Round Table Discussion on Nursing Education

Kai Tiaki : the journal of the nurses of New Zealand, Volume XXII, Issue 1, 1 January 1929, Page 3

Round Table Discussion on Nursing Education

(Continued from- our October Number)

Miss Every read the following paper on Midwifery and Maternity Training:—

A very vital question to-day is this: Is it right that the general trained nurse should complete her training without any knowledge of maternity work? I say, t( No r

Maternal welfare is being recognised throughout the world as a burning question. In Australia, in England, in America and on the Continent, the minds of the public and the brains of the profession are being focussed on the question: How can maternal and infant mortality be reduced, and the ills attendant upon childbirth be lessened?

At Home, our Queen has graciously interested herself in the subject, being a mother and very much a woman. In Australia we find splendid men like Dr. Marshall Allan deputed to make a very thorough investigation of the whole position, and our American cousins are very deeply concerned and dismayed at the appallingly high rate of maternal mortality in their country and especially among the old pioneer stock.

And in the platform occupied by our own Minister of Health, is not one of the main planks a fixed determination to reduce to the irreducible minimum this blot on the escutcheon of the profession— a profession which is slowly waking up, like one in a very deep sleep — to the fact that midwifery, which has been the Cinderella among the sister branches of medicine — should at least have an equal place ? When all is said and done, "obstetrics" — the frills and furbelows of medicine, as some have called it — is the foundation on which the budding practitioner, especially in the country, builds his practice !

' There is, however, another aspect of the question that is of even more vital importance to us to-day, viz. : what is the attitude of the nursing profession thereto (for it affects deeply the women of our Dominion), and what, as an association, are we going to do about it?

That we can help, I for one, have no doubt, an das an Association we surely ought ! For our inspiration let us reflect for one moment on the conditions in those countries where midwifery is largely in the hands of competent midwives. As you all know, it is just those very countries that boast of the lowest maternal mortality in the world.

For various reasons, economic and social, we cannot, at present, copy their lead, but I ask you to-day what is the next best thing? Does it help matters, do you suppose, that our otherwise splendidly trained general nurse leaves her training school with neither knowledge nor interest in the subject, and that the majority of those who have taken it up have done so, principally for the certificate and only to drop it as soon as their training was completed.

Should our aim not be to give every nurse, before she leaves her training school, an opportunity of acquiring some degree of training in this most basic subject of medicine, this most ancient and world- wide branch of nursing?

That there are difficulties, I know; we can all forsee them; but if, as an Association, we are convinced that such a course would improve the prestige of our profession, and benefit our country — if we admit, as we do — that it is fundamentally right, it will be our privilege as well as our duty to do all in our power to overcome the difficulties. As New Zealanders we are greatly privileged. If only we can wake up to our attendant responsibilities, may we not, perhaps, give a lead to countries older than ourselves. New Zealand has done it before — why not again? What we need is co-operation and a widening of our interests — both at home and abroad. A brief study of the position in other countries should help us. Miss Isabel M. Stewart, Assistant Professor of Nursing Education, Teachers* College, Columbia University, New York, under date December, 1927, writes the following: —

Our position in the United States and Canada is different from that in England and the Continent, in that we require all nurses to have at least three months* training hi obstetrical nursing as a part of their brsic course. We have paid very little attention to the further preparation for midwifery practice and until very recently nu ses have been unwilling to recognise the midwife as even a "poor relative." TI e reason is that the ordinary midwife here is usually an ignorant woman of foreign birth, who has no social nor jrofessional standing and often little or no training.

However, the high maternal death rate in this cc:intry and the lack of medical service in ■emote country districts creates a situation which we must face. Those who have studied the question in other countries have advocated the training of public he lth nurses as midwives for these rerrote districts. As yet we have no recogn sed schools in this country for such train ng, but we are advocating further expc *imentation along these lines and hope chat we may soon be able to give our nurses an additional course of about fou to six months' training, which will qualif 'them as nurse midwives.

And in peaking of the two certificates she says : — " I should feel that there is much dan er in the maternity certificate unless it is supplementary to a good sound nursing ti lining, and I should certainly feel that such women should not be admitted to a professional association."

And fro .1 Miss Mary Beard, Adviser in Nursing of the Rockfeller Foundation, I received t ;e following: —

"Midwr es in the United States are not generally ecognised, and although a conservative estimate gives 50,000 women practising midwifery, they are not, except in a few States, subjected to centralised training, control or any sort of standardised procedure."

"In Canada, it is maintained that such women do not exist."

And again, she says : —

" The tendency in England as you no doubt know, is to improve the special midwifery training for graduate nurses. It is difficult to assure a reasonably pro-

tected life for the nurse who practises independently. England has in no way succeeded in doing this. As you will see by studying midwifery in Denmark, that country has been particularly successful in safeguarding the economic conditions surrounding the lives of Danish midwives, and furthermore, is regulating their practice and providing post-graduate work for them so that they offer a splendid service which is invariably sought by all the women. ... In the United States a special committee of the American Nurses' Association is conferring with a special committee of the American Medical Association to see if these two professions cannot reach an agreement about the type of maternity training which it is desirable for us to develop."

I have quoted these extracts that we may remind ourselves we are not the only country in which endeavours are being made to clarify the position regarding midwifery and maternity nursing.

It is interesting, too, to observe that in America, midwifery is depraved and a smattering of maternity training is general, and there the maternal mortality is six and a fraction per 1,000, and to quote themselves more than doable that in certain country districts.

In England we find a splendid body of most efficient nurses combining general and C.M.B. certificates, such as the famous Queen's Nurses, who "year after year have a maternal death rate half that of the national, and a quarter that of the States." Side by side with these women and their supervision there is being developed another group of nurses known as "Nurse Midwives" whose midwifery training is built upon a foundation of practical knowledge, including rudiments of public health, nursing and hygiene and general suitability. They are tested women, mostly of the middle class, who prove eminently suitable for the work they are undertaking, but not being general trained, are satisfied with less remuneration.

Xow, in New Zealand the position has been rather unique. We have trained a large number of midwives who have had neither inclination nor scope to practise their profession.

The non-general trained midwives — with the exception of a few who were allured into the less exacting realm of infant welfare, have been content to practise with the doctors as maternity nurses in hospital or private. They were equipped for emergency and were recognised at home and abroad, and we are glad to avail ourselves of this opportunity of acknowledging the value of the contribution they have made to our association, and of the loyal and magnificent service they have rendered to the country.

Of the general trained Nurses, however, the great majority who have taken the training, have done so as a means to some other end which was quite understandable — owing to dearth of material — only a very limited number of those desiring it, could receive the midwifery certificate, and it was felt some other way must be found.

When the new Act was introduced, we were told the object was to give the minimum training to a maximum number of women, and a maximum training to the few who were likely to use it.

In actual happening the training of the midwife has been, rightly, very greatly improved.

The maternity certificate which we expected to demand a very thorough knowledge of all normal work, in all four branches of the subject, and a nodding acquaintance with the abnormalities, has, after passing through various vicissitudes come to demand the same theoretical, and very much the same practical work as the midwifery.

Now the examination standard is to be raised, and in other ways it is proposed to still further minimise the difference between the two trainings.

Add to this the fact that the nurse, general trained or otherwise, wishing to obtain her midwifery certificate, has met with a severe handicap — a handicap which fortunately, to some extent has been removed — and it is not difficult to see why the maternity certificate has not proved attractive to the women of New Zealand. The demands it made have not been proportionate to the benefits it bestowed.

And thus it has come about that the dearth of applicants for this work, especially suitable ones, has steadily increased.

Just how acute it has become throughout New Zealand, others are better qualified to tell you than I am.

The question we have to consider is how to improve matters.

Let us recognise the known fact that the general trained nurse, \ ith many channels open to her, is not wiling, and does not want to devote hersvlf to maternity nursing, nor is she enc mraged if she gives herself to midwifery.

On the other hand, the coui try needs efficient, well-trained dependab e women, who not only will do it, but laving no counter attractions, will dev >te themselves to the work for which they are trained.

There are many such womer, who, for divers reasons are unable to tal 2 the general training. If we could 1; xt inspire them with a vision of the scoj e and opportunities this work offers to a woman, if we could induce them to take t up — but will we succeed when we dem? id a rigid training and give a return a doubtful certificate and a dubious status and competition with women who ha . e had no training at all.

Would it not be wise to follow the lead of England, and develop i class of midwives — rather than risk be ig drawn into the deplorable position of America, where midwifery is at a discount, maternity nursing a little higher and the maternal mortality highest of : 11?

Miss Oppenheim: In discus: ing Miss Every's paper, the first point is right. I quite agree with Miss Every in this question that every trained nurse should have •a certain amount of knowledge of maternity work which should be taken during the course of her three years' training. Miss Every has told us that this course was not satisfactory. I think it would be an excellent scheme it the Hospital Boards can be persuaded to allow their fourth year nurses an opportunity of obtaining some experience in this branch of the work. Unfortunately, the majority of general trained nurses appear

to have no system in regard to Public Health Work, Infant Welfare, and so on. It is interesting to read what other countries have done in regard to midwifery training. I think each country has its own problem to solve. During the last few years we have had very few women coming forward for this class of work. At one time I used to have a long list of waiting applicants, but now I simply have to take them as they apply. I feel confident it is the women themselves who are going to decrease the mortality in New Zealand. I think we should do all in our power to encourage the ones who are going to do the work to join the Trained Nurses' Association, and I think we should do all in our power to encourage women to take maternity training. Miss Barnitt : I would like to endorse one of these remarks. A few years ago I had a long list of women wishing to take their midwifery training, but now we are faced with the position of trying to get nurses to take up maternity training. Miss MacDonald : We have very few applications from untrained women, perhaps one in twelve months, and all the other applicants are trained nurses from other hospitals and they take midwifery training in the fourth year. Miss Barnitt: My Board has now enforced a four years' training, and the feeling is that the nurses would like to take midwifery in the fourth year. SOME ASPECTS OF POST-GRADU-ATE EDUCATION FOR NURSES, ESPECIALLY IN RELATION TO PUBLIC HEALTH NURSING. The next subject was: Some Aspects of Post-Graduate Education for Nurses, especially in relation to Public Health Nursing," the paper being written by Miss Hooper. One need not say how intensely interesting it has been to listen to the presentation of these urgent practical matters in connection with the basic general and midwifery training of nurses. Although my subject is not so pressing a matter, I hope you will agree with me that it is ap-

propriate on this occasion to touch also on some aspects of post-graduate education for nurses, especially in relation to public health nursing — a younger, but no less important, branch of the profession. First, I would refer to the special postgraduate course as a branch of nursing education, and second, to what one may perhaps call "staff education" for want of a better term — -that is, a means of keeping the qualified nurse up-to-date and progressive in her special work. It is interesting, indeed, to follow the changes in emphasis which are taking place so rapidly all over the world in matters relating to medicine and nursing — particularly the growth of the preventive ideal, and the increasing importance of the trained nurse in public health work. If the nursing profession is to keep abreast of the best modern thought, it seems that even in the basic general nursing training a gradually increasing emphasis is bound to be placed on the preventive point of view, so that all nurses, whether in hospital, private or public health practice, may approach disease with the idea of prevention as well as cure. The short-period, post-graduate course, especially Avhen its object is to prepare the nurse for public health work, must be in line with modern preventive ideals ; to achieve success, it must be based upon a careful and consistent teaching plan. One therefore feels that experience in this special branch may perhaps enable a contribution of some interest to be made to the wider problem of nursing education as a whole. Tn the short post-graduate course, the teaching of the student nurse must be taken in hand at once and follow an ordered plan — every opportunity must be taken as it arises to correlate theoretical teaching with practical application — a "point of view" must be given as well as details of method. The teaching staff must have a very clear grasp of the essentials of the training and a firm and abiding conviction of their value. Although certain members of the staff will be specially concerned with the teaching, all sisters — and also district nurses, where out-

door work is included in the course — must be recognised as part of the teaching staff, in that clear and consistent instruction in all details of routine work forms the basis upon which rests good work in the broader aspects of the subject.

The task of the teaching staff is a difficult one in the short period course. A new class — raw material — must be taken in hand every few months — there is constant repetition — much individual coaching is necessary as well as class teaching. Without "that mountain-moving quality of enthusiasm," which creates enthusiasm, and a firm belief in the "worthwhileness" of the work, probably little success could be achieved in the short time available.

Any scheme of special nursing education must, of course, be worked out from a clear idea of the objects and requirements of the work for which the nurse is being trained, also taking into consideration the general type of applicant for training.

May we now refer to the Plunket Nursing Course as illustrative of certain points. This, as you know, is a four months* post-graduate training for a special branch of public health nursing — maternal and child welfare. The great majority of students and double certificated nurses — during the past two years, 110 nurses have taken the training, and of these 80 were general and midwifery trained.

The main object of the training is to qualify the student for Plunket nursing work. The function of the Plunket nurse is expressed in its broadest terms in the aims and objects of the Society's work, which state that "her duty will be to give sound, reliable advice and assistance on all matters relating to the health and well-being of mothers and children, with a view to conserving the health and strength of the rising generation." Public health nursing in the truest sense. Consequently it is important that the nurse in training should grasp the value of a correct approach to the mothers, and see the preventive point of view. She is preparing for work which

is firstly educational and preventive — only secondarily and in small d *gree curative. This point needs stressing because usually the previous professional experience of the general trained nurse has been almost entirely concerned with the abnormal and the curative. In more particular terms, the teaching plan is designed to give the student detailed knowledge relating to the health of mothers and children. The main course of classes is given by the teaching staff and a short series by the honorary medical staff. A certain time is spent "on tht district," the student going on her rounds and attending the rooms with one of the district Plunket nurses, so gaining insight into the actual application of the work with the mothers and children in the homes. In view of the teaching aspect of public health work, each student is required to answer letters from mothers asking for advice, and to pr ipare and give a short "talk to mothers' with appropriate demonstration, before the assembled class and teaching staff. The term ends with a summing-up of the work done, and of its essential principles* In addition to study, the nurse in training does approximately an eight-hour daily duty in various branches of work, thus gaining experience in the practical details of mothercraft, the management of normal children, premature !>abies and ill babies, the preparation of food, etc.

The teaching methods are simple and direct. Class teaching is supplemented by individual coaching — demonstrations are used whenever possible — test papers are given weekly, and time is spent in individual correction if necessary — cases in residence are systematically used for teaching purposes.

By means of this teaching plan, it is endeavoured to equip the student for the special work. Needless to say, the plan is by no means final. Progress demands adaptation and change from time to time, and a constant watch for better methods.

As regards the other aspect of this subject of post-graduate education, that is, a means of keeping the qualified nurse up-to-date, progressive and enthusiastic in her special work — although this is an

aspect of nursing education which most affects public health workers, none, in these days, however well qualified, can say they know and have finished learning. The busy worker, up to her eyes in the multitudinous detail of her daily round, is apt to lose sight of the work "as a whole" ; the nurse working alone in a country district is apt to suffer for lack of contact with other workers. Obviously the public health nurse specially needs some means of periodically refreshing in her work if she is to give continued efficient service.

Those who were able to attend the Refresher Courses for Public Health Nurses, arranged last year on behalf of the Health Department by Miss Moore and Miss Lambie, must have been struck with the possibilities of the scheme.

If we may turn once again to the Plunket Nursing Service for an illustration — we have here a body of over 100 nurses working under one organisation, but widely distributed over the whole country. Although six to twelve nurses are engaged in each of the largest city centres, the majority are working alone in country or small town districts.

Two main methods of "staff education" have been developed in connection with the service — first, periodical Refresher Courses at the main training centre, and second, periodical local conferences of Plunket nurses.

The Refresher Courses are planned to survey all the aspects of the service — ante-natal, post-natal and pre-school — by means of lectures, round table discussions, demonstrations, etc.

The local conferences are arranged as a series held in about a dozen of the larger centres. They are attended not only by the local nurses, but also by all those from the town and country districts round. By this means, almost all the nurses, widely scattered as they are, are enabled to meet in groups and discuss problems and methods with one another and with the Director of Plunket Nursing, Miss Pattrick, whose wisdom and wide vision has brought about these and

other developments of nursing education in the service.

The Plunket Society actively supports these measure for keeping the nurses up-to-date and progressive in the work by granting leave of absence and travelling expenses of nurses attending Refresher Courses or Conferences.

Again, these developments are not final. One merely touches on them as suggestions and brings them forward for discussion. Living, as we do, in times of research and experiment, we can but keep alert for changes in emphasis, alive to new movements, and ready to go forward.

Miss Hilditch: I know the time is getting on, and I will not say very much. In speaking on this matter of Nursing Education, we are glad to be able to say that there has been great advancement made during the last few years, and we now take a wider view of the subject. Instead of thinking of ourselves we women who are engaged in this profession work together for the common good.

Miss Tennent : I would like to say how pleased we are to have Miss Bicknell with us to-day, and I think it is a very great honour to have her presiding over our Round Table Conference. (Loud applause.)

Miss Bicknell: I thank you very much. I am very glad indeed to be here, for I always enjoy these conferences. lam certainly most interested in hearing what the nurses have to say and getting their point of view. lam sympathetic towards nurses and anything that interests them, interests me. I cannot go round the country, as much as I would like to, but I always make a point of being able to attend these conferences.

Miss Young: I would like to move a very hearty vote of thanks to those ladies who prepared these papers and those who discussed them. They must have entailed a great deal of work, thought, and construction. They have been very helpful, and we appreciate the work that has been done.