The ''Art'' of Patient Care

By Eileen P. Williamson, RN, MS
January 10, 2000

Nursing – Is it an art or a science? The likely answer from most nurses would be that it is both. Although defined as one of the oldest sciences, Florence Nightingale called nursing a fine art. And like all works of fine art, nursing has a story to tell – a story with many chapters on how and where nurses have nursed.

Dating back to ancient times, primitive "nursing" was linked first to the care of babies and children but grew to include care of the elderly, the poor, members of the military, those imprisoned, and those generally thought to be outcasts of society.

Early "nurses" were viewed more as nurturers and comforters than healers, but over time were called upon to be educated, knowledgeable in the sciences and competent and skilled technically. In its evolution from primitive beginnings to a modern-time profession, nursing underwent many changes from giving comfort, to providing healing, to promoting wellness. And nowhere were these changes more evident than in the "art" of the methods used by nurses to deliver care to the patients they nursed.

Patient Care Models and How They Grew

By the turn of the twentieth century, most nursing was still being carried out in the community – usually in the patient's home. But as hospitals and schools of nursing increased in number from the early 1900s on, more patients were hospitalized for care, more nurses were available, and hospitals soon became the largest employer of RNs.

When nursing began to manage itself and took on the responsibility for nursing care planning, provision and evaluation, nursing leaders continually looked at new and better ways for their nurses to deliver care to patients. Those of us who have been in nursing for any period of time have probably lived through a number of the models that were set up to meet that objective. Care delivery systems, as they are called, were developed for various reasons but always in response to the changing marketplace as ever new and more sophisticated patient services emerged, enrollments in nursing schools fluctuated, and greater demands for fiscal constraint were placed on nursing by the employer. Some of the better-known models were functional nursing, team nursing, the primary and all-RN nursing models, and the more recent patient-centered or patient-focused models. Working with the RN in these delivery systems was the LPN and various assistive personnel whose titles changed over time but whose role of supporting the RN remained constant. Regardless of the care delivery system employed, hospitals generally used the multidisciplinary team approach to meet the diverse care needs presented by patients.

Service and Education Side by Side

Over the years nursing management and nursing faculty collaborated on nursing education and care delivery. Nursing faculty looked at establishing curricula that were responsive to the varied hospital practice settings, and nursing service focused on providing meaningful practical experiences for an ever-changing student population. According to Connie Vance, RN, EdD, FAAN, professor and former dean at the College of New Rochelle, School of Nursing, "The ongoing challenge for educators has been to adapt curricula to changes that are occurring in the hospital and in the external environment." Vance says that nursing educators have the responsibility of knowing what is happening both in and out of the hospital, and they need to focus on both patient and student in curriculum design, "always with an eye toward the future." Vance adds, "I believe that the vision of nursing education is to transform care through curriculum." As models of care change in the practice setting, nursing educators have to prepare their students for the "real" world of practice by familiarizing them with the care model they will encounter after graduation and preparing them for their special leadership role in that model.

Input from Professional Organizations

Along with nursing education, professional nursing organizations have also had a hand in addressing patient care needs through their input to nursing curriculum design. One of these, The American Association of Colleges of Nursing (AACN), a national organization that includes deans of nursing from universities and colleges throughout the nation, has had a voice in setting direction for the education of nurses for nearly forty years.

"The AACN has periodically issued position statements on what should be included in nursing curricula,” Vance says. Position statements such as these are written in light of changing variables in and out of the hospital, including demographics related to student and patient populations, workforce diversity issues, increased technology, quality demands for quality, professional accountability, and changing finances. Position statements have wide influence on nursing education and play a major role in ongoing improvements in the preparation and education of professional nurses.

Communicating on Care Across the Continuum

With the number of patients being cared for outside of the hospital proliferating almost daily, we close the century as it began – with nursing a major force in patient care in the community. In contrast to the past, only about 60% of working nurses are currently employed in hospitals and more are working outside of that setting than ever before.

As inpatient lengths of stay continue to be shortened, the care patients receive in the home is in large measure dictated by the care they receive as inpatients within the hospital nursing model. Nurses in both settings need to communicate with one another on their patients – in the community they need to be well versed on what happens in the hospital and in the hospital they need to be up to date on what's available in the community. According to Emma Kontzamanis, RN, MA, vice president of patient services for the Visiting Nurse Association (VNAB) of Brooklyn, Inc., "Our nurses need a clear snapshot of the patient's condition on discharge from the hospital so that a smooth transition into the home care environment can be made. How and by whom that care was given, the patient's support systems and safety concerns, along with all of his physical needs, are critical pieces of information for us. We have to know about a hospital's care model and team in order to get the whole picture of a patient's stay." Patients in the current healthcare system are placed on home care with complex physical needs as well as a variety of social, emotional and environmental ones "that are greater than in the past," says Kontzamanis, adding that, "The lines of communication must be strong and the assessments from the hospital nurses excellent for us to continue the patient's care in a quality manner."

Models of care, changing and varied as they have been, are so much a part of the fabric of our profession and of the wonderful story nursing has to tell. We begin this new millennium with the belief we've long held as nurses – that nursing has beauty, that it has a great history and although it will always be a science – Florence Nightingale was right – truly, nursing is a fine art!

Eileen P.Williamson, RN, MS, is executive director of Nursing Spectrum, New York/New Jersey edition.