Dose of realism, injection of hope

July 18, 2003

A good clear-out at home and worry that the curriculum had lost touch with what it is to be a nurse spurred Keith Ward to search for the 'real stuff' of nursing.

You know how it happens. You finally get around to clearing out old documents and papers but begin to read them instead. Memories flood back, old friends remembered, past events relived, places revisited. That is how I came across my old state-registered nurse exam paper from 1976 and the question: "Mr Tate is a 54-year-old postman who has been admitted for an above-knee amputation. Describe the care he will require for the first 48hrsI" Fast forward years. The state final paper has gone, along with the nursing course, to be replaced with nursing modules and module assessments. In the new millennium, nursing students are as likely to be assessed on their understanding of the research process or change-management theory as on patient care. Somewhere along the line, the curriculum has lost touch with what it is to be a nurse and, along with many of my colleagues, this concerns me.

Three years ago, I set about tackling the problem by building a virtual hospital ward. The three-year gestation produced a healthy 65,000 lines of computer code, and Penfield Virtual Hospital was born. The delivery was protracted and was made possible only when Jim Hartley joined the team as a computer-coder-cum-midwife from the steel mills of Sheffield via an MSc in computing.

Penfield is thriving on a diet of ideas. It now weighs in at a healthy 150,000 lines of computer code.

Student nurses tour the virtual wards and interact with patients through a limited set of manufactured case histories. The drawback is that the wards are clean and well staffed and the cases straightforward - the opposite of most people's experience.

In search of the real "stuff of nursing", I decided last year to get a set of real case histories through a project financed via the Fund for Developments in Teaching and Learning. A consortium of universities - Huddersfield, Glamorgan and Sheffield - began gathering 200 case histories from two UK National Health Service trusts. As an information source, these have proved 24-carat gold. So why did I still have misgivings?

It gnawed away at me until I realised that, even if we have case histories, what we teach nurses is still determined by the nursing curriculum, which is still written by people like me who have not seen the whites of a patient's eyes for years. A cocktail of sheer hard work, laced with roughly equal amounts of self-belief and good luck, led to the award of a national teaching fellowship, which has given me an opportunity to begin to tackle those misgivings.

The starting point for the fellowship is the belief that nursing is what nurses do, that nursing occurs in a context, and that my teaching should reflect this. What nurses do - and in what context - will be determined by an analysis of the case histories. Not everything that is nursing is recorded or indeed recordable, but tackling this limitation will have to be placed on the back burner for now.

Nine regional groups, each consisting of a ward sister, a student group and an academic, will be established to check the analysis against experience.

The case histories will be adapted to match. Ultimately, the analysis will form the basis for a nursing curriculum that reconnects nursing to patient care.

Students, clinicians and academics have bought into the principle of a context-based curriculum, but it is a bit like the Middle East "road map" for peace: everybody sees the purpose and signs up, but implementing it is difficult. Some academic staff are suspicious of anything that threatens their right to determine the curriculum and say that such an approach to curriculum design will lead to a "dumbing down" of nurse education.

It is a tall order for a fellow to go out there and influence the wider national community. But discovering my old exam paper reminded me how proudly I used to wear my student nurse badge, often "forgetting" to remove it when I travelled home on the bus. I want today's students to feel equally proud of their training.

Keith Ward is a senior lecturer in the School of Human and Health Sciences, University of Huddersfield.

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