import of language. The language NPs use must be summoned to the forefront for examination. How faculty talk with and about students, colleagues, and patients is translated into how students interact with these individuals. In the pathophysiology course, students and faculty strive to hear the language and the voices of the patients and families. In essence, language as meaning permeates the totality of existence.
In addition to promoting critical and conceptual thinking skills and abilities, the authors strive to stimulate the ability to bring creativity and meaning into the domain of nursing art and science. The purpose of course activities is to encourage students to achieve an understanding of selected pathophysiological processes from both theoretical and patient or personal experience perspectives.
Again evoking the TB exemplar, an excerpt of poetry from a patient, Billy Ray, who corresponded with an NP student in 1993 follows:
TB: The Poem
Time for me is not too swell
sitting in this TB cell
Wondering when I'm going to be well
They are night sweats and coughs and
weight loss you never had
that always keep you feeling bad.
Your mind is in shock that keeps you
looking in the clock
knowing only time can tell
how long it will be before you are well
and out of the TB spell.
In further correspondence, Billy Ray called TB "the beast" and acknowledged his nurses' support and belief that "TB is a disease that anyone can catch,... and they help you feel that you are not an animal or an alien in a mask." As part of the student's final presentation, classmates were given masks which they wore for the reading of Billy Ray's writings and descriptions of his feelings. Student presentations in this course are particularly poignant and tap into the fount of the affective learning domain.
Brad, a 28-year-old male, suffering from TB superimposed on AIDS, was the subject of another student's presentation. He shared with his student NP provider that his "life felt gray and out of focus." The videotaped presentation of Brad was shot slightly out-of-focus through a gray filter. Brad was seen as an unrecognizable, hazy form as he spoke about what his life was like as he became less and less able to care for himself. It is important to note that signed patient consent is obtained by students prior to any discussions or use of audiotapes or videotapes.
Names have been changed for purposes of anonymity.
Attending to the Connections
Returning to the metaphor of education as a journey, the focus is on the being/knowing connections between the linear-logical and the personal-perceptual. The blending of these patterns of thinking serves to excite the student to wide-awakeness, or enhanced sensibility and a more finely honed awareness. This blending is likened to the realization experience when the patients' realness in the world is called to the learner's consciousness. No longer can a patient be merely a disease state, nor can the nurse practitioner be merely a caretaker. In these synthesizing moments which have the potential for being transforming, there are instances of mutual sharing and understanding and a widening of horizons for those engaged in this multidimensional journey.
Returning to the clinical course entitled The Culture of Primary Health Care, major health issues and their meanings to patients, families, and communities are addressed in an ecologically enlightened framework. Students learn that patients' health status is a reflection of all that touches them and not merely a manifestation of errant organ systems and cellular dysfunction.
Recalling our TB exemplar, students examine the personal meanings that TB inflicts on patients in terms of their sense of self and quality of life. These meanings are examined in the context of relationships, roles, and family dynamics observed during home visitation. Student awareness of the insidious encroachment of TB in the community at large is assessed relative to the epidemiology of the disease process, case finding, treatment, and follow-up activities.
Nurse practitioner students traverse many environments including census tracts, occupational sites, the inner city, rural counties, the suburbs, or wherever their community assessments take them. It is through these expeditions that the everyday lives and work worlds of patients and families become part of their awareness. In essence, students leam that:
the idea of community encompasses much more than groups and aggregates of people living in some manner of circumscription. Community is about people living on land, in some form of housing. It is also about standard of living; it is about the socioeconomic and political factors that affect the lives of individuals and families; it is about their health and well-being; it is about social justice (Jones, Jones, & Schenk, 1995, p. 83).
The educational journey is accomplished by attending to the biotechnical, the realms of meaning, and the connections. To prevent the impression that this approach to education is somehow facile, some of the things that must be attended to as the composition of the curriculum is created and recreated will be shared. Much thought and attention are given to the everyday processes in the planning of the educational journey. For example, as a result of preparing this article, the authors were made aware of the need to revisit the philosophy and language of the program, course syllabi, and selected textbooks, and how the course activities are negotiated. This ongoing process raises the authors' own consciousness again, especially with respect to the desire for a co-intentional "doing with" students approach, rather than a paternalistic "doing to" students approach.
The educational courses referred to in this article are courses in the Nurse Practitioner graduate program at Georgia State University School of Nursing, Atlanta, Georgia.
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- Stevens, W. (1964). The collected poems. New York: Alford Knopf.