Chapter 1 Nursing today

Jill White

LEARNING OUTCOMES

Mastery of content will enable you to:

• Define the key terms listed.

• Discuss the rich history of professional nursing in Australia and New Zealand.

• Describe nursing practice and the roles nurses undertake.

• Discuss educational and career pathways available to registered nurses.

• Discuss the influence of social, economic and political changes on nursing practice.

Nursing defined

In 2002 the International Council of Nurses (ICN) issued a newly constructed definition of nursing to capture the broadening nature of nursing practice:

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 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. (Revised April 2010.)

This definition provides several keys to understanding within the contemporary healthcare system or nursing today, including the following:

• the spectrum of age—birth to old age or life’s end

• the spectrum of the health status of the person receiving care—health promotion, illness prevention, illness care, care of the disabled or the dying person

• the spectrum of nursing roles—including clinical practice, environmental care, client advocacy, research, client management, health systems management, education and health policy

• the spectrum of nursing relationships—autonomous one-to-one client care, collaborative family care, intra- and interprofessional collaboration, and all variations on these.

From the 1960s to 2002, the ICN used the description of nursing written by the famous nursing writer Virginia Henderson as its definition. When we compare the new and old definitions, some critical changes become apparent. Henderson’s 1966 definition is as follows:

The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.

As can be seen immediately, Henderson’s definition positions nurses at the metaphorical bedside, focusing on the heart of nursing practice—the care of individuals, sick or well. In contrast, the 2002 position assumes that nurses also have a role in a range of contexts outside the hospital, including the community, the health service boardroom, the government and the university.

Not only were there issues with the limited contexts of practice, but there also were two other aspects of Henderson’s definition which had become somewhat contentious. Henderson’s use of the word ‘independence’ led to ongoing argument that maintaining health is nearly always a collaborate endeavour rather than one of functioning alone. The second aspect is really a time-bound one. In the past it was ‘normal’ to use she to describe nurses and he to describe patients. This is no longer viewed as appropriate.

There is, however, something lyrical about Henderson’s definition, a gentle caring sense that is not captured in the current definition. References to ‘strength, will and knowledge’ are also missing from the current definition. For generations, nurses have found these patient/client characteristics helpful to consider when planning care. Perhaps we need to retain elements of both definitions in our own personal working definitions. In conversations with nurses about Henderson’s definition, the comment has been made that while ‘strength, will and knowledge’ are critical for the nurse to ‘lend’ to the patient for the time the patient is vulnerable, there also needs to be consideration of the ‘action’ component of nursing—the therapeutic work that nurses do.

Developments in any profession that offers a human service are influenced by outside events, be they social, economic or political. These certainly heavily influence nursing. Later in this chapter, we will look at the contemporary events in our societies that have had major impacts on nursing and its practices. We will also come to see how nursing research is beginning to offer nurses an opportunity to shape understandings of healthcare, such that we can influence policy rather than remain only reactive to it.

Nursing has traditionally responded and adapted as new challenges arise. The evolution of nursing has brought the profession to one of the most challenging and exciting times in history. There are enormous opportunities to improve the health and quality of the lives of people and their communities as the nursing profession and nursing practice are continually developed.

When communities face healthcare crises, such as those that occur from infectious diseases or lack of healthcare resources, nurses are there to undertake health assessments and to establish community-based immunisation and screening programs, treatment clinics and health promotion activities. In times of war, nurses have responded, serving to meet the needs of the wounded in combat arenas and in military hospitals at home and abroad. People are most vulnerable when they are injured, sick or dying. Nurses are present and will continue to be present not only to meet the needs of the client but also to help meet the related needs of the person’s family and friends.

Because of the nature of the work nurses do, and the commitment of nurses to work in the best interests of those for whom they care, the profession has been held in the highest esteem by the community. The most recent annual Roy Morgan Images of Professions survey in Australia (2011) revealed that up to 90% of Australians aged 14 years and over rated nurses as the most ethical and honest of professions. This was the 17th consecutive year in which nurses headed this list, representing every year since nurses were included in the survey (see Box 1-1).

BOX 1-1 A MATTER OF TRUST

An opinion poll conducted by Roy Morgan Research on occupations and the percentage of Australians who gave them ratings for ‘high’ or ‘very high’ standards of ethics and honesty produced the following selected results (reported by Roy Morgan Research, 21 April 2011):

	OCCUPATION	%
Highest	Nurses	90
	Pharmacists	87
	Doctors	87
	Police	69
	Ministers of religion	51
	Bank managers	40
	Lawyers	38
	Federal and State MPs	14/12
	Real estate agents	7
Lowest	Car dealers	3

Nurses are at times active in the social policy and political arenas. Nurses and their professional organisations lobby for healthcare legislation to meet the needs of clients, particularly the medically underserved such as the aged and those with mental health illnesses. Nurses may be active in local government planning to ensure that healthcare resources are available in all communities, particularly for young families, the elderly and the mentally ill. Nurses help lead knowledge development through healthcare research, determining ‘best practices’ in relation to the care they provide, for example in areas such as skin care management and pain control.

Given that you are reading this large textbook, it is not unreasonable to imagine that one or more of these challenging aspects of care, captured in these definitions, has attracted you, and you have taken the decision to embark on a nursing career. Congratulations! This book will help you explore your future responsibilities and possibilities.

Your growing understanding of contemporary nursing is based on our rich and diverse history. Chances are that if you are reading this edition you are a nursing student in Australia, New Zealand or a near neighbour. Australia and New Zealand, while geographically close, have very different nursing histories. This history provides the links among developments in the profession, in education and in nursing roles and practices.

The history of modern nursing

The historical roots of Western nursing enable both students and practising professionals to better appreciate how we prepare for the healthcare needs of the future. Nursing is a melding of knowledge from the physical sciences, humanities, social sciences and the clinical competencies needed to meet the individual needs of clients and their families. Knowledge of the profession’s history increases nurses’ understanding of the complex social, political and intellectual origins of their discipline (Box 1-2). Although it is not feasible to describe all of the historical aspects of professional nursing, some of the more significant milestones are described below. It is acknowledged that this history is of Western or European nursing, and that other cultures have their own rich history which we encourage you to explore.

BOX 1-2 MILESTONES IN NURSING HISTORY

(All dates are CE)
300	Entry of women into nursing.
1100-1200	Formation of Hospital Brothers of St Anthony’s; formation of the Brothers of Misericordia; formation of the Alexian Brothers; founding of the original Order of St John.
1633	Sisters of Charity founded.
1811	Sydney Hospital opened and nursing was undertaken by convict men and women.
1836	Deaconess Institute of Kaiserwerth, Germany, founded.
1838	Five Irish Sisters of Charity, Australia’s first trained nurses, arrived in New South Wales.
1840	Settlement of New Zealand as a colony and the establishment of state hospitals.
1848	Opening of Yarra Bend Asylum at what was to become known as Melbourne to enable the mentally ill to be transferred from gaol.
1854	First purpose-built ‘lunatic asylum’ was opened in Wellington, New Zealand.
1860	Establishment of the Nightingale Training School for Nurses at St Thomas’s Hospital in London, England. Florence Nightingale published Notes on nursing: what it is and what it is not.
1868	Sir Henry Parkes requested Nightingale-trained nurses for New South Wales. Arrival of Lucy Osburn and four Nightingale nurses at Sydney Infirmary (to become Sydney Hospital).
1870	New Zealand had 37 hospitals as a result of the population increase of the gold rush.
1871	Nightingale-trained matron appointed to the Alfred Hospital, Melbourne.
1882	Inspector of Hospitals in New Zealand sent for Nightingale nurses from Britain.
1895-1906	Grace Neill, a nurse, appointed assistant Inspector of Hospitals in the Department of Health, Wellington.
1899	Australasian Trained Nurses Association founded in New South Wales.
1933	Australian Capital Territory nursing registration commenced.
1939-45	Australian and New Zealand nurses served outside their countries in World War II.
1949	Formation of College of Nursing Australia (now RCNA).
1952	Nursing Research, a journal reporting on the scientific investigations of nursing, was established in the United States.
1971	Carpenter Report on nursing education in New Zealand published.
1973	Christchurch and Wellington Polytechnics commenced diploma-level nursing education courses with other programs following rapidly. University post-registration bachelor’s degrees began at Massey University and Victoria University, Wellington.
1975	First nursing diploma program in Australia in a College of Advanced Education (CAE) in Melbourne, followed quickly by programs in New South Wales, South Australia and Western Australia.
1983	New South Wales announced that all nursing education in the state would be transferred to CAEs by 1985. International Council of Nurses embedded in new constitution the categories ‘first-level nurse’ (the registered nurse, RN) and ‘second-level nurse’ (the enrolled nurse, EN). Magnet Hospital research began in the United States.
1990	Last student graduated from New Zealand hospital program. All nursing education transferred to tertiary sector and at degree level in Australia.
1991	Reforms of healthcare system signalled in New Zealand in ‘Green and White Paper’, resulting in a decade of restructuring.
1992	Introduction of cultural safety into nursing curricula by Nursing Council of New Zealand (NCNZ). Degree programs began in New Zealand polytechnics following Education Amendment Act 1990 allowing polytechnics to offer degrees.
1995	Clinical training agency set up in New Zealand to fund postgraduate clinical nursing programs.
1998	Ministerial taskforce on nursing held in New Zealand.
2000	Review of undergraduate nursing education by NCNZ (first major review since Carpenter Report in 1971). International nursing shortage recognised and becomes a government priority in both New Zealand and Australia. Increase in ‘medical error’ becomes an international concern.
2002	Two national reviews, the Senate Review of Nursing and a National Review of Nursing Education, are carried out in Australia. Nurse practitioners begin to gain authorisation to practise across Australia and in New Zealand.
2003	Primary healthcare framework document released by New Zealand’s Ministry of Health.
2004-06	National nursing and nursing education taskforce in Australia.
2005	Australian Nursing Council becomes Australian Nursing and Midwifery Council.
2009	Health and Hospitals Reform Commission in Australia report released.
2010	Implementation of national system of registration and accreditation for healthcare professionals—including nurses and midwives—in Australia (Nursing and Midwifery Board of Australia for registration and Australian Nursing and Midwifery Accreditation Council for accreditation).
2010	Access to Medical Benefits Schedule and Pharmaceutical Benefits Scheme for nurse practitioners and eligible midwives in Australia.

Florence Nightingale

In 1853 Florence Nightingale went to Paris to study with the Sisters of Charity and was later appointed superintendent of the English General Hospitals in Turkey. During this period she brought about major reforms in hygiene, sanitation and nursing practice and reduced the mortality rate at the Barracks Hospital in Scutari, Turkey, from 42.7% to 2.2% in 6 months (Woodham-Smith, 1983). It was her work at Scutari that led to her becoming known as the founder of modern nursing. Florence Nightingale established the first professional nursing philosophy based on health maintenance and restoration in Notes on nursing: what it is and what it is not (Nightingale, 1860). Her views on nursing were derived from both her intense community involvement with people of all classes and a strong spiritual philosophy, developed in her adolescence and adulthood (Gill, 2004), and reflected the changing needs of society. She saw the role of nursing as having ‘charge of somebody’s health’ based on the knowledge of ‘how to put the body in such a state to be free of disease or to recover from disease’ (Nightingale, 1860). During the same year as her book was written, she developed the first organised program for training nurses, the Nightingale Training School for Nurses at St Thomas’s Hospital in London.

Nightingale was the first nurse epidemiologist and she developed some of the first known graphical representations of health-related data, which she used to describe the situations she witnessed in the British Army in her book of 1858, Notes on matters affecting the health, efficiency, and hospital administration of the British Army. Her statistical analyses connected poor sanitation with cholera and dysentery. She viewed nursing as a search for truth in finding answers to healthcare questions (Gill, 2004). Nightingale had a profound effect on both Australia and New Zealand, with the governments of both countries writing to Britain to request that Nightingale-trained nurses be sent to the colonies to improve the standards of care being provided in hospitals.

The influence of Nightingale could have been even more profound in New Zealand had it not been for an accident of timing. Governor Gray, the governor of New Zealand, wrote to Florence Nightingale asking her opinion on how he should manage the health needs of the ‘native’ population. However, by the time Nightingale replied, Governor Gray had been posted to South Africa and it was not until a century later that the letter from Nightingale was discovered. Lady Jocelyn Keith, a New Zealand Nightingale scholar, discovered the letter, in which Nightingale had suggested a radically different approach to indigenous health from the medical advice at the time. Nightingale’s suggestions were based on what we would recognise today as contemporary and sound public health principles, such as increasing the distance between beds.

Historical perspectives on Australian and New Zealand nursing

The history of nursing in Australia is inextricably linked to the country’s penal past. In the establishment of the colony at Sydney Cove, little attention was paid to the provision of care for the ill and infirm. When Sydney Hospital was opened in 1811, the majority of 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 common while on duty (McCoppin and Gardiner, 1994).

One of the first Australian lunatic asylums was opened at Tarban Creek in 1838. Untrained mental attendants staffed the institution and physical restraint was used as the primary means of control for large numbers of disturbed people. There was virtually no emphasis on treatment, but rather removal from society.

The first trained nurses arrived in Sydney in 1838; they were five Irish Sisters of Charity. The Nightingale influence began in 1868 when Lucy Osburn and her four Nightingale nurses landed. Gradually, the Nightingale principles for the care of the physically ill were adopted. Nurses were trained in practical skills such as the application of dressings, leeching and the administration of enemas. Of equal importance were the character traits of punctuality, cleanliness, sexual purity and, above all, obedience (McCoppin and Gardiner, 1994).

A large proportion of nursing work was akin to housekeeping, dominated by domestic tasks. It was, however, acknowledged that diligence and compassion were desirable characteristics in those who cared for the sick.

New Zealand, in contrast, was settled a little later by ‘free settlers’, largely Scottish in background, and in family groups, as opposed to the largely male population of convicts and gaolers in Australia.

A fundamental difference between the two countries occurred in the relationships that developed between Europeans and the indigenous populations. The cohabitation of both countries was far from peaceful. A formal treaty recognising indigenous rights eventuated only in New Zealand; there has never been such a treaty developed in Australia. The Treaty of Waitangi has been a fundamental and governing platform for indigenous and European relationships to this day. In Australia the history is more troubled, and the health status of the Aboriginal and Torres Strait Islander peoples today has its origins in the early treatment of black by white. Until relatively recently, Australia was regarded in law as terra nullius (‘the land of no one’) prior to European settlement. This legacy of poor relationships in the past may be seen as contributing to the contemporary health inequalities so vividly and politically highlighted through federal intervention in 2007 (see Chapter 2).

By the late 1800s, both countries had experienced a large population increase in response to the discovery of gold. This increased the need for hospitals, and by 1870 New Zealand had 37 hospitals. Another common development was the perceived need to develop places of asylum for ‘lunatics’, and both countries had developed lunatic asylums by the mid-1880s.

Through the latter half of the 1800s the governments of both countries saw the need to improve hospital standards, and their governments independently sent word to Britain to send Nightingale nurses to the colonies. Under the Nightingale influence, schools of nursing were established and training programs implemented. It was not long before this new style of nurse was in need of professional affiliation. Professional associations and professional journals began independently in each country within a matter of years of each other. The Australasian Trained Nurses Association was founded in 1899 in New South Wales and the first journal was published in 1903 (Russell, 1990). The New Zealand Trained Nurses Association was established in 1909, combining pre-existing local associations from Christchurch, Dunedin, Wellington, and the New Zealand journal Kai Tiaki Nursing New Zealand was begun in 1908 (Papps, 2002).

It was New Zealand which led the way in professional regulation. Under the stewardship of Grace Neill, a senior government nurse who had addressed the International Council of Women’s conference in London in 1899 on the need for the registration of nurses, New Zealand passed its Nurse’s Registration Act in 1901. Australia, now federated, still maintained state control of nursing and the states trickled along with their independent regulation of nursing, from South Australia in 1920 to the Australian Capital Territory in 1933. The New South Wales registration Bill, passed in 1924, was the culmination of over 20 years of struggle through parliament for such recognition. This differing pace of political change—affecting healthcare, nursing education and practice—remains a difference between New Zealand and Australia today.

Nursing in the United States began its association with the university sector early, with the first university-affiliated nursing program starting in 1901 and the first professor of nursing appointed in 1907—Mary Adelaide Nutting. This was significant in the early establishment of research and publication as important nursing roles. The first research journal, Nursing Research, was published in 1952 and continues today. Australia and New Zealand both suffered from the lag in linking to the education sector. They both continued to follow the British tradition of hospital-based training. In 1925 in New Zealand there was an innovative attempt to have a university nursing program at the University of Otago, but it foundered for lack of funding. In 1928 a postgraduate school was set up in Wellington, but it was for nurses already registered and was not linked to a traditional education path through master’s and doctoral work. Hospital training remained the basis of nursing education in both Australia and New Zealand until the 1970s.

In 1970 New Zealand commissioned a review of the nursing education system and the report that followed, the Carpenter Report (1971), clearly advocated the education of nurses to take place within an educational institution. However, the government decided that the appropriate place would be not the university but rather the polytechnic system. This was understandable, given the geographical accessibility of the polytechnics, but it had a consequence of keeping the education standard at a diploma level for nearly 20 years and of not encouraging higher degrees for students or even for teaching staff. A further consequence was the lack of emphasis on research and publications that would have come from a university presence. New Zealand nurses’ pre-registration programs were held at diploma level until 1992, when the Education Amendment Act 1990 enabled polytechnics to offer degrees.

In Australia during the 1960s and 1970s there were no fewer than 15 expert committee reports about nursing and nursing education. Among them the influential Truskett Report (1970) recommended that control of nursing education be transferred from the Minister for Health to the Minister for Education, but this movement of control was met with significant disagreement within the profession (Russell, 1990).

The first Australian diploma-level basic nursing course was introduced into the College of Nursing (Australia), a college of advanced education (CAE) in Melbourne in 1975, closely followed by similar courses in New South Wales, Western Australia and South Australia; by 1982 Queensland and Tasmania also had tertiary nursing programs (Russell, 1990). However, hospital training continued to be the dominant mode of education until 1985, when all nursing education programs in New South Wales were moved to the CAE sector and hospital training ceased. The whole country followed not long after, and the education of registered nurses has taken place in the tertiary sector across Australia since 1990.

A significant difference in nursing education between Australia and New Zealand has been the location of nursing education. In Australia, the university base has meant that nurses have access to the full range of tertiary programs—graduate certificates, graduate diplomas, masters, and doctoral programs—both the doctor of philosophy (PhD) and more recently the professional doctorate or doctor of nursing (DNurs). In New Zealand, Massey University was the only venue for obtaining university-based postgraduate degrees in nursing until 1994, when a second program was opened at Victoria University. Once two programs existed and entrance criteria were made less restrictive, there was a huge increase in the number of nurses stepping forward for further study. Recently, polytechnics and other universities have started postgraduate nursing education in New Zealand.

One further distinction between the two countries has been the emphasis in nursing on culture. 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 the emphasis has been reversed. New Zealand sees itself first as a bicultural country, with many different cultures in the non-indigenous population. The specific concern for the Māri population’s interaction with healthcare led to the development of the concept of cultural safety, which was introduced into nursing curricula in 1992. The definition of the Nursing Council of New Zealand (NCNZ, 1992:1) at the time was:

The effective nursing of a person/family from another culture by a nurse who has undertaken a process of reflection on our cultural identity and recognises the impact of the nurses’ culture on our nursing practice.

The Florence Nightingale pledge often used in both countries at graduation ceremonies included the words ‘regardless of colour or creed’. Papps (2002:96) suggests ‘cultural safety requires that nurses provide care regardful of those things which make people unique’. The NCNZ published a comprehensive guideline on cultural safety in nursing education and practice in 2005. These were amended and updated in 2011 and are available on NCNZ’s website (www.nursingcouncil.org.nz). The debates between cultural safety and the more multicultural focus of transcultural nursing are taken up in Chapter 17 of this textbook.

The 1990s brought turmoil to healthcare systems internationally, with resulting changes to nursing work role, workload and control over work. These changes are discussed in more detail later, but the outcomes for nurses, despite the differences in political approach, have led to some opportunities for change. Both Australia and New Zealand have introduced nurse practitioner (NP) roles where nurses, duly authorised, have the authority to prescribe medications, order diagnostic and pathology tests, and refer clients to other healthcare professionals as required. This is an essential final step in the clinical nursing career path, and means that career paths for nurses are available in management, education and clinical practice.

• CRITICAL THINKING

Florence Nightingale was a most extraordinary nurse, focused on public health as much as personal healthcare. Discuss in a small group the similarities and differences between Nightingale thinking and the return to a primary healthcare agenda of the current Western healthcare systems.

Social, economic and political influences on nursing

There are many external forces that affect nursing. These include demographic changes such as the ageing of the population; consumer expectations, which have been greatly enhanced both by social forces and by internet access to information which was once privileged only to professionals; the increasing gap between rich and poor in our communities and the consequences of this for access to services, particularly healthcare services but also other services which affect health such as employment, housing and child care; and the explosion in the cost of medical equipment and pharmaceuticals (Palmer and Short, 2010).

Health reforms

During the 1990s the Western world experienced a sweeping new political philosophy of new public-sector management. This was not specifically directed at healthcare, but since healthcare is such a large component of government budgets, it was inevitable that it would be affected. The major thrust of these health reforms was to limit the government’s role in the provision of services that had been public services and to have these facilities run at arm’s length from government as businesses. Managers were taken from private business and employed to run services such as hospitals. This happened across the United States, the United Kingdom, New Zealand and parts of Australia, most notably Victoria. (The effect of these reforms on New Zealand healthcare is detailed in Gauld, 2001.) As nursing was the largest single budget item, it was seen as the most obvious first target for budget cuts. Perhaps the most accessible paper on the outcomes of the reforms of the 1990s for nursing is Claire Fagin’s (2001) paper ‘When care becomes a burden’. In this paper Fagin describes the changes in three areas:

• the nature of hospitalisation

• hospital reorganisation

• the lack of accepted expectations about caregiving.

The changes in the nature of hospitalisation, Fagin (2001) suggests, involve a marked decrease in the length of stay of patients and therefore, as everyone in hospital is acutely ill, an increase in what is known as patient acuity (i.e. the level of nursing care required or ‘dependency level’), plus a marked increase in day surgery and in patients admitted on the day of surgery as opposed to the practice of bringing patients in for tests and preparation prior to surgery. The outcome of this for nurses is that patients are sicker, turned around more quickly and are rarely in hospital during stages of recuperation. There is, therefore, less time for nurses to get to know their patients and little opportunity to witness their recovery—sources of joy for nurses in the past.

The reorganisation of hospitals has resulted in increased numbers of managers of hospitals without a healthcare professional background and, consequently, little understanding at senior levels of the nature of nursing and its value to the ‘business’ of the hospital. Many senior nurses were let go in favour of ‘cheaper’, more-junior staff and many directors of nursing were restructured out of a job.

In relation to caregiver expectations, Fagin emphasises the importance of the need for the public to understand these changes to hospitals and hospitalisation, and not to feel disappointed in nurses for not providing the hospital experience of their previous encounters.

Nursing shortage

The above has painted quite a bleak picture, and one that you might find disturbing as you embark on a nursing career. But do not despair; you are joining the profession at the end of a dark period and the beginning of a period of new light and opportunity.

There is now research evidence that the single most important element in the prevention of adverse events happening to people in hospital is the level of experience and education of the nursing staff (Aiken, 2002). A world shortage of nurses and an increase in the incidence of ‘medical error’ or something going wrong for a patient in hospital have made politicians and health service managers appreciate the necessity of the input of registered nurses. There is a growing emphasis on recruitment and retention of nurses. Emphasis has been placed on the working environment of nurses and the need for a healthy workplace for nurses (Baumann and others, 2001). For instance, in 2007 the theme for ICN’s International Nurses Day was ‘Positive Practice Environments: Quality Workplaces + Quality Patient Care’ and the toolkit provided by ICN contained an up-to-date summary of the important research that has underpinned these claims (see www.icn.ch).

In New Zealand in 1998, the Minister of Health set up a ministerial taskforce on nursing which looked at ‘expanding the scope of nursing, accessing funding, education research, leadership and workforce issues’ (Ministry of Health, 1998:998). This was followed by a review undertaken by the NCNZ that looked predominantly at education. In Australia, the groundswell of public concern about nursing led to the setting up of two national reviews at almost the same time—the Senate Review of Nursing which released its report The patient profession: time for action in June 2002 (Senate Community Affairs Committee, 2002), and the National review of nursing education, a joint review undertaken for the Department of Health and Ageing and the Department of Education, Science and Training, the report of which was published in August 2002 and which resulted in the formation of a taskforce to implement the recommendations. The National Nursing and Nursing Education Taskforce (called N3ET) completed their work in late 2006; the outcomes are accessible online at www.nnnet.gov.au.

The reviews in both countries indicated a significant level of concern for and commitment to issues of nursing recruitment and retention and the need to improve the culture of the workplace, and both countries unequivocally endorsed the bachelor degree as the appropriate minimum education for entry to practice. In both countries there have been new workforce authorities set up to attempt to ensure an adequate health workforce for the future. In both countries the greatest need going into the future is for nurses, particularly registered nurses. The websites of Health Workforce New Zealand (www.healthworkforce.govt.nz) and Health Workforce Australia (www.hwa.gov.au) will keep you up to date with the research and project work they are undertaking to assist the meeting of workforce needs.

You will help shape a new generation of nursing. Both Australia and New Zealand have healthcare needs that are not currently being met, particularly those of the chronically ill, the mentally ill, the poor and those in rural and remote areas. The New Zealand Ministry of Health released a document in 2003 outlining the fundamental place of nursing in meeting these needs. Investing in health: a framework for activating primary health care nursing in New Zealand (Ministry of Health, 2003, updated 2007) proved to be a nurse-led document and blueprint ahead of its time. There has since been an international resurgence of interest in primary healthcare. In 2008 the World Health Organization’s annual World Health Report was called Primary health care (now more than ever). It called for all governments to invest in primary healthcare and to integrate healthcare systems and services to a more community-based approach rather than a focus on tertiary hospital care. Primary healthcare and the growing use of nurses in the community are equally important to Australia’s healthcare future. In the latest reforms in Australia, NPs have gained access to the Medical Benefits Schedule (MBS) and the Pharmaceutical Benefits Scheme (PBS; reimbursement from the government for seeing patients and subsidised medications). This opens the door for many new models of nurse-led service delivery. This is the time for optimism, and you will be part of the new generation of healthcare professionals with a much stronger focus on care in the community as well as healthcare institutions.

RESEARCH HIGHLIGHT

Research focus

This important research project explored variability in the working environment across nursing units (or wards) in New South Wales.

Research abstract

The key finding in this research was that there was no such thing as a ‘typical’ unit or ward. It was found that patient acuity had risen and the diversity of patient conditions on any ward had increased substantially within medical–surgical units over the five years to 2005. The fast turnover of patients and the movement of patients from ward to ward as beds became available increased the nursing workload; this was called ‘churn’. The skill-mix, i.e. the proportion of registered nurses (RNs) to enrolled nurses or assistants in nursing (AINs), was very important to the quality of patient care. The research confirmed the work from Magnet hospitals that within this research work environment, elements such as nurses’ autonomy, control over their practice and good leadership were important for both the nurses’ satisfaction and safe patient care. It was also found that stability in the ward staffing improved patient outcomes.

Overall, more than 80% of nurses reported that they thought the quality of nursing care received by patients was excellent or good.

Evidence-based practice

• Patient movements between wards and shortened length of stay produces extra workloads for staff (‘churn’).

• Patients in principal referral hospitals are sicker than previously—higher acuity—thus increasing nursing workload.

• There is a greater number of nursing staff other than RNs which has changed the skill-mix. Too great a dilution of the number of RNs has a deleterious effect on patient outcomes.

• The higher the proportion of RNs, the lower the rates of decubitus ulcers, pneumonia and sepsis. Patients were less likely to fall with increased number of RN hours.

• Adequate staffing, control over work environment and good leadership increases job satisfaction for nurses.

• Adequate RN staffing improves patient outcomes.

Reference

Duffield C, Roche M, O’Brien-Pallas L, et al. Glueing it together: nurses, their work environment and patient safety. Sydney: NSW Health, 2007.

Evidence-based practice and nursing research

A further response to social change is that the informed consumer is seeking an evidence base to the healthcare practices in which they take part. Nursing practice is dynamic and always changing because of new information originating from research, practice trends, technological development, and social issues affecting clients. One way to meet these consumer expectations is to provide evidence-based nursing practice. Evidence-based practice is defined as ‘the integration of best research evidence with clinical expertise and patient values’ (Sackett and others, 2000). Evidence-based nursing practice involves accurate and thoughtful decision making about healthcare delivery for clients (see Chapter 4). Nursing has contributed significantly to this development, particularly through the establishment of the Joanna Briggs Institute, set up originally by nurses at the University of Adelaide and now an international community of researchers in all healthcare disciplines that explores the appraisal and synthesis of evidence and its translation, transfer and utilisation in practice (www.joannabriggs.edu.au).

Nursing knowledge and research findings have expanded rapidly over the last few years. The scientific knowledge base for professional practice is developed through scholarly inquiry of nursing and biomedical research literature, use of research findings, and the actual conduct of research (see Chapter 4). Through nursing research, nurses base their care on scientific findings rather than only on tradition. The beneficiary of this care is the client. Through research, nursing practice changes to provide the highest, state-of-the-art quality nursing care.

Nursing as professional practice

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 we say a person acts ‘professionally’, for example, we imply that the person is conscientious in actions, knowledgeable in the subject and responsible to self and others. Professions possess the following main characteristics:

• A profession requires an extended education of its members, as well as a basic liberal foundation.

• A profession has a theoretical body of knowledge leading to defined skills, abilities and norms.

• A profession provides a specific service.

• Members of a profession have autonomy in decision making and practice.

• The profession as a whole has a code of ethics for practice.

Science and art of nursing practice

Nursing is a multidimensional profession. It reflects the needs and values of society, implements the standards of professional performance and care, meets the needs of each client and integrates current research and evidence-based findings to provide the highest level of care. Although nursing has a specific body of knowledge, socialisation into the profession and practice are essential components of education in the discipline. Clinical expertise takes time and commitment. According to Benner (1984), an expert nurse passes through five levels of skill acquisition when learning and developing generalist or specialised nursing skills (Box 1-3). Benner’s work enables the nurse to see a path for development. This path is mapped in detail in Benner’s 1984 book. Even though published quite some time ago, it remains a seminal text for nurses’ understanding of the movement towards expertise in practice.

BOX 1-3 FROM NOVICE TO EXPERT

Novice—beginning nursing student, or any nurse entering a situation in which there is no previous level of experience. The learner learns via a specific set of rules or procedures, which are usually stepwise and linear.

Advanced beginner—a nurse who has had some level of experience. This experience may be only observational in nature, but the nurse is able to identify meaningful aspects or principles of care.

Competent—a nurse who has been in the same job for 2–3 years. This nurse understands the organisation and the specific care required for clients. This nurse is a competent practitioner who is able to anticipate nursing care and establish long-range goals. In this phase, the nurse has usually had experience with all types of psychomotor skills required by this specific group of clients.

Proficient—A nurse with more than 2–3 years of experience in the same job. This nurse perceives the situation as a whole, is able to assess the entire situation and can readily transfer knowledge gained from multiple previous experiences. This nurse focuses on managing care as opposed to managing and performing skills.

Expert—a nurse with diverse experience who has an intuitive grasp of the problem or potential problems. This nurse is able to zero in on the problem and focus on multiple dimensions of the situation. This nurse is skilled at identifying client-centred problems, as well as problems related to the healthcare system or perhaps the needs of the novice nurse.

From Benner P 1984 From novice to expert: excellence and power in clinical nursing practice. Menlo Park, CA, Addison-Wesley.

Nurses use the competencies of critical thinking to integrate information from the scientific and nursing knowledge bases, derive knowledge from past and present experiences, apply critical thinking attitudes to a clinical situation and implement intellectual and professional standards (see Chapter 4). Providing well-thought-out care with the compassion and caring attributes of the profession enables the nurse to provide each client with the best of the science and art of nursing care (see Chapter 6). The exercise of clinical judgment is fundamental to professional nursing practice and brings together what is best for this person, in this place, at this time, and given the available resources (White, 2012).

Professional responsibilities and roles

Contemporary nursing requires the nurse to possess knowledge and skills for a variety of professional roles and responsibilities. In the past, the main role of nurses was to provide care and comfort as they carried out specific nursing functions. However, changes in nursing have expanded the role to include increased emphasis on health promotion and illness prevention, as well as concern for the person as a whole, particularly where there is a chronic or complex condition.

Caregiver

As caregiver, the nurse helps the client regain health through the healing process. Healing is more than just caring for a specific disease, although treatment skills that promote physical healing are important to caregivers. The nurse meets the holistic healthcare needs of the person, including measures to restore emotional, spiritual and social wellbeing. The caregiver helps the client and family set goals and meet those goals with minimal cost of time and energy.

Teacher

As a teacher or patient educator, the nurse explains to the client concepts and facts about health, demonstrates procedures such as self-care activities, determines that the client fully understands, reinforces learning or behaviour and evaluates the client’s progress in learning. Some teaching can be unplanned and informal, such as when a nurse responds to a question about health issues in casual conversation. Other teaching activities may be planned and more formal, such as when the nurse teaches a person with diabetes to self-administer insulin injections. The nurse uses teaching methods that match the person’s capabilities and needs and incorporates other resources, such as the family, in teaching plans (see Chapter 13).

Communicator

The role of communicator is central to all nursing roles and activities. Nursing involves communication with clients and families, other nurses and healthcare professionals, resource people and the community. Without clear communication, it is impossible to give care effectively, make decisions with clients and families, protect people from threats to their wellbeing, coordinate and manage care, assist in rehabilitation, offer comfort and teach. The quality of communication is a critical factor in meeting the needs of individuals, families and communities (see Chapter 12).

Manager

As a manager, the nurse coordinates the activities of other members of the healthcare team, such as dietitian, physiotherapist or occupational therapist, when managing clients’ care. To effectively manage a single client or a group of clients, the nurse implements skilled clinical judgment. As a clinical decision maker, the nurse uses critical thinking skills throughout the nursing process to provide effective care. Before undertaking any nursing action, whether it is assessing the person’s condition, giving care or evaluating the results of care, the nurse plans the action by deciding the best approach for each person and family. In each of these situations, the nurse collaborates and consults with other healthcare professionals (White, 2011; World Health Organization, 2010).

Autonomy and accountability

Autonomy is an essential element in professional nursing. Autonomy means that a person is reasonably independent and self-governing in decision making and practice. Nurses attain increased autonomy through higher levels of education. Through clinical competence and diverse practice settings, nurses are increasingly taking on independent roles in nurse-run clinics, collaborative practice and advanced nurse practice settings.

With increased autonomy come greater responsibilities and accountability. Accountability means that the nurse is responsible, professionally and legally, for the type and quality of nursing care provided. The nurse is accountable for keeping abreast of technical skills and knowledge needed to perform nursing care. The nursing profession itself regulates accountability through nursing audits and standards of practice. Whatever the nurse-designated work role, there are elements of the multitude of roles that constitute nursing.

Nursing competencies and standards

In order to ensure that nurses continue to practise at a high standard that ensures the safety of the public, competency standards have been developed. In Australia, the Nursing and Midwifery Board of Australia (NMBA) has approved the Australian Nursing and Midwifery Council (ANMC) National Competency Standards for the Registered Nurse and National Competency Standards for the Enrolled Nurse (sometimes referred to as simply the National Competency Standards) (www.nursingandmidwiferyboard.gov.au). The Nursing Council of New Zealand (NCNZ) has developed new competencies for registered nurses, nurse assistants and enrolled nurses (www.nznc.org.nz). The aim of these competencies is similar in both countries. In Australia, for example, these are to:

• provide a means of communicating to consumers the expected competency standards of nurses

• determine the eligibility for initial registration or enrolment of persons who have undertaken nursing courses in Australia

• determine the eligibility of nurses who have undertaken nursing courses outside Australia and who wish to practise in that country

• provide the basis for assessing nurses who wish to re-enter the workforce after a period of absence defined by the registering authority

• assess qualified nurses who are required to show that they can demonstrate the minimum level of competence for continuing practice.

Standards of nursing practice serve as objective guidelines for nurses to provide care and as a means of evaluating care. Standards of nursing practice are developed and established based on strong scientific research and the opinions of clinical experts. They provide a way of assuring clients that they are receiving high-quality care, ensuring that nurses know what is necessary to provide nursing care and that measures are in place to determine whether care meets specific standards.

In Australia, only educational institutions which have duly accredited nursing programs, accredited with the Australian Nursing and Midwifery Accreditation Council (ANMAC), can recommend students for registration and then only if the student has demonstrated the required competencies. Following registration, it becomes the responsibility of the individual nurse to ensure that this level of competency is maintained and further developed through mandatory continuing education.

The standards and competencies can be accessed via the internet. The websites for the ANMAC, NMBA (previously ANMC) and NCNZ contain a wealth of relevant information for nurses and for the public. The websites also contain the codes of conduct and the codes of ethics. The Code of professional conduct for nurses (ANMC, 2008) is a set of expectations of nursing conduct identifying minimum requirements for all nurses in the profession. It is written not only to nurses but also to facilitate public trust and confidence. The purpose of the Code of ethics for nurses in Australia is to ‘identify the fundamental moral commitments of the profession, provide nurses with a basis for professional and self-reflection on ethical conduct, act as a guide to ethical practice and indicate to the community the moral values which nurses can be expected to hold’ (ANMC, 2005). The ANMAC, NMBA and NCNZ websites also hold links to all professional nursing organisations, Australian state and territory registration boards and many other organisations of relevance to nurses.

Both countries require continuing education for continuing competency to ensure nurses understand and keep up with changes in practice trends for the safety of the public. These requirements are also given on the websites.

Career development

Innovations in healthcare, expanding healthcare systems and practice settings, and the increasing needs of clients have been a stimulus for new nursing roles. Today, nurses need to commit to lifelong learning and career development in order to provide clients with the state-of-the-art care they need.

Career roles are specific employment positions or paths. Because of increasing educational opportunities for nurses, the growth of nursing as a profession and a greater concern for job enrichment, the nursing profession offers expanded roles and different kinds of career opportunities. Examples of career roles include clinicians/advanced practice nurses/nurse practitioners, nurse managers/administrators, educators/academics, nurse researchers and quality-improvement nurses. The specific healthcare professional work roles are explored in Chapter 2.

Clinician/registered nurse

Most nurses enter the profession with the goal of providing direct care. Nurses providing direct client care account for the majority of practising nurses. Until recently, this has been largely in the acute care hospital setting. As healthcare returns to the home care setting, there are increased opportunities for nurses to provide direct care in the person’s home or in community facilities. The clinical nurse provides direct care, using the nursing process and critical thinking skills. The focus is restorative, curative or ameliorating symptoms in chronic disease. The clinical nurse provides education to the client and family to promote health maintenance and self-care. In collaboration with other healthcare team members, the clinician focuses on returning the person to their home and to a functioning state of health.

Nurses may choose to practise in a community care setting, a medical–surgical setting or concentrate on a specific area of practice, such as critical care or emergency care. Most hospital-based specialty care areas require some experience as a medical–surgical nurse and additional continuing or in-service education. Many intensive care unit (ICU) and emergency department nurses are required to have training in advanced cardiac life support and certification in critical care, emergency nursing or trauma nursing. Hospital-based nurses may also choose to practise in specialty areas such as transplantation, rehabilitation or oncology.

Clinical nurse specialist/consultant

The clinical nurse specialist (CNS) or clinical nurse consultant (CNC) is a clinician (titles vary across states and countries) with nursing expertise in a specialised area of practice who may work in any practice setting. Traditionally, the CNS/CNC has practised most often in the hospital setting. The CNS/CNC may specialise in a specific disease, such as diabetes mellitus, cancer or cardiac problems, or in a specific field, such as paediatrics or gerontology. The CNS/CNC functions as an expert clinician, educator, case manager, consultant and researcher to plan or improve the quality of care provided to the client and family.

Nurse practitioner

The NP provides healthcare to clients in a hospital, outpatient clinic, day-surgery (also called ‘same-day surgery’ and ‘ambulatory care’) or community-based setting. Nurse practitioners provide care for clients with complex problems and provide a more holistic approach, attending to symptoms of non-pathological conditions, comfort and comprehensive care. A significant percentage of primary care encounters extend beyond the boundaries of medicine and demand the expertise of the nurse. An NP may work with a specific group of clients or with clients of all ages and healthcare needs. An NP has the knowledge and skills necessary to detect and manage self-limiting acute and chronic stable conditions. The NP’s educational preparation includes a master’s degree in nursing or a specifically identified alternative pathway for expert clinicians. Authorisation in Australia is required through the NMBA. Recently, in Australia, NPs were given access to the MBS and PBS, as mentioned above. This expands the possibilities of practice enormously.

Nurse educator/nurse academic

The nurse educator works mainly in staff development departments of healthcare agencies, and client education departments. Nursing educators generally have a background in clinical nursing, which provides them with practical skills and theoretical knowledge. A faculty member in a faculty or school of nursing—an academic—prepares students to function as nurses or teach advanced nursing practice or research. Nursing faculty members are responsible for teaching current nursing practice theory and the skills necessary in laboratories and clinical settings. Many hold a doctorate or advanced degree(s) in nursing, education or administration, such as a master’s degree in business administration (MBA). Generally, they have a specific clinical, administrative or research specialty and advanced clinical experience.

Nurse educators in staff development departments of healthcare institutions provide educational programs for nurses within their institution. These programs include orientation of new personnel, critical care nursing courses, assisting with clinical skill competency, quality and safety education, and instruction about new equipment or procedures.

The main focus of the nurse educator in an agency’s department of client education is to teach ill or disabled clients and their families how to provide care in the home. These nurse educators may be specialised, such as the diabetic educator or an ostomy care nurse, and see only a certain population of clients.

Nursing administrator/nurse manager

A nurse administrator or nurse manager manages client care and the delivery of specific nursing services within a healthcare agency. Nursing administration begins with positions such as nurse manager. Experience and additional education may lead to a middle management position, such as nurse manager of a specific client care area or areas, or to an upper management position such as director of nursing services.

Nurse manager positions usually require postgraduate qualifications, often with specialisation in management, at least at the graduate diploma level; nursing directors and nurse executives normally have higher degrees in nursing or a related field. Although nurse managers may have advanced degrees such as an MBA or master’s degree in public health (MPH), nurse executive positions in large healthcare organisations increasingly require qualifications at the doctoral level.

In today’s healthcare organisations, directors may have responsibility for more than nursing personnel. Responsibilities may include a particular service or product line, such as medicine or cardiology, and include supportive functions and personnel such as medicine clinics, and cardiac, diagnostic or outpatient services such as cardiology technicians, respiratory therapists, social workers and dietitians.

Directors of nursing (or equivalent) often have responsibilities for all clinical functions within the hospital. This may include all ancillary personnel who provide and support client care services. The nursing administrator needs to be skilled in business and management, as well as understand all aspects of nursing and client care. Functions of administrators include budgeting, staffing, planning of programs and services, employee evaluation and employee development.

Nurse researcher

The nurse researcher investigates nursing or patient problems with the aim of improving nursing care and to further define and expand the scope of nursing practice (see Chapter 4). The nurse researcher may be employed in an academic setting, a hospital or a community service agency. Preparation for a career in research involves a combination of both coursework and research degrees at the graduate level. Research degrees involve independent research under the guidance of an academic supervisor and may be undertaken at the undergraduate (honours programs), master’s and doctoral levels.

Clinical professor of nursing

The relatively new role of clinical professor of nursing is vital for bringing together the best of the education sector with the best of the healthcare sector. These professors may be jointly appointed between the health and the university sectors, or hold full-time university appointments. However, the major focus of their working with senior clinical nurses is to establish the research base for practice and to support practice development.