It is the time of year we watch another class of students anticipate their graduation. Over and over again, in many ways, we hear students voice their concerns- "Am I really prepared to be a nurse? Have you taught me all that I need to know?" This issue of the Journal of Nursing Education focuses on students, their experiences in nursing programs, how they cope with stress, what professionalism means to them, and the experience of taking the NCLEX-RN. Here, I would like to share my message to students, addressing their anxieties as they enter the nursing profession.*
You have completed a rigorous program of studyliberal arts, social sciences, chemistry, biological sciences, followed by intensive study of nursing science and the practice of the clinical arts. When I was in your place more years ago than I care to say, our commencement speaker warned of a brave new world on the horizon. While the change has been enormous in the interceding years, we still are not finished.
In 1993, Peter Drucker wrote:
Every few hundred years in Western history there occurs a sharp transformation. We cross... a 'divide.' Within a few short decades, society rearranges itself- its worldview; its basic values; its social and political structures; its arts; its key institutions. Fifty years later, there is a new world, and the people born then cannot even imagine the world in which their grandparents lived and into which their own parents were born. We are currently living through just such a transformation (Drucker, 1993, p. 1).
Futurists love to imagine health care circa 2010 or 2020. Forecasts include anything from hip-replacement cruises for the wealthy, to techno-fixes for the masses. There is no doubt that nursing in 10 to 20 years will be nothing like nursing today. New technology, changes in public attitudes toward their health and health care, availability of health information, scientific advances in genetics, and a rapidly shrinking workforce will force the profession to remake itself, perhaps many times. The rate of knowledge turnover is exponential. I tell my students, "Half of what I tell you today will turn out to be irrelevant, or just plain wrong within 5 years. The only problem is I don't know which half."
Are you prepared for this future? Absolutely not- in the traditional sense. There is no way your faculty could teach all you need to know for today's practice, must less tomorrow's. Your graduation marks not the end, not even the beginning of the end, but the beginning- the commencement of lifelong learning and transformation.
You are well prepared for this future in another sense. Your education has prepared you to be knowledge workers- those who analyze informa* tion and "apply specialized expertise to solve problems, generate ideas, teach others, or create new services" (McDermott, 1995, p. 12). It has provided you with theoretical and analytical knowledge that cannot come with on-the-job training. It also has taught you the habits and skills of reflection on practice and critical thinking that fuel continuous learning.
You also are prepared in another more fundamental sense. During your years in school, you have connected with other aspiring professionals. Some of these friendships and deep connections will last a lifetime. With these colleagues you have developed a deep sense of the core of nursing- the heart of it. Surely, there is a science to it, but we would not have so much trouble articulating the "it" if there was not much more to it. It is this core that will not change as the world swirls around us. The futurists refer to it blandly as the "human touch," in a world characterized by high technology and disconnected human relationships.
I think we understand and connect to this core through our stories. It is the substance of human relationship, the privileged intimacy we know in nursing, and the meaning, intents, and spirit behind our actions that show up best when we tell and retell the stories of our practice. You always will remember those significant stories of learning, those experiences with your patients that transformed you as a nurse and person.
A colleague of mine, Joann Rader, a geropsychiatric clinical nurse specialist, tells a story I think defines the essence of nursing. In her words,
This is a story of Opal, a 96-year-old resident of a nursing home. Opal did not like to be touched, and she would be aggressive toward others with no provocation. She would dump a pitcher of water on someone or roll up in her wheelchair behind someone, and whop that person on the back of the head. Sometimes Opal would walk but she also used a wheelchair. She was what I call one of the charter members of our "frequent fallers' club." We did not restrain her. But at night, she would get up from her bed and crawl to the other side of her room and under her roommate's bed. I have no idea why she did this. She just did. So we would get her up and lay her in her own bed.
Opal did not think she was in a nursing home. She had been an office manager, and as far as she was concerned this was her office and she was in charge. She would sit in front of the nurses' station and oversee everybody coming and going. Once in a while, she would ooze out of her wheelchair, so she was at risk for falling. As she fell more often, the staff decided they needed to do something to modify her environment, so they moved her chair into the nurses station and up to the desk. If she stood up, she would have something solid onto which to hang. The problem was the telephone and charts were at the desk, and Opal would answer the phone, take doctors' orders, and so on. She also would pull call lights apart. Some of the staff starting saying, "We cannot have this. This is upsetting our staff and our routine."
But other staff members said, "No, this is Opal's environment and we need to make it work for her." So they did something simple. They moved the telephone to the other side of the desk, out of Opal's sight. It was inconvenient for the staff but it worked for Opal. They had the mindset they were there to individualize for Opal.
As Urne passed, Opal's health began to worsen. She still was sitting in her space by the nurses' station, but one day she oozed out of her chair and ended up in the space under the nurses' station desk, and curled up and fell asleep. The staff covered her with a blanket and she continued to sleep soundly. When the next shift arrived, they said, "Ummm there is a resident sleeping under the nurses' station." The evening shift said, somewhat apologetically, "Yeah, we know we should have moved her, but she has not been sleeping well and now she is sleeping like a baby." The next shift said, "That is all right. If she likes it there, let her stay there." So that is what they did. They provided her with an egg crate mattress, afghan, and pillow, and they made a bed for her under the desk. The families and some residents were distressed, so the staff posted a sign that said, "Do not be alarmed. This space has been especially designed for the comfort and safety of one our residents."
Eventually, Opal could not get down into that space by herself, so a nurse would put her arms around her. Now I told you that Opal did not like to be touched. When you touched her, she would slap away your hand. But the nurse knew she liked that space, so she started to put her arms around Opal to help her into her space. Opal raised her hand and the nurse stopped because she knew what that fist meant. However, she looked into her eyes and saw her eyes were friendly, so she went ahead. Opal reached up and instead of hitting the nurse, caressed her face. For the last 2 weeks of her life, Opal allowed the staff to touch, hold, and cuddle her. On the day she died, she said to the nurse, with a beautiful smile on her face, "I can hear the angels come." The nurse said, "Yes, the angels will be here soon. But until the angels come, we are here to take care of you."
Opal had found an incredibly safe and peaceful place to spend the last weeks of her life because the nurses knew and understood her, and were attuned to how she responded to different events, so they were able to modify her environment in a way she could find peace and security. This is the soul of nursing.
This, you are prepared for. Remember today and always why you came into this crazy, challenging, heart-wrenching, and wonderful profession of nursing. Remember your stories, and the sustaining wonders of our work. No matter what the future holds, you will be prepared by keeping a story in your heart. Welcome to the profession!
- Drucker, RF. (1993). Postcapitalist society. New York: Harper Business Publishers.
- McDermott, R. (1995). Working in public- learning in action: Designing collaborative knowledge work teams. In M.M. Beyerlein, DA. Johnson, S.T. Beyerlein (Eds.), Advances in interdisciplinary studies of work teams (Vol. 2, pp. 35-39). Greenwich, CT: Jai Press.