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Opinions of Saturday, 15 August 2009

Columnist: Asigri, D. Z.

Change Curriculum-Change Negative Behaviour!

Upon reading Ghanaweb Feature article of 23rd July 2003 which depicts the horrible experience of some ‘attendants’ in Accra Psychiatric Hospital, I developed a will to say ‘something’ at least, to that effect. GNA source reported that two mental health nurses were assaulted by mental health clients and the said nurses lost their sights having been blinded “in their left eyes”. The Acting Chief Psychiatrist of the Ghana Health Service according to the above source added that “attacks on attendants are very frequent but are very deadly when they occur.” He cites the process of “restraining patients from bolting” as possible causes of aggressive behaviour by the clients/patients. I emphasise with both the carers and the cared but what measures are being adopted or adapted to prevent similar incidents from happening again? Not all that simple I guess but I think we can only learn from our mistakes through the inspiration of others in the health care profession as well as reading research journals pertaining in relation to the changing approaches in nursing. Indeed, more incidents appear to be piling up (Ghanaweb Feature Articles for example) against the nursing profession generally which gives some grim reading, and in the writings of the late Florence Nightangle, this is a nursing disgrace! GNA source in the Ghanaweb (7 August 2009) shared some of my concerns in relation to the continuing failing nursing standards in Ghana as echoed by Mrs. Cecilia Kalitsi, Deputy Registrar of Nurses and Midwives Council responsible for indexing and registration on the lack of human dignity endured by patients. Mrs. Kalitsi stated that, “Some of the concerns have to do with the impolite way patients or clients are welcomed to the health facility, the insults rained on them when they are unable to provide vital information and the impatient manner in which prescriptions are explained”. I very well remember reading a nursing booklet in the early 1980, written by Ms. Eve Bendall a former Registrar of the United Kingdom Council for Nurses (UKCC) entitled “And So Nurse You Have Passed” which simply raises some awareness in the minds of nurses that having passed your state final examination, one ought not remain complacent but to continue to develop the ‘self’ professionally.

Many health care researchers (including myself), have argued that nurses generally have far long been ‘other directed rather than self directed’ in their daily work as a consequence of the routine method of training in some elements of the nursing curriculum! I think any assessment of what constitutes effective nurse education must recognise that workplace learning (as in nursing) needs to be defined broadly rather than focusing on conventional definitions of job-related instruction. The mounting cries raining on nurses in Ghana today calls for, in my view, curriculum renewal-one that is vibrant and flexible thus producing knowledgeable ‘thinkers’ and ‘doers’. One thing worth noting is that nursing is an experience that occurs between two people. Indeed, the experience is so deep that, one cannot adequately communicate to another person. Mrs. Kalitsi as shown above, laments about the impolite behaviour and insults rained on patients by some nurses because of the lack of effective communication between the carer and the cared in an attempt to convey therapeutic meanings. I think this is repugnant, don’t you? One cannot deny the fact that the practice of nursing be it mental health, adult, paediatric or mental handicap specialty, are embedded within interpersonal interaction, without which nursing becomes an empty vessel and redundant. Patient/client care contemporaneously, is being constructed around the centrality of the concept of nurse-patient relationship which fosters equal partnership and enhances therapeutic healing. Further, it is a process by which human needs can be sprinkled on to the other.

As can be deduced from recent publications in the Ghanaweb Feature Articles one is obliged to query the dynamic nature of the nurse training curriculum in Ghana today. For example, you may ask as to whether the current curriculum effectively addresses the concept of cultural diversity and its implications in health care practices bearing in mind that our dear country is not only multicultural but most importantly, multi-tribal? Further, from my own thinking and learning, it has become evident that the experience of others adopting the notion of cultural diversities in health care practices as well as reflective teaching methods in learning can be an inspiration for others. We need to ask ourselves as to whether the nurse ever understands her patient/client’s world view, let alone the patient’s cultural practices? It can be argued that reflective practice provides space for nurses to enter into a new dialogue and relationship with their patients and helps in the promotion of healing. As such, the concepts of cultural care diversity/transcultural nursing (Leininger, 1971, 1977, 1985, 1991, 1995) and reflective practices are paramount elements in nursing curriculum innovation and as such should be handsomely incorporated within the current teaching methods. I am of the opinion that these two major educational subjects (Transcultural nursing and reflective practices) would go a long way to up lift the knowledge and skills of both staff and student nurses. Nursing as we all know it involves situations that are complex and if we understand nursing and ourselves as nurses, we need to try and make sense of the complexity. Reflection as Jarvis (1992) posits, does not constitute only thoughtful practice but an experience of learning. For example, the purposes of reflection on practice include helping nurses increase their awareness thus improving the quality of their practice. Interestingly, nurses are willing practitioners and always ready to share their flections and in doing so may increase their colleagues’ awareness and enhance quality of nursing care more widely.

As we live in a multi-tribal community, neighbourhood becomes more diverse, and there is a need to consider cultural backgrounds of patients for whom we nurse. For example, when you travel outside your community, you will be exposed to ideas that are different than those you practiced as a child. Becoming a patient calls for a deeper understanding of your needs not merely ‘proteins and vitamins’ alone! Patients may look and speak differently; they eat different foods, worship different Gods, wear different clothes, and use different standards of daily hygiene, and we observe gender differences in their styles of nursing care, etc, etc. As Leininger above points out, culture care diversity (transcultural nursing), expands the understanding of vigilance as caring expression and contributes to the body of knowledge about nursing care in society. A patient in one of my study expressed that a common occurrence in her experience since being on admission was the power nurses had over him. He said: “...I think I have learnt when to speak and when not to, when to ask questions and also the sort of Questions you do ask. I think it’s alright, it’s like speaking when you’re spoken to”.

Nursing care as we have realised is influenced, in part, by the experience of the nurse involved in his care. We need to note that experience is not simply the passing time but involves changing as a result of the experience. It is equally worth noting that, learning based on experience is a valuable tool in developing expert nursing practice, and integrating experiential understanding into clinical reasoning is important in the provision of expert nursing care (Benner, 1984, 1996).

It is important to note that in working with patients/clients, the nurse quickly learns that behaviours have meanings which if adequately assessed and interpreted can be integrated into nursing care. The challenges for the nurse are to determine the meaning of the behaviour that patients and their families (and indeed ourselves) exhibit. I believe that understanding diverse and unique meanings and how they apply to a clinical situation can be a major challenge that must be addressed because of its significance to patient care outcomes as well as the nurse as a person.

By: Asigri, D. Z. (Ed.D; M.Ed., M.A., Bsc Psy., DipEd.,RGN., RSCN., RMN., RNMH., Cert.Ed., RNT)

Senior Lecturer

Practitioner Researcher

Middlesex University London