By: Suzanne Owen

Introduction
(to be written)

In considering the contribution of nursing to whole person care it is important to first consider the nature of nursing, its role and values and its attempts  to establish models of care that structure the patterns and routines of nursing life. Florence Nightingale wrote in 1859 “That the very elements of nursing are all but unknown” (Nightingale, 1946). Since that time the elements, values and knowledge held by nurses have been endlessly debated and researched. The training of student nurses before the 1970’s concentrated very much on the sciences; anatomy, physiology, pathology, pharmacology and microbiology alongside the technicalities of nursing such as dressings, bandaging and bed-making. At this point in time the nurses were still very much directed by doctors and had not become the thinking and autonomous professionals that they are now. The nurses of the day were admonished to be busy and ‘find something to do’, listening to patients and hearing their anxieties and concerns was not valued by the senior ward staff, and nurses who were seen talking to patients were sent off to find something useful to do! Student nurse training in the 1980’s drew upon ground breaking research (e.g. ‘Information – a prescription against pain’ by Jack Hayward, 1975) which demonstrated the value of listening to the patients and answering their questions, and the consequent reduction in pain levels experienced by the patient.

Studies such as these influenced the training provided to nurses to the extent that students of that time were encouraged to talk to patients if they had nothing else to do. Sadly, due to inexperience this often proved to be a rather superficial exercise that probably provided little value to the patient, and a high degree of anxiety for the student since the value was not perceived by the ward staff who thought that the student was lacking in motivation! Further knowledge and experience allowed these skills of listening to the patient to be developed.

Similarly, the introduction of the nursing process in the 1970’s-1980’s was a conceptual leap for the nurses of that time, focusing as it did on the assessment of the patient from a nursing perspective, planning the care based upon the assessment, implementing the care planned and then evaluating the effect which lead on to re-assessment and so on. For nurses who had trained prior to this period, in which great change was taking place within the profession, the introduction of the nursing process was irksome and threatening to the established patterns and routines of nursing. The nursing process enforced a conceptual shift from task driven routines such as ‘bottle rounds’, ‘back rounds’ and ‘temperature rounds’, and the work books in which all this activity was recorded to an individual approach to nursing care. Patients were no longer referred to as ‘the appendix in bed 2’ and visited by a host of nurses who were each intent on the completion of their bit of the care but instead became the named patient with issues and problems and an allocated individual nurse.

This named nurse dealt with all the details of the required care (within the scope of her competence), for that particular patient. This change left behind an efficient system of getting the job done, i.e. the tasks were completed, and introduced a pattern where individual nurses had to think for themselves about the priorities of care. The old system also had a subtle hierarchy to it so that the more menial or unpleasant tasks such as toileting and back rounds were left to the more junior staff, while the more technical and ‘prestigious’ tasks such as drug rounds and ward rounds with the doctors were done by senior staff. The nursing process blew this away, and senior nurses found themselves once again involved with the fundamental aspects of nursing care. This was welcomed by many, but also disliked by others.

The nursing process was acclaimed as the ‘essence and tool’ of professional nursing practice, and as a means of evaluating the quality of care provided by nurses, and it included a sense of accountability/responsibility to the patient, (George 1990). The task allocation system did not put the patient central to the care, the completion of the tasks was the main goal, but the nursing process, whilst succeeding in putting the patient central to the care had an unforeseen negative impact  - that of nurses beginning to respond to queries with ‘it’s not my patient’, which introduced the potential for a divided team, especially when other nurses in the team did not have the same response and felt the liberty to respond to requests from other patients. Despite the negative aspects of the nursing process and the fact that the implementation was badly managed in many places (an imposed top down approach was taken, with little consultation), the new approach did achieve its aim of putting the patient central to the care, and including the patient in discussion about his needs and problems. This was the beginning of a long journey towards holistic care and then whole person care.

An increasing emphasis on professionalism, technical nursing and evidence based practice is however, being criticised as compromising the core values of nursing. Questions are being raised as to whether ‘nurses are too posh to wash?’ or ‘too clever to care?’ (Gallagher 2005). The debate concerning the priorities of technical nursing over care have been continuing for over a decade. Alison Kitson (1995) referred to ‘nursings’ persistent inability to grasp the nettle of reconciling our technical skills with our caring skills’. Despite lip service, not all nurses demonstrate a commitment to ethics or values in practice and do not always fulfil their caring role – perhaps because they are engaged in more technical activities (Gallagher 2005). If this statement were true, though, intensive care units would lack care and nursing homes would be highly caring – but neither of these statements is entirely true either. Perhaps the truth of the matter lies in the values and attitudes of each individual nurse, wherever he or she works, and this theme will be expanded later in the chapter.

Development of nursing models
Nursing models, or models of nursing, were perhaps the inevitable evolution of the changes brought about by the implementation of the nursing process, although in reality they have always existed but not always acknowledged or recognised as such. Task allocation, as described earlier is a model of nursing as it represents a way of thinking about how nursing care is delivered, (Walsh 1991). Models can simply be thought of as sets of ideas about the way nurses and patients interact, rather than watertight theories, (Walsh 1991). Models have been much criticised and dismissed as representing ‘grand theories in pretentious jargon’, (Salvage 2006), and the implementation of models seen as an illusion, with nurses believing that change has occurred when in reality little has altered apart from using different bits of paper and introducing new jargon, (Walsh 1991).

Attempted implementation of models by a ‘top down’ approach from management who do not understand the basic concepts of the model, or the care that needs to be delivered in different settings will guarantee failure. Models will only find their way into nursing practice if nurses can see advantages in their introduction and can feel fully involved in their development, (Walsh 1991) – but more significantly the model must reflect the values that the nurses hold themselves. The best way to introduce a model is to determine the core values of a nursing team or their philosophy of care and to recognise the nursing theory that complements this and will underpin it. Luker, (1988) in fact argues that each nurse carries around their own informal model of nursing, which guides and influences their practice. A formal model, imposed upon a nurse may differ significantly to the internal model, causing immense dissatisfaction and stress to the individual nurse. However, it is equally true that a nursing team, comprised of individuals with their own personal models are unlikely to produce a unified and cohesive approach to care, (potentially generating a lot of confusion for patients) and that the implementation of an appropriate model may offer a common framework and shared language that unify the team in their approach.

A simple example to highlight the problem is that of a patient who has had a stroke (CVA), and is very clumsy at doing his buttons up one-handed. Nurse A may have the view that she is there to care for the patient and look after him, minimising any stress and discomfort the patient may feel, so she does the buttons up for the patient. The next day, Nurse B cares for the patient, and she has the view that she is there to enable the patient to rehabilitate and return to the optimal level of independence possible, and she will therefore encourage the patient to do up his own buttons, irrespective of how long it takes. Nurse C the next day simply has the view that efficiency is the order of the day and in the interests of getting all the work done does the buttons herself so that she can move on to the next patient. It is easy to see that these variations in values produce different approaches to a small detail of care, which could be magnified over a spectrum of patient/nurse interactions, causing confusion to the patient who is unclear about the expectations placed upon him. The use of a model, therefore, helps bring our private models to consciousness, to make the hidden and intuitive explicit and allows debate amongst colleagues, with the agreement of a common approach, (Salvage, 2006).

Perhaps the most well known model in nursing is the Roper, Logan and Tierney (RLT) model, which was first published in 1980. The RLT model was offered as a guide to practice, and derives from the notion that humans carry out a series of everyday activities which are essential to normal functioning. The model identifies 12 activities and seeks to structure nursing around this framework, (Walsh 1991). The assessment process of this model uses the 12 activities as a framework but commonly the other elements of the model are ignored. Most nurses are familiar with the 12 activities and recite them with little trouble, but few could elucidate that the model considers that humans exist on an independence-dependence continuum for each activity, and that part of the assessment process should be to identify how the person has shifted along that continuum for each activity, (and in which direction), and whether that change is reversible if it represents a deterioration in independence).

The deficit in independence, which has been lost due to the illness process, should be the basis upon which the care plan is formulated, in order to regain the independence. The model also identifies three other components of nursing, which are carried out directly in relation to the activities of living which are the ‘preventing’, ‘comforting’ and dependent’ components. These three components overlap considerably at times, (Walsh, 1991), but are very rarely (if ever) implemented in practice as part of the model. From the list of activities of living it is clear that the model uses a biological approach to provide the basic framework, omitting any reference to psychological or social factors that may contribute to the health, sickness or wellbeing of the patient, and is a common criticism of the RLT model. The model, not unsurprisingly therefore, has been criticised for ‘dehumanising’ the patient, (Walsh 1991), which is disappointing when the attempt was to provide a more holistic approach. Although this model has been heavily criticised, and subsequently modified over time, it is acknowledged to promote the philosophy of encouraging independence, which is a widely held internal model for many nurses, and the RLT model, despite its flaws, is a popular choice for many wards.

(Other models could be mentioned to provide some contrast if word count allows)

It can be seen from this brief look at nursing models that they are helpful in framing and structuring the documentation and care plans, but if they do not accord with the internal values of the nurses then the model is unlikely to be fully effective.

The Burrswood Model of Care
The whole person approach to care is detailed elsewhere in this book from the perspectives of other disciplines, so this chapter will focus on the whole person care approach from the nursing team, and the vision/concept of the ‘Burrswood Nurse’. Holism, holistic care, whole person care is a concept that most people think they intuitively understand, since it connects loosely with the notion of looking after the whole person, (Kitson, 2004).

Whole person care does indeed involve caring for the whole person, but if it is to work effectively the understanding has to be shared by all members of the nursing team. Whole person care will not work if only one or two members of the team value the concept, since whole person care requires involvement with the patient from a therapeutic relationship perspective, which demands more of the nurse than a simple task orientated approach. Practising whole person care requires a certain level of autonomy and self confidence on the part of the nurse, but also an awareness of the boundaries around one’s own way of nursing. An example of this at Burrswood is the nursing care required by some who come specifically to receive medical and spiritual care and counselling, to help heal deep wounds from the past.

These patients often do not need nursing care in the traditional way, but they do need a very different type of care, which has become known at Burrswood as ‘friendship support’. This type of care is emotionally demanding on the part of the nurse, and requires that nurse to be very self aware of her own boundaries so that an unhealthy dependence does not develop. Instead, the nurse provides loving support, kindness and compassion but at an emotional level rather than through physical care. It may mean that the nurse sits quietly while the patient is distressed, holding their hand if touch is appropriate. It may involve the nurse praying for the patient, or reading a favourite piece of scripture, or accompanying them to one of the little chapels. It also requires skill on the part of the nurse to know how to ‘end’ that contact in a way that is affirming to the patient and not a further rejection, (which may prompt the patient’s already low esteem to tell the patient that the other patients need the nurse more than they do).

This situation is commonly experienced at Burrswood, and produces tensions between the needs of the patients who require intense and lengthy physical care, and those who may need as much time but for a different type of care, the emotional/spiritual support. Resolution/reduction in these conflicts is a current challenge to the team.

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