A critical reflection on the discipline of nursing based on the correct analysis of the relationship between medicine and nursing

The current nursing education curriculum in China can be divided into three categories: (1) general public courses, such as physical education, college English, and so on; (2) basic medical courses, such as physiology, biochemistry, anatomy, pharmacology, and so on; and (3) nursing professional courses, such as General Nursing, Internal Medicine, Surgery, Obstetrics and Gynecology, Pediatrics, Community Nursing, and so on. The following areas have existing problems.

Currently, based on the nursing training objectives, the College of Nursing of Jilin University has set goals in four areas of student education: concepts, knowledge, abilities, and quality. The School of Nursing of Central South University has proposed training requirements for quality, knowledge, and skills. The Nanjing Medical University School of Nursing proposed seven specific training objectives. Li et al.7 proposed three educational goals after studying the training objectives of undergraduate nursing courses in China: knowledge, ability, and quality.

However, many problems exist in these training objectives. The National Bureau of Education noted that for professional nursing certification, a nursing program should cultivate critical thinking abilities, solid theoretical knowledge, strong practical abilities, and scientific research abilities in their nursing students.8 However, although our undergraduate nursing education programs have greatly emphasized the learning of theoretical knowledge in the curriculum setting, they have not paid sufficient attention to courses of practical value such as statistics. Moreover, undergraduate medical students can graduate without a thesis defense requirement, which further weakens the ability of most students to conduct scientific research. Furthermore, undergraduate nursing students are not required to take a diagnostics course, which is a major reason why nurses do not have the right to prescribe medication. Under this circumstance, we may want to reflect on whether nursing education under the guidance of a medical model is a better choice for the discipline.

Nursing science education aims to train students to gain a solid theoretical foundation, practical ability, scientific research ability, humanistic qualities, as well as strong evaluation and observation abilities. The faculty team in nursing education plays critical roles in achieving these goals. Presently, the personnel engaged in nursing professional teaching in Chinese colleges and universities can be roughly divided into three groups: (1) the specialized nursing teachers who are no longer clinical practitioners; (2) clinicians who also serve as nursing faculties; and (3) senior head nurses who have extensive clinical experience. The advantage of having clinicians as teaching faculties for the nursing major lies in their strong background in medical theories. However, because the doctors are not graduates from the nursing major, their teaching may lack insight into nursing care. Specialized nursing teachers often have solid knowledge of the theories of nursing, but they are out of touch with clinical practice, and these staff members are in short supply.9, 10 Studies have shown that the academic qualifications of current nurses in the clinic are generally poor, and they have limited theoretical knowledge compared to that of the specialized teachers. However, nursing is a practical and application-oriented discipline. Thereby, more clinical nurses with higher academic qualifications, better nursing skills, and better comprehensive quality should be encouraged to become nursing educators. As clinical nurses, they innately have some core qualities that qualify them as great teachers, such as the ability to keenly observe a situation, perform medical treatment, provide life support, ensure safety and security, conduct health education, provide human care, and perform technical operations.

There are many advantages to recruiting clinical nurses to join the nursing education faculty team.10 First, clinical nurses can introduce the latest technology and more advanced knowledge from the first line of clinical practice into the content of teaching so that the phenomenon of education lagging behind clinical practice can be changed. To a certain extent, clinical nurses can also add new elements to the connection between theoretical knowledge and clinical practice. Second, clinical nurses have long been engaged in clinical work and have a wealth of clinical experience. In teaching professional knowledge, they can use personal examples from their own work to explain the theories, thus helping the student better understand and promote more active thinking. For example, to explain the measures adopted in nursing care, by combining clinical cases, the teacher can simplify concepts that may appear boring and difficult for the students to remember; they can also assist the student in making connections between textbook knowledge and clinical practice in real life. However, clinical nurses lack the clinical experience of doctors; therefore, she or he will not be able cultivate the students’ diagnostic thinking or simplify the textbook concepts for application in clinical practice. The teaching may lead to the students’ systemic disconnection from the entire disease that they have learned. Third, every nursing student will be in clinical contact with patients in the future. In clinical settings, nurse–patient communication and humanistic care are essential core qualities that reflect nurses’ competency. Specialized nursing teachers can only teach textbook theories to students, whereas clinical nurse faculties can use the actual case studies encountered in their work to explain the theories to the students. Consequently, the students can recognize the importance of having active communication and providing personal care to the patient and appreciate the immense value of the work performed by each nurse or nursing student. Most of the nursing educators in the United States and other countries are senior practitioners in clinical care.

The traditional nursing education model is a singular model. It emphasizes the transfer of knowledge and is accustomed to methods such as “injection” or “full house irrigation”, which are passive methods of placing knowledge into students’ brains.11 The single indoctrination mode of “teacher speaking, student listening” is commonly accepted by students. In the classroom, teachers teach textbook knowledge either in strict accordance with the textbook or in combination with some of their own cases while students merely listen. Most of the teachers complete the task mechanically and rarely ask the students any questions or initiate any interactions or discussions. The students, conversely, are often confused, and their minds shut down, not allowing them to think independently or creatively. Naturally, given our large population, adopting some teaching methods used by well-developed countries with much lower teacher-to-student ratios will be difficult. However, we can still select some educational approaches that are suitable for the situations in our country, for instance, “discovery teaching”, in which the teachers guide the students to discover, explore, and solve problems to drive everyone’s interest and lead the students to acquire knowledge through active learning, thinking, and participation.

Currently, the 4-year undergraduate degree in nursing science education in China is mainly composed of a 3-year theoretical study and a subsequent clinical internship for at least 8 months. In this type of curriculum arrangement, connections between the textbook knowledge and clinical practice are weak, and knowledge learned from the textbooks is not applied to clinical practice in a timely manner.12 Because of the long time interval between theoretical study and clinical practice, the textbook theories are not further reinforced through practice quickly enough. Consequently, when the clinical internship begins, the knowledge learned before has faded and fails to be adopted into clinical practice. Furthermore, during clinical practice, the nursing students only learn ward care and professional skills required by the internship department and do not take the initiative to study the theories again to further comprehend the knowledge learned in the classes. Conversely, in Australia and some other countries, nursing students complete a clinical internship after the end of each semester and also undergo a rigorous internship evaluation.

Although the Chinese clinical nursing model has shifted from a functional nursing care model to a holistic nursing care model, the number of clinical nurses still only matches the functional nursing model, resulting in a shortage of nursing professionals. Moreover, the large number of nursing interns requires more teaching members; thus, some nurses who are not well-experienced or qualified began to conduct clinical teaching to these interns. Because of their heavy workload and lack of fundamental knowledge in theories, these nurses can only show the interns how to perform rigid procedures of care but not with critical and comprehensive thinking during the process, which causes the nursing students to repeat the daily mechanical execution of the doctor’s orders. Hence, the clinical work procedures are never truly mastered during the 8-month internship.13

Evidence-based thinking and executing ability are the new objectives in the development of clinical nursing education. Presently, evidence-based nursing care is a new trend in the development of nursing science in the international nursing community. Its scientific and practical features have attracted broad attention from many domestic nursing staff members. However, evidence-based nursing is still in its infancy in China. Because clinical nurses have very limited knowledge and experience in evidence-based nursing, its teaching in clinical practice remains significantly behind that of other developed countries. Our clinical nursing care is still conducted at a simple and mechanically repeating level. Conversely, in some developed countries, evidence-based medicine is not only adopted in clinical nursing care but also applied to the investigative studies of the psychological health of nurses for nursing management and nursing research.

According to the statistics of the World Health Organization and the National Health Bureau, the bed-to-nurse ratio in China still fails to meet the standard guidelines. Clinical nurses should be able to provide care services in areas, such as life care, health education, safety and security, human care, condition observation, medical treatment, and so on. However, because of the nurse shortage, each nurse is responsible for more than a reasonable number of patients. With such a heavy workload, the nursing staff only handle work that requires little time to complete, such as observing the patient’s condition, and have no time to provide psychological or other forms of care. This leads to the simplification of the job function and failure to truly appreciate the value of the nursing staff and the characteristics of nursing disciplines.