CHAPTER 1 Nursing: Historical, present and future perspectives
At the completion of this chapter and with further reading, students should be able to
• Discuss the historical development of nursing
• Explain the purpose of nursing models
• Explain the differences in the educational preparation of registered nurses (RNs) and enrolled nurses (ENs)
• List the five characteristics of a profession and discuss how nursing demonstrates these characteristics
• Discuss the reasons nursing is in a constant state of change
• List at least one nursing theory and discuss its impact on nursing today
Australian Health Practitioner Regulation Agency
Australian Nursing and Midwifery Accreditation Council (ANMAC)
Australian Nursing Federation (ANF)
International Council of Nurses (ICN)
New Zealand Nurses Organisation (NZNO)
Nursing and Midwifery Board of Australia
Nursing Council of New Zealand
To understand contemporary issues in nursing the student nurse needs to understand how nursing has evolved in Australia and New Zealand. This chapter includes a discussion of the history of nursing, factors influencing nursing practice and the role of the nurse in contemporary healthcare and professional nursing organisations. This chapter will help the student understand and appreciate the influences of the past, present and future on modern nursing. A study of nursing theory can help the student develop an understanding of the purpose of nursing practice. This chapter introduces the student to a variety of nursing theories that inform nursing practice.
I can’t believe the changes in nursing since I became a nurse in the 1950s. Some of it I think is for the better but not all the changes. I prefer nurses in nice starched uniforms; it gives nurses a sense of pride and belonging.
WHAT IS NURSING?
Nursing is a profession with a specialised body of knowledge that draws from the social, the behavioural and the physical sciences. Nursing is a unique profession because it addresses responses of individuals and families to health promotion, health maintenance and health problems. There are many philosophies and definitions of nursing. Over 100 years ago Florence Nightingale defined nursing as ‘the act of utilising the environment of the patient to assist him in his recovery’ (Nightingale 1969 (1860)). Nightingale considered a clean, well-ventilated and quiet environment essential for recovery. Often considered the first nurse theorist, Nightingale raised the status of nursing through education. Nurses were no longer untrained housekeepers but people educated in the care of the sick (Berman et al 2012).
Virginia Henderson was one of the first modern nurses to define nursing. The definition she posed in 1966 was adopted by the International Council of Nurses (ICN) in 1973 and still holds wide appeal in the nursing profession. Henderson defined nursing as:
assisting the individual, sick or well, in the performance of those activities contributing to health, its recovery, promoting quality of life or to a peaceful death that the client would perform unaided if he or she had the necessary strength, will or knowledge.
(Henderson, in Crisp & Taylor 2009)
In 2002 the ICN updated the definition of nursing:
Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well, and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of the ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.
(ICN 2002)
Nursing also helps individuals carry out prescribed therapy, to be independent of assistance and function to maximum potential as soon as possible (Crisp & Taylor 2009).
There are themes that are common to the many definitions of nursing (Berman et al 2012):
In nursing, a combination of technical skill, clinical experience and theoretical knowledge is required. Historically there has been a tendency for nursing education to focus on the mastery of nursing skills. However, nursing practice is far more complex than technical skills alone. Nursing expertise is required for interpreting clinical situations and for complex decision making and case management. It is the basis for the advancement of nursing practice and the development of nursing science (Institute of Medicine 2011). When providing nursing care, the nurse makes clinical judgments about the care needed for clients based on fact, experience and standards of care. Knowledge, expertise and lifelong learning are gained through the continual process of critical thinking (Crisp & Taylor 2009).
Patients, consumers or clients? What’s in a name?
There has been a shift in the provision of nursing care over the last 25 years. Hence the traditional ‘patient’ has now become a multi-context ‘client’ and recipients of nursing care can be in hospitals, community health centres, home environments, general practice clinics, almost anywhere. As nursing moves into a more multi-dimensional health arena other terminology has been proposed to replace ‘patient’.
In times past the term ‘patient’ was used for those who were waiting for or undergoing medical treatment and care in a hospital. Usually, people became patients when they sought assistance because of illness or for surgery. This term was understood to have implied connotations about the medical model of health: some believed that the term ‘patient’ implied passive acceptance of the decisions and care of health professionals (McLaughlin 2009). Other terms are now frequently used by health professionals in place of ‘patient’. Nurses and others are now increasingly using the term ‘clients’, ‘consumers’, ‘customers’ or ‘service users’ (McLaughlin 2009).
However many of these alternative terms proposed to replace the ‘patient’ can also be found wanting (McLaughlin 2009). For example, a ‘consumer’ is defined as an individual, a group of people or a community that uses a service or commodity. Individuals who use healthcare products or services are consumers of healthcare. This implies the ‘consumer’ is a purposeful seeker of healthcare who expects to get what they came seeking. This is not the case in most instances in healthcare, where the provider is more accountable to the manager and key performance indicators than to the needs and wants of the consumer (McLaughlin 2009).
A ‘customer’ signifies that health is a commodity in which the customer possesses an understanding of their health needs and the services available equal to that of the health professional. It is well known in healthcare that a knowledge imbalance exists between ‘consumer’ and service provider.
A ‘client’ is a person who engages the advice or services of another who is qualified to provide this service. The health status of a client is the responsibility of the individual in collaboration with health professionals (Berman et al 2012).
Although still not a perfect capture of what or who a person who seeks healthcare is, there remains no other preferred term. Throughout this book the term ‘client’ is the preferred nomenclature.
Historical perspectives
A brief history of nursing
Nursing is a profession steeped in tradition and history and historical accounts of nursing reflect the dynamic and evolving nature of the profession. The word ‘nurse’ is derived from a Latin word meaning to nourish or cherish and, as birth, illness, injury and death are common to all human beings, there has always been a need for someone to take on the task of caring for others. In earlier times, and still today in some cultures, superstition and witchcraft surround illness and form the basis of the treatment of illness. For some cultures it was, and still is, believed that sickness was a punishment for wrongdoing and that the signs of illness were evidence of the presence of evil spirits. Treatment was prescribed by witch doctors and priests and, although much of it was barbaric and caused more suffering than the illness, many old herbal remedies are still used in a modified form today. Until well into the eighteenth century those who suffered a mental illness were considered to be possessed by the devil and were treated with extreme cruelty.
Some of the earliest organised nursing was performed by men who staffed the hospitals founded by military religious orders during the crusades; for example, the Knights of St John of Jerusalem, the Teutonic Knights and the Knights of St Lazarus. During the twelfth and thirteenth centuries several secular orders were active in caring for the sick, whose members included men and women (Burchill 1991). Some of the orders were the Ursulines, the Poor Clares, the Beguines and the Benedictines. Also at this time a religious order called the Augustinian Sisters of the Hôtel Dieu was founded in Paris; this is the world’s oldest order of nuns devoted purely to nursing.
During the sixteenth century, Henry VIII of England ordered the dissolution of the English monasteries and the confiscation of their property and enormous wealth. This meant that large numbers of sick and destitute people previously cared for by the religious orders were left to die. Workhouses were built to house the poor, many of whom were sick. These people lived in appalling conditions and were required to work in return for the accommodation provided. Finally, conditions in the city of London became so dreadful, and after many petitions from the people of London, that Henry VIII was forced to allow hospitals such as St Bartholomew’s, St Thomas’s and St Mary’s to be re-founded, and others to be established. The hospitals were insufficiently staffed by untrained workers, many of whom were of very poor character. Patients were housed in dreary, grossly overcrowded wards (Russell 1990).
The period from the beginning of the eighteenth century to the middle of the nineteenth century has been termed the ‘Dark Ages’ of nursing, during which the care of the sick and the status of the nurse reached the lowest level imaginable. The squalid conditions in hospitals and the undesirable character of those attending the sick were publicised by people such as the prison reformers, John Howard and Elizabeth Fry, and the writer Charles Dickens, who in Martin Chuzzlewit created the unsavoury characters Sairy Gamp and Betsy Prig to typify the nurses of the time—criminals and women of low moral standards and uneducated and who themselves lived and worked in appalling conditions.
In 1836, with the help of his wife, a Lutheran clergyman named Theodor Fliedner established an institution called Kaiserwerth, situated near Dusseldorf in Germany. There they trained carefully selected women as deaconesses, and Kaiserwerth became famous for the high standard of training and the quality of care given to the sick. It became a centre of nurse training and received many trainees from overseas countries, some of whom set up similar institutions in their own countries.
Modern nursing has evolved as a result of the influence that Kaiserwerth had on people like Elizabeth Fry, who founded the Protestant Sisters of Charity in an attempt to ensure that the sick were cared for by women of good reputation, such as Agnes Jones. Jones revolutionised conditions in the workhouses and established a school of nursing to train nurses in the care of sick people in the workhouses, and Florence Nightingale, the founder of modern nursing, was inspired by Elizabeth Fry’s training program (Burchill 1991).
Florence Nightingale was born in 1820 during a trip made by her English parents to the Italian city of Florence, after which she was named. Her parents were wealthy and cultured and Florence received an extensive education far beyond the standard usually received by the young women of her time. She travelled widely and led the full social life common to one in her place in society but, despite this, felt unhappy and dissatisfied. She was interested in nursing but this met with strong opposition from her family and it was not until she was over 30 years of age that she was able to realise her ambition. In 1850 she spent two weeks at Kaiserwerth and visited again in 1851, after which she was appointed Superintendent of the ‘Establishment for Gentlewomen during Illness’ in 1853 in London (MacDonnell 1970).
Florence Nightingale first achieved fame when, in 1854 during the Crimean War, she was asked to take a party of 38 nurses to Scutari in the Crimea. On arrival the nurses met with fierce opposition from the medical officers, who would not allow them to care for the sick and injured soldiers. Nightingale devoted her energies to improving the filthy conditions by introducing the principles of personal and communal hygiene, obtaining medical supplies, organising a good food supply and generally establishing sanitary conditions, such as handwashing, and the importance of fresh air. Within 2 or 3 weeks opposition had been overcome and the nurses were invited to take over the care of the sick. To the soldiers, Nightingale became an idol and, as she brought ease and comfort to the very sick by the light of the lamp she carried at night, she became known as the ‘Lady of the Lamp’ (Russell 1990).
After the Crimean War the English public raised almost £50 000 as a mark of appreciation of Nightingale’s work. She used the money to establish a School of Nursing at St Thomas’s Hospital in London. The first probationer nurses were admitted to the Nightingale School in June 1860 and given one year of training followed by two years of experience in the hospital. Many of these nurses became matrons of the large hospitals in London and elsewhere. By the time Florence Nightingale died in 1910 at the age of 90, not only had she facilitated remarkable progress in nursing services and education of nurses, she had made many significant achievements in public health matters of the time.
Nursing in Australia—the beginning
The first people arrived in Australia from South-east Asia over 40 000 years before Europeans first landed in the seventeenth century. These were the first nations of Aboriginal people and they are acknowledged as the traditional caretakers of the land.
Australia’s white colonisation began as a penal colony which is where the beginnings of modern nursing in Australia commenced. When Sydney Hospital was opened in 1811, most nurses were convict women, with some convict men also performing nursing duties. They were provided with their keep but no wages in exchange for their labour. The nurses were frequently described as being of poor character, with drunkenness while on duty common (Burchill 1991).
The first trained nurses, five Irish Sisters of Charity, arrived in Sydney in 1838 to provide care to the sick and infirm who, up to this stage, had been housed in squalid buildings and cared for by untrained staff.
In the 1840s the transportation of convicts to Australia ceased and the country was opened to free settlers. Gold was discovered in 1851 and once people in other countries heard about the gold mining boom many people rushed to Australia to make their fortune. However, the country lacked even the most basic infrastructure (fresh water supply, sewerage systems, healthcare) so these services had to be very rapidly developed as the country was colonised.
Prior to 1868 the state of nursing was, to say the least, substandard. Unskilled persons were often promoted to nursing roles despite no education or training—some could not even read or write. Stories abound of ‘nurses’ attending patients in hospitals dishevelled and intoxicated, and leaving patients unattended most of the time. Conditions were so bad patients who went to hospital once vowed never to return (MacDonnell 1970).
The Florence Nightingale nurses
The state of healthcare in Australia in the mid-nineteenth century had become so deplorable that a group of doctors sent a letter to Henry Parkes, then Colonial Secretary of New South Wales, urging him to do something. Henry Parkes responded by writing a letter to Florence Nightingale requesting her to provide a contingent of nurses to Australia, to clean up the hospitals. A similar action was undertaken by leaders of the time in New Zealand. Florence Nightingale sent six of her best trainees to Australia to set up a training school. These six nurses were Lucy Osburn, Mary Barker, Bessie Chant, Eliza Blundell, Annie Millar and Haldon Turriff (MacDonnell 1970). (See Clinical Interest Box 1.1.)
CLINICAL INTEREST BOX 1.1
I solemnly pledge myself before God and this assembly to pass my life to purity and in the practice of my profession faithfully.
I will abstain from what is deleterious and mischievous and will not take or knowingly administer any harmful drug
I will do all in my power to elevate the standards of my profession
And will hold in confidence all private matters that come to my knowledge in the practice of my calling
With loyalty I will endeavour to aid the physician in his work
Over time the Nightingale principles for the care of the ill were adopted. Nurses were trained in practical skills such as the application of dressings, leeching and administering enemas. Of equal importance were the character traits of punctuality, cleanliness, sexual purity and, above all, obedience. (See Clinical Interest Box 1.2.) A large proportion of nursing work was housekeeping, mostly domestic tasks. However, personal traits such as diligence and compassion were desirable characteristics in those who cared for the sick and were looked upon favourably (MacDonnell 1970).
CLINICAL INTEREST BOX 1.2
Job description of a floor nurse (1887)
(Developed in 1887 and published in a magazine of Cleveland Lutheran Hospital)
In addition to caring for your 50 patients, each nurse will follow these regulations:
1. Daily sweep and mop the floors of your ward, dust the patients’ furniture and window sills.
2. Maintain an even temperature in your ward by bringing in a scuttle of coal for the day’s business.
3. Light is important to observe the patient’s condition. Therefore, each day fill kerosene lamps, clean chimneys, and trim wicks. Wash windows once a week.
4. The nurse’s notes are important to aiding the physician’s work. Make your pens carefully. You may whittle nibs to your individual taste.
5. Each nurse on day duty will report every day at 7 A.M. and leave at 8 P.M., except on the Sabbath, on which you will be off from 12 noon to 2 P.M.
6. Graduate nurses in good standing with the Director of Nurses will be given an evening off each week for courting purposes, or two evenings a week if you go regularly to church.
7. Each nurse should lay aside from each pay a goodly sum of her earnings for her benefits during her declining years, so that she will not become a burden. For example, if you earn $30 a month you should set aside $15.
8. Any nurse who smokes, uses liquor in any form, gets her hair done at a beauty shop, or frequents dance halls will give the Director of Nurses good reason to suspect her worth, intentions, and integrity.
9. The nurse who performs her labour, serves her patients and doctors faithfully and without fault for a period of five years will be given an increase by the hospital administration of five cents a day providing there are no hospital debts that are outstanding.
(Scrubs nd) (http://scrubsmag.com/a-list-of-rules-for-nurses-from-1887/)
Australian nurses in wartime
Australian nurses have redeemed themselves and the reputation of nursing in the years since Australia’s beginnings with their efforts and achievements. There are many amazing stories of nurses throughout Australia’s history and nurses are particularly well represented in the heroic and inspiring stories from wartime (Australian War Memorial 2011).
Boer War
More than 60 Australian nurses went to the Boer War. Some were funded by governments or by privately raised funds, while others went at their own expense. The nurses served the sick and wounded under very harsh conditions. Three were awarded Royal Red Cross medals. The Boer War marked the death of nurse Frances Hines—the first Australian woman to die in a declared war (Australian War Memorial 2011).
World War I
Prior to Australia’s Federation in 1901, each colony controlled its own defence force, of which the nursing services formed a part. In July 1903 the nursing services of each colony combined to form the Australian Army Nursing Service. The Service, which was part of the Australian Army Medical Corps, was made up of volunteer trained nurses who were willing to serve in times of a national emergency (Fig 1.1).
Figure 1.1 Portrait of Number 11 Australian General Hospital, matron and staff nurses, c. 1919
(Australian War Memorial)
At the outbreak of World War I staff were recruited from both the nursing service and the civilian workforce. They served at field and base hospitals in Australia as well as in Egypt, England, France, Belgium, Greece, Salonika, Palestine, Mesopotamia and India. (See Clinical Interest Box 1.3.) Two thousand one hundred and thirty-nine Australian nurses served in World War I (Australian War Memorial 2011).
CLINICAL INTEREST BOX 1.3 Australian Army Nursing Service Pledge of Service
I pledge myself loyally to serve my King and Country and to maintain the honour and efficiency of the Australian Army Nursing Service. I will do all in my power to alleviate the suffering of the sick and wounded, sparing no effort to bring them comfort of body and peace of mind. I will work in unity and comradeship with my fellow nurses. I will be ready to give assistance to those in need of my help, and will abstain from any action which may bring sorrow and suffering to others. At all times I will endeavour to uphold the highest traditions of Womanhood and of the Profession of which I am Part.
World War II
The Australian Army Nursing Service was one of only two women’s services (the other being Voluntary Aid Detachments) that were active at the outbreak of war in 1939. Initially the enlisted nurses were the only females to serve outside Australia. Members served in England, Egypt, Palestine, Libya, Greece, Syria, Ceylon, Malaya, Singapore, Papua New Guinea and the Solomon Islands as well as throughout Australia. They served on hospital ships, troop transports, base and camp hospitals and some spent time in prisoner of war camps (Australian War Memorial 2011).
The first six Australian nurses were captured at Rabaul in January 1942. Shortly before Singapore fell, 65 nurses were evacuated on the Vyner Brooke. Twelve died when the ship was sunk off Sumatra and 21 in the Banka Island massacre on 16 February 1942. Thirty-two of these nurses became prisoners of war, held with civilian internees in camps on and around Palembang, in Sumatra. Conditions were horrendous and over three and a half years of captivity the nurses suffered with tropical disease and the effects of malnutrition. Eight of these nurses died in captivity (Australian War Memorial 2011).
History of nursing in New Zealand
New Zealand was settled later than Australia by free settlers—largely Scottish and in family groups—as opposed to the mostly male population of convicts and gaolers in Australia. Governor Gray, Governor of New Zealand in the early to mid-1800s, also wrote seeking Florence Nightingale’s assistance to send nurses and improve hospital standards; however, as fate would have it, Governor Gray was posted to South Africa before he received Ms Nightingale’s response and so the reforms she suggested did not come until much later (Crisp & Taylor 2009). As with Australia, a gold rush brought a large influx of European and Asian settlers to New Zealand, causing a great strain on health services and leading to poor conditions and high mortality rates (Crisp & Taylor 2009).
With the passing of the Nurses Registration Act on 12 September 1901, New Zealand became the first country to have separate legislation for the registration and regulation of nurses. The designer of the 1901 Act was a nurse, Grace Neill, who was Assistant Inspector of Hospitals. In 1899 she attended the International Council of Women’s Conference in London, where nursing registration was discussed. On her return to New Zealand she worked with Dr Duncan MacGregor, the Inspector-General of Hospitals, to draft the Nurses Registration Act. The Act came into force in January 1902 and the register was kept by Dr MacGregor. Nurses who had already trained could apply to have their names entered. Others were to sit a State examination. The first name recorded was that of Ellen Dougherty, who had trained at Wellington Hospital in the 1880s. Within 18 months 320 nurses were registered.
The Nurses and Midwives Registration Act 1925 and the Nurses and Midwives Act 1945 set up statutory boards to regulate nursing. In addition to keeping the register, the boards could take disciplinary action against a nurse for serious misconduct. As nursing practice became more specialised, separate registers were established for maternity nurses (1925), nursing aides (1939), psychiatric nurses (1944), male nurses (1945), psychopaedic nurses (1960), community nurses (1965) and comprehensive nurses (1977). In 1977 community nurses became ENs. Midwives had separate registration from 1904 but were regulated by the same statutory body as nurses. With the introduction of the Nurses Act 1971 this body became the Nursing Council of New Zealand. The 1901 Act ushered in a century of control, discipline and regulation and also confirmed nursing’s standing as a profession and as a vital part of the health system of a new country.
Progress of nursing in Australia and New Zealand
As scientific advances were made, the recognition of the need for nursing training grew. By 1900 most of the larger Australian and New Zealand hospitals had three-year training programs for student nurses, with lectures delivered by medical staff. Unfortunately, because of the long hours of work, student nurses were frequently too tired to concentrate during such classes. During the twentieth century a move towards professionalism emerged and with it came considerable conflict between the view that nursing is a vocation, which should be inherently subordinate to medicine, and the view that nursing is a profession, different from, but of equal status with, medicine (Russell 1990).
Trailing far behind the New Zealand nurses, the first state in Australia to pass relevant registration legislation was South Australia, in 1920. Western Australia followed in 1922, New South Wales and Victoria in 1924. The emerging sense of professionalism among nurses led to a greater focus on industrial issues. The Australian Nursing Federation held its first meeting in 1924 and through this forum the quest for greater professional recognition, increased wages and improved working conditions began—a quest that continues today (Crisp & Taylor 2009).
In 1984 the Australian Federal Government announced full support for the transfer of nursing education into the tertiary sector. At about the same time New Zealand commenced a transition from hospital-based training to the education sector. This move was slowly integrated into nurse education in both countries over the subsequent decade.
Table 1.1 outlines the major milestones in Australia’s and New Zealand’s nursing history.
Table 1.1 I Milestones in Australian and New Zealand Nursing
Sources: ANMC, Crisp & Taylor 2009, NMBA, RCNA
Nursing practice in Australia
Australian Nursing & Midwifery Council competencies
To ensure that nurses continue to practise at a high standard that ensures safety of the public, the Australian Nursing & Midwifery Council (ANMC) developed the National Competency Standards for the Registered Nurse (1998) (ANMC) and reviewed the National Competency Standards for the Enrolled Nurse in 2002 (ANMC). Standards of nursing practice are developed and established from a basis of strong scientific research and the advice of clinical experts. Standards of nursing practice serve as objective guidelines for the provision of nursing care and as a means to evaluate that care. They provide a method to ensure that clients receive high-quality individualised care, to ensure that nurses know what is necessary to provide expert nursing care and to ensure that measures are in place to determine that the care meets specific standards.
Educational institutions can recommend students for registration only if they have demonstrated the required competencies. After registration or enrolment it becomes the responsibility of the individual nurse to ensure that this level of competency is maintained. It is the responsibility of the employing health facility to provide continuing education to ensure that competency standards are not only maintained but further developed (Crisp & Taylor 2009). The responsibilities included in the competency standards are illustrative of the types of core activities that an EN would be expected to undertake on entry to practice. All ENs have a responsibility for ongoing professional development to maintain an up-to-date knowledge base and skill level.
The Competency Standards document (2002) was developed to reflect four domains of EN practice: professional and ethical practice, critical thinking and analysis, management of care and enabling. There are 10 competencies and each competency contains several elements. The elements enable measurement of whether or not the competency has been attained by an EN on entry to practice. Clinical Interest Box 1.4 outlines these 10 competencies.
CLINICAL INTEREST BOX 1.4 NMBA competency standards for the enrolled nurse (2002)
Professional and ethical practice
Competency Unit 1. Functions in accordance with legislation, policies and procedures affecting enrolled nursing practice
1.1. Demonstrates knowledge of legislation and common law pertinent to enrolled nursing practice.
1.2. Demonstrates knowledge of organisational policies and procedures pertinent to enrolled nursing practice.
1.3. Fulfils the duty of care in the course of enrolled nursing practice.
1.4. Acts to ensure safe outcomes for individuals and groups by recognising and reporting the potential for harm.
1.5. Reports practices that may breach legislation, policies and procedures relating to nursing practice to the appropriate person.
Competency Unit 2. Conducts nursing practice in a way that can be ethically justified
2.1. Acts in accordance with the nursing profession’s codes.
2.2. Demonstrates an understanding of the implications of these codes for enrolled nursing practice.
Competency Unit 3. Conducts nursing practice in a way that respects the rights of individuals and groups
3.1. Practises in accordance with organisational policies relevant to individual/group rights in the healthcare context.
3.2. Demonstrates an understanding of the rights of individuals/groups in the healthcare setting.
3.3. Liaises with others to ensure that the rights of individuals/groups are maintained.
3.4. Demonstrates respect for the values, customs, spiritual beliefs and practices of individuals and groups.
3.5. Liaises with others to ensure that the spiritual, emotional and cultural needs of individuals/groups are met.
3.6. Contributes to the provision of relevant healthcare information to individuals and groups.
Competency Unit 4. Accepts accountability and responsibility for own actions within enrolled nursing practice
Critical thinking and analysis
Competency Unit 5. Demonstrates critical thinking in the conduct of enrolled nursing practice
Management of care
Competency Unit 6. Contributes to the formulation of care plans in collaboration with the RN
6.1. Accurately collects and reports data regarding the health and functional status of individuals and groups.
6.2. Participates with the RN and individuals and groups in identifying expected healthcare outcomes.
6.3. Participates with the RN in evaluation of progress of individuals and groups towards expected outcomes and reformulation of care plans.
Competency Unit 7. Manages nursing care of individuals and groups within the scope of enrolled nursing practice
7.1. Implements planned nursing care to achieve identified outcomes.
7.2. Recognises and reports changes in the health and functional status of individuals/groups to the RN.
7.3. Ensures communication, reporting and documentation are timely and accurate.
7.4. Organises workload to facilitate planned nursing care for individuals and groups.
Enabling
Competency Unit 8. Contributes to the promotion of safety, security and personal integrity of individuals and groups within the scope of enrolled nursing practice
8.1. Acts appropriately to enhance the safety of individuals and groups at all times.
8.2. Establishes, maintains and concludes effective interpersonal communication.
8.3. Applies appropriate strategies to promote the self-esteem of individuals and groups.
8.4. Acts appropriately to maintain the dignity and integrity of individuals and groups.
Competency Unit 9. Provides support and care to individuals and groups within the scope of enrolled nursing practice
9.1. Provides for the comfort needs of individuals and groups experiencing illness or dependence.
9.2. Collaborates with the RN and members of the healthcare team in the provision of nursing care to individuals and groups experiencing illness or dependence.
9.3. Contributes to the health education of individuals or groups to maintain and promote health.
9.4. Communicates with individuals and groups to enable therapeutic outcomes.
Competency Unit 10. Collaborates with members of the healthcare team to achieve effective healthcare outcomes
10.1. Demonstrates an understanding of the role of the EN as a member of the healthcare team.
10.2. Demonstrates an understanding of the role of members of the healthcare team in achieving healthcare outcomes.
10.3. Establishes and maintains collaborative relationships with members of the healthcare team.
10.4. Contributes to decision-making by members of the healthcare team.
(NMBA 2002)
Doctor Patricia Benner’s seminal research, From Novice to Expert, explores how nurses progress in the development of expertise to explain the domains of nursing practice. Clinical Interest Box 1.5 outlines the development of nursing expertise.
CLINICAL INTEREST BOX 1.5 Benner’s stages of nursing expertise
No experience (nursing student). Performance is limited, inflexible and governed by context-free rules and regulations rather than experience.
Demonstrates marginally acceptable performance. Recognises the meaningful ‘aspects’ of a real situation. Has experienced enough real situations to make judgments about them.
Stage III. Competent practitioner
Has 2–3 years experience. Demonstrates organisational and planning abilities. Differentiates important factors from less important aspects of care. Coordinates multiple complex care demands.
Stage IV. Proficient practitioner
Has 3–5 years experience. Perceives situations as wholes rather than in terms of parts, as in Stage II. Uses maxims as guides for what to consider in a situation. Has holistic understanding of the client, which improves decision making. Focuses on long-term goals.
Performance is fluid, flexible and highly proficient. No longer requires rules, guidelines or maxims to connect an understanding of the situation to appropriate action. Demonstrates highly skilled intuitive and analytic ability in new situations. Is inclined to take certain action because ‘it felt right’.
(Benner 2004)
Scope of practice
In Australia the exact nature of the scope of practice of the EN varies across states and territories, but duties are usually conducted under the direction and supervision of the RN and reforms are currently underway to standardise educational preparation and scope of practice across Australia.
The scope of practice for enrolled nurses in NZ changed on 31 May 2010. The new scope of practice enables enrolled nurses to make a broader contribution to health services by giving greater support to registered nurses and assisting the newly transitioned nurse assistants into EN scope of practice.
The global shortage of nurses and the expanding roles for nurses has seen health services and aged care services utilising unlicensed/unregulated healthcare workers. There are many and varied arguments for and against this unlicensed healthcare worker role; however, suffice to say it exists within Australian and New Zealand health contexts and nurses need to be aware of the existence of the role.
In April 2007 the then Australian Nursing and Midwifery Council released A national framework for the development of decision-making tools for nursing and midwifery practice (Nursing and Midwifery Board of Australia). According to this framework, the scope of practice of an individual nurse is that which the individual is educated, authorised and competent to perform. To practise within the full scope of practice of the profession may require individuals to update or increase their knowledge, skills or competence. However, the actual scope of practice is influenced by the:
• Context in which the nurse practises
• Level of competence, education and qualifications of the individual nurse
• Policies of the healthcare service provider
• Legislation (Brown & Edwards 2012).
If nursing is responsive to individual, group and community needs for a healthcare service, then it follows that scope of practice will be relatively fluid in order to accommodate the public need for flexibility and diversity in the provision of nursing services. In order to gauge their scope of practice nurses are required to know the law regulating and relating to nursing practice and to have a realistic appreciation of their knowledge and skills (Brown & Edwards 2012).
To read the full guidelines and view the decision-making flowchart for Australia go to: http://www.nursing midwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx#decisionmakingframework
For the New Zealand nursing scope of practice document go to: http://www.nursingcouncil.org.nz/index.cfm/1,22,0,0,html/Scopes-of-Practice
NURSING—THE PROFESSION
Nursing is not simply a collection of specific skills, and the nurse is not simply a person trained to perform specific tasks. Nursing is a profession. No one factor absolutely differentiates a job from a profession, but the difference is important in terms of how nurses practise. When a person is said to act professionally, for example, it is implied that the person is conscientious in actions, knowledgeable in the subject and responsible to self and others. Although there is not universal agreement on a definition, a profession is generally expected to include the following characteristics:
• An extended and broad-based education of its members
• A theoretical body of knowledge leading to defined skills, abilities and norms
• The provision of a specific service
• Autonomy in decision making and practice
• The regulation of practice, both legally through legislation, and ethically through a code of ethics for practice.
The claim that nursing is a profession is not entirely unproblematic. The area of autonomy and decision making in practice is particularly controversial, especially in the light of the dependent relationship found at times between nursing and medicine. Five characteristics of a profession are worth consideration in relation to nursing. They are education, theory, service, autonomy and a code of ethics (Crisp & Taylor 2009).
Nurse education
There are generally two levels of nursing and thus nurse education in Australia and New Zealand. The first level or registered nurse (RN) requires the completion of an undergraduate degree in the higher education or university sector. The course is generally of 3 years duration but some programs extend over 3½ or 4 years. The RN can practise nursing without supervision and is regarded as responsible and accountable for all decisions and actions taken in relation to client care.
The enrolled nurse (EN) is a second-level nurse and requires the completion of a certificate, advanced certificate or diploma (depending upon which state or territory the qualification is undertaken in), generally through the technical and further education (TAFE or Polytechnic) system or a private registered training organisation (RTO). The duration of these programs varies from 12 months to 2 years.
Theories and models of nursing
The practice of professional nursing and development of nursing knowledge has to some extent evolved from nursing theories. Theoretical models serve as frameworks for nursing curricula, clinical practice and research. Nursing theories can help make sense of processes and practices. Nursing theories are an attempt to elucidate the nature of nursing practice, the principles on which practice is based and the proper goals and functions of nursing in society. In this way nursing theories help create an understanding of the practice of nursing, how nurses interact with clients and how nursing actions and provision of nursing care is structured (Daly et al 2009).
The development of nursing theory was an essential part of establishing professional status and independence. Nursing theory has clearly demonstrated that nursing, as a profession, shares a common body of knowledge with medicine (Crisp & Taylor 2009). However, nursing has a different perspective, namely to care rather than to cure. This perspective provides nursing with its own set of knowledge and theoretical assumptions.
Defining theory and model
A theory is an abstract statement formulated to explain or describe the relationships among concepts or events. A nursing theory conceptualises an aspect of nursing for the purpose of describing, explaining, predicting and/or prescribing nursing care (Crisp & Taylor 2009). A model is a conceptual framework developed from a set of concepts and assumptions; it is a conceptual representation of reality. A model provides the outline for which theory provides the functions. Thus, a model represents structure while a theory suggests function. Numerous conceptual models of nursing practice have been devised, most of which:
Nursing theories serve several essential purposes, as is illustrated in Clinical Interest Box 1.6.
CLINICAL INTEREST BOX 1.6 Purposes of nursing theories and conceptual frameworks
• Assist nurses to describe, explain and predict everyday experiences
• Serve to guide assessment, intervention and evaluation of nursing care
• Provide a rationale for collecting reliable and valid data about the health status of clients, which are essential for effective decision making and implementation
• Help to establish criteria to measure the quality of nursing care
• Help build a common nursing terminology to use in communicating with other health professionals. Ideas are developed and words defined
• Enhance autonomy of nursing by defining its own independent functions
Components of nursing theoretical models
A domain is a field or scope of knowledge of a discipline and contains the subject, central concepts, values and beliefs, phenomena of interest and the central problems of the discipline. The components of a discipline’s domain are described in a paradigm. A paradigm is a model that explains the links to science, philosophy and theory accepted by the discipline. Nursing’s paradigm directs the activity of the nursing profession and includes four major concepts—person, health, environment and nursing (Berman et al 2012; Crisp & Taylor 2009).
Overview of selected nursing theories
Many nursing theories have been developed in the past and many are still being developed today. The following selection of nursing theories is an historical overview that discusses nursing’s four fields of interest: person, health, environment and nursing.
Peplau’s theory
In 1952 Hildegard Peplau made an attempt to analyse nursing action using an interpersonal theoretical framework. Her theory focuses on the relationships formed by people as they progress through each developmental stage. She viewed the goal of nursing as developing a relationship between the nurse and client whereby the nurse acts as resource person, counsellor, teacher and surrogate.
Abdellah’s theory
In 1960 Fay Abdellah, with her colleagues, devised a theory that emphasised the delivery of nursing care to the whole person. Using a problem-solving approach the nurse formulates a plan to help clients meet their physical, emotional, intellectual, social and spiritual needs (Crisp & Taylor 2009). Abdellah identified 21 basic nursing procedures. These are to:
1. Maintain good hygiene and physical comfort
2. Achieve optimal activity, exercise, rest and sleep
3. Prevent accident, injury or other trauma and prevent the spread of infection
4. Maintain good body mechanics and prevent and correct deformities
5. Facilitate the supply of oxygen to all body cells
6. Facilitate the maintenance of nutrition to all body cells
7. Facilitate the maintenance of elimination
8. Facilitate the maintenance of fluid and electrolyte balance
9. Recognise the physiological responses of the body to disease conditions, pathological, physiological and compensatory
10. Facilitate the maintenance of regulatory mechanisms and functions
11. Facilitate the maintenance of sensory functions
12. Identify and accept positive and negative expressions, feelings and reactions
13. Identify and accept the interrelatedness of emotions and organic illness
14. Facilitate the maintenance of effective verbal and non-verbal communication
15. Facilitate the development of productive interpersonal relationships
16. Facilitate progress towards achievement of personal spiritual goals
17. Create and/or maintain a therapeutic environment
18. Facilitate awareness of self as an individual with varying physical, emotional and developmental needs
19. Accept the optimal possible goals in light of limitations—physical and emotional
20. Use community resources as an aid in resolving problems arising from illness
21. Understand the role of social problems as influencing factors in the cause of illness.
Henderson’s theory
In 1966 Virginia Henderson described the goal of nursing as helping the client to gain independence as rapidly as possible.
Henderson identified 14 basic needs that provide a framework for nursing care. These are to:
3. Eliminate by all avenues of elimination
4. Move and maintain a desirable position
6. Select suitable clothing; dress and undress
7. Maintain body temperature within normal range
8. Keep the body clean and well groomed
9. Avoid dangers in the environment
11. Worship according to faith
12. Work at something that provides a sense of accomplishment
13. Play or participate in various forms of recreation
14. Learn, discover or satisfy the curiosity that leads to normal development and health
Johnson’s theory
In 1968 Dorothy Johnson portrayed the goal of nursing as reducing stress so that the client can recover as quickly as possible. Johnson viewed people as a collection of behavioural subsystems that interrelate to form a whole person, and her theory focuses on a person’s needs in terms of the following behaviours:
• Mastery of oneself and one’s environment according to internalised standards of excellence
• Taking in nourishment in socially and culturally acceptable ways
• Ridding the body of waste in socially and culturally acceptable ways
Johnson saw the nurse’s role as identifying the client’s inability to adapt to stress, and as providing the nursing care necessary to assist them in resolving problems to meet their needs (Crisp & Taylor 2009).
King’s theory
Imogene King (1971, cited in Crisp & Taylor 2009) viewed the goal of nursing as helping individuals and groups to attain, maintain and restore health, or to die with dignity. King saw nursing as a process of interaction between nurse and client whereby, through communication, goals are set and agreement reached on ways to achieve goals.
Orem’s theory
In 1973 Dorothea Orem depicted the goal of nursing as helping the client to achieve health through self-care (Crisp & Taylor 2009). Orem saw nursing as a service required when individuals are unable to care for themselves, or unable to be cared for by others of significance to them; that is, when demands exceed their self-care abilities. The nurse identifies why an individual is unable to care for themself and implements measures that assist them to meet their needs. The overall goal of nursing care is to assist the client to achieve self-care whenever possible.
Roy’s theory
Callister Roy viewed the goal of nursing as assisting people towards health by promoting and supporting their ability to adapt to various demands (Crisp & Taylor 2009):
Roy saw nursing as being concerned with people as total beings, and intervening when necessary to assist them to adapt to one or more of these demands.
Roper, Logan and Tierney’s theory
Roper, Logan and Tierney in 1985 viewed the goal of nursing as helping people to prevent, alleviate, solve or cope with problems related to activities of living. Their model of nursing is based on their model for living and includes five main concepts:
The activities of living, which are the focus of the model, are:
Many of these theories influence the way Australian and New Zealand authorities promote the profession of nursing, by providing a framework for regulation, ethics and conduct.
Relationship of theories to nursing process
The nursing process is a tool and framework for contemporary nursing practice. It is a series of planned steps that produces a particular end result. In simple terms, the nursing process is a method used to assess, plan, deliver and evaluate nursing care. Clinical Interest Box 1.7 illustrates the relationship of two theories to the nursing process. Providing the framework for nursing care, the nursing process consists of five components, each of which follows logically one after the other:
CLINICAL INTEREST BOX 1.7 Selected nursing theories and the nursing process
Orem’s general theory of nursing
Involves collecting data about the client’s capacities (knowledge, skills and motivation) to perform universal, developmental, and health-deviation self-care requisites. Determines self-care deficits
Stated in terms of the client’s limitations for maintaining self-care (a deficit in self-care agency)
Involves considering and designing, with the client’s participation, an appropriate nursing system (wholly compensatory, partially compensatory, supportive-educative, or a mix) that will help the client achieve an optimal level of self-care (i.e. enhance the client’s self-care agency)
Assisting the client by acting for or doing for, guiding, supporting, providing a developmental environment and teaching
Determining the client’s level of achievement in resolving self-care deficits and in performing self-care
Roy’s adaptation model
Involves two levels. First-level assessment includes collecting data about output behaviours related to the four adaptive modes (physiological, self-concept, role function, and interdependence modes)
Second-level assessment includes collecting data about internal and external stimuli (focal, contextual or residual) that are influencing the identified behaviours
Focuses on adaptation problems and uses one of three alternative methods:
1. Stating behaviours within one mode with their most relevant influencing stimuli
2. Clustering behavioural information and labelling it according to indicators of positive adaptation and a typology of common adaptation problems related to each mode. Roy provides a typology of indicators of positive adaptation and a typology of commonly recurring adaptation problems according to each of the four modes
3. Labelling a behavioural pattern when more than one mode is being affected by the same stimuli
Setting goals in terms of behaviours the client is to achieve and planning nursing interventions to promote the effectiveness of the client’s coping mechanisms and adaptive behaviours
Altering and manipulating the focal, contextual and residual stimuli by increasing, decreasing or maintaining them
Determining the client’s output behaviours with those identified in the goals
The process is adaptable to different clients and different care settings. In addition, the process offers a systematic approach to nursing practice, enhances research opportunities and is compatible with many other systems in the healthcare delivery system, such as computer-generated care plans, patient information systems and patient acuity systems. Although the nursing process is central to the domain of nursing it is not a theory. It provides a process for the delivery of nursing care, not the knowledge component of the discipline. However, there have been attempts to build a comprehensive theory from the process and to use the nursing process in conjunction with other theories that lack a process element. (For more information on the nursing process refer to Ch 15.)
Service
Nursing has always been a service profession, although in the past the service was usually viewed as a charitable one largely directed towards the care of the physically ill. Nurses today need to acknowledge and value the importance of nursing care across a broad range of practice settings and with different groups of clientele. Moreover, they need to work with the client and family, individualising care, considering cultural and religious differences and providing support for the entire extended family.
Autonomy
Autonomy is an essential element of professional nursing. Autonomy means that a person is reasonably independent and self-governing in decision making and practice (Crisp & Taylor). RNs attain increased autonomy through higher levels of education, through clinical competence and in diverse practice settings. RNs are increasingly taking on independent roles in nurse-run clinics, nurse practitioner roles, collaborative practice and advanced-nurse practice settings. ENs also have increased autonomy in certain settings; for example, in the aged-care sector and in the community.
All nurses are accountable for the type and quality of nursing care provided. The degree to which nurses are held accountable for their actions reflects the level of education they have received, which in turn informs the degree of responsibility the nurse has in the workplace. The nursing profession regulates accountability through nursing audits and standards of practice.
Code of ethics
The need for a code of ethics was acknowledged during the Australasian Nurse Registering Authorities Conference (ANRAC) in 1990. It was deemed that there was need for focus on ethical behaviour for Australian nurses and that a documented code of ethics would assist in achieving this focus. The ANMC Code of Ethics for Nurses in Australia (ANMC 2008) comprises eight value statements, each of which is further defined by several explanatory statements. The eight value statements are:
1. Nurses value quality nursing care for all people
2. Nurses value respect and kindness for self and others
3. Nurses value the diversity of people
4. Nurses value access to quality nursing and health care for all people
5. Nurses value informed decision making
6. Nurses value a culture of safety in nursing and health care
7. Nurses value ethical management of information
8. Nurses value a socially, economically and ecologically sustainable environment promoting health and wellbeing.
These value statements are deliberately broad to reflect the variety of nursing practice areas, and variation in populations and their healthcare needs. The websites for the Nursing and Midwifery Board of Australia and the Nursing Council of New Zealand contain information for nurses and for the public. The websites contain codes, guidelines and position statements. See Clinical Interest Box 1.8 for the New Zealand Code of Conduct.
Registration
Nursing and Midwifery Board of Australia
In Australia a national regulatory scheme was established and effective as of 1 July 2010. The Nursing and Midwifery Board of Australia has established State and Territory boards to support the work of the national board in the national scheme. The national board will set policy and professional standards, and the State and Territory boards will continue to make individual notification and registration decisions affecting individual nurses and midwives (see Clinical Scenario Box 1.1).
Clinical Scenario Box 1.1
Margaret, 72, came into the Nursing and Midwifery Board of Australia’s (NBMA) registration enquiry desk to ask for assistance. She stated that she had been a nurse for over 50 years and she did not understand why she had been refused her registration renewal. The nursing officer who attended to her enquiry asked her if she was currently working, she replied that she had not worked for 30 years but she did not see what that had to do with her nursing registration. She stated she had been a nurse for over 50 years and no-one should have the right to take that away from her. She had sent her renewal with her payment every year and never been refused before.
When the nursing officer explained that registration was a licence to practise and as the NMBA had a duty to ensure nurses who had registration to practise were skilled and competent practitioners and that it was no longer acceptable to just renew your registration every year, Margaret became teary. She said, ‘Well, if I cannot keep my registration I am not a nurse anymore!’ The nursing officer advised her that she would always be a nurse, just not a practising one and she could apply for a non-practising nurse registration.
The functions of the Nursing and Midwifery Board of Australia include:
• Registering nursing and midwifery practitioners and students
• Developing standards, codes and guidelines for the nursing and midwifery profession
• Handling notifications, complaints, investigations and disciplinary hearings
• Assessing overseas-trained practitioners who wish to practise in Australia
• Approving accreditation standards and accredited courses of study (Nursing and Midwifery Board of Australia)
Australian Health Practitioner Regulation Agency
The Australian Health Practitioner Regulation Agency (AHPRA) supports the Nursing and Midwifery Board of Australia. The primary role of the board is to protect the public and set standards and policies that all registered health practitioners must meet. AHPRA:
• Supports the Nursing and Midwifery Board of Australia in their primary role of protecting the public
• Manages the registration processes for health practitioners and students around Australia
• Has offices in each State and Territory where the public can make notifications about a registered health practitioner or student
• On behalf of the boards, manages investigations into the professional conduct, performance or health of registered health practitioners, except in NSW where this is done jointly by the Health Professional Councils Authority and the Health Care Complaints Commission
• On behalf of the national board, publishes national registers of practitioners so important information about the registration of individual health practitioners is available to the public
• Works with the Health Complaints Commission in each State and Territory to make sure the appropriate organisation investigates community concerns about individual, registered health practitioners
• Supports the boards in the development of registration standards, and codes and guidelines
• Provides advice to the Ministerial Council about the administration of the national registration and accreditation scheme (AHPRA).
Australian Nursing and Midwifery Accreditation Council
The role of the Australian Nursing and Midwifery Accreditation Council (ANMAC) is now, as Australia’s independent accreditation authority for nursing and midwifery, to undertake:
• Development of accreditation standards
• Accreditation of Australian nursing and midwifery courses
• Accreditation of Australian providers of nursing and midwifery courses
• Assessment of, for the purposes of permanent migration, internationally qualified nurses and midwives
• Provision of policy advice on matters relating to accreditation and skilled migration of nurses and midwives (ANMAC).
Nursing Council of New Zealand
In New Zealand the Nursing Council of New Zealand (the Council) is the regulatory authority responsible for the registration of nurses. Its primary function is to protect the health and safety of members of the public by ensuring that nurses are competent and fit to practise. It fulfils this function by:
• Setting ongoing competence requirements and issuing practising certificates
• Setting scopes of practice and the qualifications required for registration
• Accrediting and monitoring education providers and setting the state examination
• Providing guidelines and standards for practice
• Receiving and acting on notifications of health and competence concerns
• Receiving and acting on complaints about the conduct of nurses
• Promoting public awareness of the Council’s responsibilities (NCNZ)
Professional nursing organisations
Australian College of Nursing
In 2011 the Royal College of Nursing, Australia (RCNA) and The College of Nursing (TCoN) united to become the Australian College of Nursing (ACN). The ACN provides a strengthened base for the nursing profession that communicates with government, other sectors and the public. It fosters research, policy and strategic development and provides a foundation for professional development and education activities (RCNA 2011).
Australian Nursing Federation
The Australian Nursing Federation (ANF) was established in 1924. It is the national union for nurses and the largest professional organisation in Australia. The ANF’s core business is the industrial and professional representation of nurses and nursing through the activities of a national office and branches in every state and territory. ANF has an enrolled-nurse special interest group, the National Enrolled Nurse Association (NENA), whose mission is to promote the value of ENs and raise awareness of the EN role within the community. The National Enrolled Nurse Association also provides a forum for all ENs to participate at a national level.
INFLUENCES ON NURSING
Societal influences on nursing
The societal influences on nursing include developments in medical science and technology, which have impacted on the changing role and function of the nurse, and other factors such as demographic changes, cultural diversity and the consumer movement, which have also had an impact on the structure and practice of nursing.
Demographic changes
Changes that have influenced healthcare in recent decades include the population shift from rural areas to urban centres, increasing life span, the higher incidence of long-term illness and increased incidence of substance abuse, mental illness and diseases such as cancers. Nursing as a profession responds to such changes by exploring new methods for providing care, by changing educational emphasis and by establishing practice standards in new areas (Crisp & Taylor 2009).
Cultural diversity
Australia and New Zealand are multicultural societies, which means that nurses frequently encounter clients from cultures different from their own. Nurses need to be open to the challenges presented by cultural diversity and seek the information they require to provide culturally sensitive care (Crisp & Taylor 2009).
In Australia for many years there has been recognition of the multicultural nature of the country but little emphasis on the care of Indigenous people. In New Zealand it is the reverse. New Zealand sees itself as a bicultural country, with many different cultures in the non-Indigenous population.
Concern for the Māori population’s interaction with healthcare led to the development of the concept of cultural safety, which was introduced into nursing curricula in 1992. In 2005 (amended 2011) the Nursing Council of New Zealand published a comprehensive guideline on cultural safety in nursing education and practice which is available on their website (NCNZ) (Crisp & Taylor 2009).
Consumer movement
The availability of information through sources such as the internet means that consumers are potentially better informed than ever before. The strength of the consumer movement is most evident in the mental health area, where pressure exerted by mental health consumers has led to initiatives such as the employment of consumer consultants within healthcare networks. The role of the consumer consultant is to provide support and advocacy to consumers receiving mental health services and to influence the development of policy regarding the care and treatment of consumers (Crisp & Taylor 2009). The consumer has become an active participant in making decisions about health and nursing care, with most consumers now believing that good health is a right of all people and that they must assume responsibility for their own health (Berman et al 2012).
Human rights movement
Respect for the right of all people to the optimal standard of nursing and healthcare is central to the philosophy of the nursing profession. This view is reflected in the codes of ethics and standards of all nursing professional organisations. Nurses need to be consciously aware of personal values and where they are likely to impact on the quality of care given to a client. Where problems arise, advice or support should be requested (Crisp & Taylor 2009).
Summary
An overview of the theories and models of nursing helps to demonstrate how theory can inform the way in which we view the person, health, the environment and nursing itself. This allows nurses to establish connections and meaning in nursing and facilitates continuity of care. The utilisation and application of nursing theory (in the form of philosophies, models and theories) help nurses think critically for professional practice. Theory and research together lead to a systematic inquiry, which informs practice (Daly et al 2009).
The profession of nursing is in a constant state of change. The evolution of nursing has brought us to the point where there are endless opportunities to improve the health and welfare of our clients and the communities in which we live. The role of the EN and the RN has changed from that of a vocation to a role that emphasises education and professional standards, exemplified by the development of competencies for the EN and the RN and codes of ethics, as well as the national framework for decision making for nursing practice. The role of the EN is expanding and embracing new areas such as technology in healthcare, the administration of medications (in some Australian States and Territories) and wound care procedures. Queensland has developed an Enrolled Nurse Advanced Practice role. The challenge for the future will be to incorporate these changes into the role of the EN while still maintaining the standards of the profession and to ensure that each nurse understands each other’s role.
1. What are the themes that are common to the many different definitions of nursing?
2. The scope of practice of the EN is influenced by what factors?
3. The Competency Standards document (2002) (Nursing and Midwifery Board of Australia) was developed to reflect four (4) domains of EN practice. List these domains.
4. What are the purposes of nursing theories and conceptual frameworks?
5. What factors have impacted on the changing role and function of the nurse?
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