1. Pasquale, Pamela MN, RN-BC, CNE


Don't comfort and hygiene matter any more?


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At a 50th wedding anniversary celebration for my former nursing instructor, other faculty members told me their horror stories of recent hospitalizations. Oral care wasn't offered, they weren't turned and repositioned, and nobody checked to ensure their nutritional needs were met after procedures. I was dismayed. After 25 years of hands-on nursing, I had earned my master's degree in nursing education in order to emulate these role models. I assured them that I still teach the basics-bed baths, oral care, back rubs, positioning, and range-of-motion exercises-and we mourned the lack of such fundamentals in many nursing curricula.


I've taught entry-level nursing in baccalaureate and associate's degree programs and sensed that some faculty see fundamentals as glorified training for certified nursing assistants (CNAs). I've felt their disrespect, as if they think that teaching fundamentals is less complex, and therefore less important, than medical-surgical courses. But I think we lack a clear vision of what nursing fundamentals should be.


As nursing curricula expand, many have deemphasized procedures focusing on patients' comfort. Rather, they stress physical assessment, the nursing process, and nursing diagnosis. Textbooks now emphasize critical thinking, developmental stages, and cultural competency, as well as technical skills such as care of IVs and chest tubes, which nursing faculty prefer to teach, thinking it helps students to feel "like nurses." In reading these textbooks, you wouldn't know that nursing was once synonymous with performing basic tasks of hygiene and personal care for hospitalized patients.


Meanwhile, in the name of efficiency, we sacrifice our ability to keep patients clean, comfortable, fed, hydrated, warm, and pain free. Many programs have limited nursing skills laboratory time. Some might eliminate lessons in bed bath and bed making: my graduate students have said that many hospitals cut back by providing premoistened bath packages and not changing linens daily.

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CNAs who perform fundamental tasks are valuable assets, but RNs must train and supervise them. How can we ensure that excellent care is given if we don't learn and practice these skills ourselves? I recently taught CNAs in an associate's degree nursing program; they took a patient's blood pressure in six different ways.


Bedside technology can enhance patients' comfort, but I wonder whether tending to the machines adds to nurses' and patients' stress level. And doesn't relying only on technology limit us? Many nurses can't take blood pressure manually and may miss other cardiovascular information they can get only by touching a patient.


Patient satisfaction studies show that bedside nurses are valued for "being perceptive and supportive of the patient's concerns; being physically present; having attitudes and displaying behaviors that [make] the patient feel valued as a human being not as an inanimate object," according to Wolf and colleagues, writing in Medsurg Nursing in 1998. But as Suzanne Gordon observed while addressing the 2005 Washington State Nurses Association Convention, nurses leaving the profession often cite the inability to practice bedside nursing as they watch patient care deteriorate.


What nursing skills should be considered "fundamental"? Contractures and pressure ulcers result from neglect, and I tell my students that. I emphasize the importance of oral assessment in recognizing early symptoms of dehydration or candidiasis. I teach students to perform oral care and maintain adequate nutrition. Professional RNs and their staff must know the causes and effects of these secondary developments in order to maintain patient safety and improve outcomes. We need instructors who are committed to basic nursing care and will pass on these concepts.