Monday, 18 January 2016

Time to listen: do we ‘care’?

Sue Dean, Claire Williams, Mark Balnaves*

Nurse education has undergone many changes over the last few decades with the transition from apprentice-type training to university education. This has profoundly altered the way teaching and learning happens. When nurse training occurred entirely within hospitals, nurses learnt by doing and this was supplemented by theoretical learning mainly in the form of lectures provided by medical practitioners using medical textbooks (nurses had not developed their own disciplinary evidence- based resources.)  After the transition, nurses’ theoretical knowledge was integrated with clinical skills development within the university, (increasingly with evidence-based resources developed by nurses), and their clinical experience within the hospitals. They were introduced to clinical skills in on-campus laboratories where they used dummies, practised on each other and role-played. For OSCAs (objective, structured, clinical assessments), people were employed to come in and act as patients and students were assessed on their interpersonal communication skills alongside their clinical skills.

As university enrolments increased, clinical opportunities narrowed due to the competition for places, funding cuts to universities demanded less resource-intensive methods of learning and teaching, and the fear of litigation led educators to favour low-risk learning environments. This was the context within which universities began to use simulated technology, mannequins, both low and high fidelity, for nurse education.

There is growing evidence that nurses are often failing to communicate in an empathic and compassionate way (Bensing et al. 2013, Francis, 2010). For example, health complaints related to communication have risen in recent times and have now overtaken complaints related to clinical issues (Australian Commission on Safety and Quality in Health Care 2011).The increasing use of high fidelity mannequins to instruct our nursing students may be contributing to the problem. It has been mooted that in the future simulation laboratories using the high technology might well replace clinical experience entirely (Jeffries 2009). While simulation technology is now being questioned in the aviation and medical arenas, there is little debate in nursing (Gilpin 2015).The pedagogical evidence for the use of simulated technology in nurse education is scarce, particularly in the area of interpersonal skill development,  and the fact that medical simulation technology is a major growth market, in an industry estimated to be worth over $2 billion globally  by 2019  is salient. The financial commitments that hospitals, universities and other training facilitates are investing in the technology guarantee an ongoing market for investors and, as investments reports highlight, tie the institutions to the technology (Markets and Markets 2014).

We have known since the early 1970’s that empathic arousal precedes and motivates helping (Hoffman 1979). Machine patients do not and cannot provide what is essential for the development of empathy: communal orientation, vulnerability, unanticipated reactions and actions, spontaneity, recognition of differences and the uniqueness of the individual, and commitment to conversation and interpretation. The emerging worlds of computer simulation reveal that we can, in fact, de-humanise people and remove empathy by mimicking human interaction at a surface level and not including dialogue at the base level (Bastian et al. 2013).

Whilst there undoubtedly are benefits from the use of high fidelity mannequins in nurse education, we need to interrogate their use rigorously and ensure that the important interpersonal dimension of nursing is not lost.

* the authors have published an editorial Dean, S., Williams, C. and Balnaves, M. (2016) Living dolls and nurses without empathy Journal of Advanced Nursing doi: 10.1111/jan.12891

References
Australian Commission on Safety and Quality in Health Care. (2011). Patient-centred care: Improving quality and safety through partnerships with patients and consumers. Sydney: ACSQHC.
Bensing, J., Rimondini, M., & Visser, A. (2013). What patients want. Patient Education and Counseling, 90, 287-290.
Francis, R. (2010). Robert Francis Inquiry Report into Mid-Staffordshire NHS Foundation Trust. The Stationery Office: London.
Gilpin, K. (2015, June 25th 2015). The benefits of Advanced Physiology Modeling to Simulation. Paper presented at the SimGhosts, Clinical skills development service, Brisbane.
Hoffman, M. L. (1979). Development of moral thought, feeling, and behavior. American Psychologist, 34(10), 958-966. doi: 10.1037/0003-066X.34.10.958
Jeffries, P. R. (2009). Guest editorial: Dreams for the future for clinical simulation. Nursing Education Perspectives, 30, 71-71.
Markets and Markets 2014. Healthcare/Medical Simulation Market by product (Patient Simulator, Surgical Simulator, Web-based simulation, Simulations Software, Dental Simulator, Eye Simulator), End-User (Academics, Hospitals, Military) & By Services - Global Forecast to 2019.

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