The Scope of Nursing in Australia: A Snapshot of the Challenges and Skills Needed
5.35 Registered Nurse - Health Promotion
As manager of health promotion for a large private acute hospital, Bridget, a registered nurse working in Queensland, has an educative role and is responsible for all the community education at the hospital.
Bridget's hours and the type of work she will do on any given day varies. She co-ordinates all patient information and runs information seminars and programs as well as creating informative material for patients that may be written, web or television based or found in the consumer focus library. She sees patients on a one to one basis, assisting them with gathering relevant health information that relates to them.
To work in health promotion, Bridget needs a wide range of skills including a sound knowledge of health promotion, theory and practice. She needs strong organisational, management, assessment and information technology skills. The number one skill identified by Bridget is to be a good communicator and communicate with a range of people in a clear, professional but also empathetic manner.
Models for Working with Others
Bridget identifies herself as playing an integral part within the hospital's staff environment. She sees herself as having a collaborative role, working in tandem with nursing staff from the wards, as well as doctors, specialists, pharmacists and other members of the allied health profession and community.
Bridget lists three main groups of people that she interacts with in her area of work. They are: hospital staff, in particular with the Clinical Nurse Consultants; patients, who she will often have one on one communication about their individual health issues; and the general community, who may be situated anywhere in Australia who give and receive information.
Skills
- Highly tuned communication skills
- Technological skills - accessing and using internet
- Developing, running and evaluating education programs
- Knowledge of consumer information and health promotion practice
- Training and education skills
- Writing patient information
- Creating budgets
- Being aware of consumer participation
- Management skills
- Negotiation and network skills
- Assessment of patients and needs
Challenges
- Marketing
- Time management
Education
Bridget expressed a number of areas such as computer skills, communication skills and time management as important and integral parts of the nursing curriculum.
The clinical, hands on component of nursing education was viewed as very important to Bridget. She also believed that the increase in community nursing and care in the home will require nurses to be more adaptable and highly skilled at assessment.
Bridget considers the University training of nurses as beneficial because:
they get a lot of the theoretical stuff...umm...... with nursing....and it's in my role too you learn by experience, you know, things happen, things go wrong, and that's how you learn... it's when you're out there..... umm..... yeah you give 'em the basic umm.... the basic concepts and then it's ...it's up to them ... (2:20:523).
6. Thematic Analysis
Analysis of the 38 transcribed in-depth interviews framed by attention to the experiences and concerns as provided by the participants themselves across a range of practice areas and geographical contexts clearly shows that registered and enrolled nurses face many challenges in the course of their daily work. Almost always such challenges are contextually driven linked to the politics and people of the place but find common ground across practice areas. Some of the challenges, skills needed and models of working with others are explored through identified grouped themes or issues in the section that follows. Each major theme or issue is not discrete, rather many overlap and interlink and need to be read as connected parts of a whole. They are presented in no particular order.
There's no such thing as a typical day
Participants in this study overwhelmingly advised that there really is no such thing as a typical day. Regardless of practice setting, even in day surgery for example where routines are the norm, nurses are called upon to be flexible and adaptable, to expect the unexpected and deal with the ever changing environment, people and politics. Nurses practice nursing wherever and whenever individuals might need care. Although located in an acute setting many nurses traverse not only ward or unit boundaries but hospital walls and interdisciplinary territories to practice nursing in the course of their daily work. Working with the community is a common feature where some see patients in their own homes others are seen 'out on the street'. The focus of their care is to facilitate people living their lives through prevention of illness and injury, health promotion and lifestyle, through community adaptation, illness and disease to living with dying. Nurses work with many people, face a myriad of challenges and need a contemporary complement of skills for practice.
6.1 Skills
Assessment is the key
Having strong theoretical and clinical assessment skills are an essential component of nursing work. However, assessment for the nurses in this study relies on the tools of observation, questioning, vigilance and monitoring. Nurses talked of the need to anticipate events, to be able to prevent a problem occurring and to be able to watch over people and circumstances. For example, one participant said:
I watch them very closely, I watch how they move around the ward, I listen to what they say, I watch their eye movement, their body movements...get an overall picture of a person ...getting as much information as I can, where he comes from, what he's done to be brought into hospital, is he violent, and so on and so on. And then eyeball the person and then put it all together. Complete the picture sort of thing. And then be aware of potential problems, you can identify any potential problems just information you get and what you see and what you hear" (38:13:316-24).
Having a proximity to patients or to the 'grass roots' of practice facilitates the ability of the nurse to make an assessment in context. Nurses also referred to knowing the person, knowing the networks, knowing the context and being able to pull everything together-like being a detective. This involves spending time with people, spending time in the environment. Lawler (1991) speaks of 'dependent knowledge', that is nurses say it depends on the context, it depends on what is going on, it depends on the person. Nurses in this study advise they use assessment as a lynch pin for their practice but that assessment knowledge is 'contextually dependent knowledge' that comes with experience facilitated by theory and is not necessarily assessment of the physical body.
Having a passion for people and being self aware
Many nurses spoke of having a passion or great love of people. Without this affinity of working alongside or providing assistance to people nurses can be seen to be ineffective, distant and cold, where going to work may become a chore. Part of the requirement for enjoying being with people, liking people is having 'life skills'. Some nurses indicated that maturity brings a depth of understanding people but age is not the indicator, rather it requires having life experiences on which to draw. In a climate of crisis, seemingly the norm for many nurses in this study, the ability to keep life in perspective, the person in context, is a core skill. Having breadth to life experience and nursing in general are seen to provide a more stable basis from which to practice. Interwoven with such breadth is the need to be self aware. The skill of being self aware allowed these nurses to monitor themselves, their capacity to cope, their motivation for practice and directions to take in their nursing career.
Communication-the basic skill
...I would say number one ... skill, you need in this job is ... to be a good communicator, to actually be able to get on with people and to communicate in a very clear, professional way, but with a lot of empathy...(2:13:326).
Every nurse spoke of the very foundational skill required of nursing, that of communication. One nurse suggested communication is not really a nursing skill yet all nurses relied upon their ability to communicate effectively. Often communication is a word that is loosely used, its definition is assumed and yet when communication skills fail nurses find many more challenges ahead. Communication skills permeate every interaction, every assessment, every intervention. Specifically nurses referred to being able to read people and situations, to be able to pick up non verbal cues and behaviour, to effectively network and traverse boundaries, to work in an interdisciplinary manner, to provide education and share information, to give direction all require diplomacy, tact, assertiveness and PR skills. Listening and talking were skills that nurses valued and found to be important regardless of the area in which they practice or their status as registered or enrolled.
The nursing workplace is fast paced and time to talk is a rare commodity. Written communication either email as a tool or documentation of nursing care provides a means by which nurses and others they interact with can stay in contact, stay in touch with practice and the person requiring their help whether it be a graduate nurse, a co-worker, a member of the health team, the patient or their family.
Lifelong learning
Almost as a given nurses spoke of 'basic nursing skills and then...' as an indication that some core knowledge of activities of daily living (ADLs), observations, and first aid were merely in the background, a part of the scenery. Each specialism had its required knowledge eg mental health, paediatrics, trauma management but these were part of not necessarily the focus of nursing work in the area. Nurses in the study referred to the need to keep up to date with new technologies, with new drugs, new techniques, new procedures and equipment. The skills required of nurses includes the use of the aforementioned 'technologies' but more importantly is the skill of problem solving, lateral thinking and clinical judgement which is underpinned by a quest for knowledge and skills to question, search for, locate and use such knowledge.
A great strength for nurses, it is suggested, is the capacity to recognise and acknowledge the unknown, to seek advise, to consider alternatives and thereby improve practice as well as improving individual nursing skills. Experienced nurses rely on the years spent in nursing practice, across a variety of settings both within and without hospital boundaries. Nurses in today's practice arenas are constantly faced with limited human and material resources. The skill such nurses benefit from is the ability to consider new ways of doing things, new or alternative ways of approaching people and their circumstances.
Hand in hand with this need for more flexible practice is the development of new initiatives such as the nurse practitioner and Advanced Skills Enrolled Nurse. Of great interest was the need for community knowledge, the sense that nurses need to function within the community with acute skills and with community and 'social work' skills in acute settings. Nurses advised that more and more of their focus involves interfaces of care, multiple networks with which they liaise and a greater emphasis on health promotion, healthy lifestyle and disease or injury prevention to facilitate living and health often among an ageing population with increasing chronic disease. Death and grief however, still colour nursing work where not all nurses are well equipped for this dimension of practice. The shape of nursing, based on the insights from participants, is changing from a hospital based model to needing one of greater seamlessness and collaboration. To illustrate the ways in which nursing is applied in today's environment, one participant stated:
I still call myself a nurse and an exercise physiologist and I use those two - I devise health promotion programs for people largely who have a pre-existing health condition. Because of my nursing background and my fitness physiology background, those health promotion programs involve lifestyle changes, diet, of course exercise and emotional health and workloads and sleep (16:4:111-116).
Management and Leadership
You have to have management skills...you've got to know about project planning, you've gotta know about quality improvement, you've gotta know about budgeting, you've gotta know about employee human resource management, staff training, those are all really important elements...I'm trying to organise the police to come and do safety awareness for our nurses, now that's not particularly my role, because I'm community .. but because you know, the assaults and everything on nurses, I'm actually liaising with the local police to come and run some... (2:12:306).
Both registered nurses and enrolled nurses across the study required management and some degree of leadership skills. The current health care environment is complex with management tools, financial systems and human resource allocation part of most everyday practice for nurses. Nurses are leaders of teams within given settings for example, enrolled nurses are seen to lead teams of AINs or PCAs in aged care settings, they manage stock and finances linked to a general practice or theatre and are required to manage not only their time but to maintain efficiency with the system. Both registered and enrolled nurses expressed the need to have good time management skills in order to progress through the requirements of any one day and to meet the needs of those in their care or those to whom they provide a service to.
6.2 Challenges
Conflict
Nurses provided insights into the turbulent nature of nursing across Australia where a health system remains under constant stress. Conflict was experienced as a significant challenge by many nurses both at an individual and interpersonal level but also at the level of conflicting philosophy and availability of resources. Nurses experienced tensions within and across their place of work involving other health professionals, doctors, patients and family members. As one nurse described:
... and sometimes it's quite difficult cause often... the family's have got a lot of conflict going on just in their own relationships and then someone's dying in the middle of it and the grief is sort of happening on top of it and sometimes it can be really difficult...you walk into [the house] and there's people sort of arguing with each other and somebody fighting over a will or something...(5:9).
At times the nurses in the study expressed concerns regarding the degree to which they function as a patient advocate and the increasing conflict that can arise form such a role. Conflict also arose between enrolled nurses and registered nurses. Tensions were evident between structures such as organisational need and the ability to carry out the required load. The burden of poor conflict resolution seems to rest with the individual with little support or action from management. The risks of conflict in the workplace have been highlighted by participants to include attrition and burnout, stress and sick leave.
Aggression and/or violence in the workplace
Of grave concern throughout the study has been the degree to which nurses have shared experiences of aggression and or violence in their practice area. Aggression can be verbal abuse from other staff, doctors, patients and/or their family members or it can be threat to harm, and at times physical assault. Many nurses expressed concerns for their personal safety and those in their care. Some workplaces within the study do not have readily available on site security or adequate systems of security. A significant challenge expressed by many nurses was the lack of support provided by management for safety and a sense of feeling ill- prepared to anticipate and manage escalating events. This is illustrated by one nurse who said:
I've had a few times when the police have brought people up that are really quite violent and they will be in the ambulance bay waiting to get in and one policeman was going to report me 'cause I wouldn't let him in, oh, they had about five police with just one guy who was just wrecking the place and I wouldn't let him in because I wanted to like get people out of the department and he was actually okay where he was but you've got to be really careful with letting someone like that in when you've got a lot of other patients within the department...so that sort of thing can be quite scary at times really. And, here we don't have chemists open after eight o'clock at night so we get a lot of people presenting for needles and they'll get really aggressive because we don't give out exchanges at the hospital (32:14:364-74).
Pace of work in the context of shrinking resources
All nurses in the study described the pace of their day as fast or too much to do with so little time. Many nurses experienced the challenge of not having enough staff to provide the care or service that they would like to, they felt they were chasing time constantly. The realities of working at this accelerated pace means risk of error and low morale. Nurses are frustrated at the lack of people, suitable equipment and resources. Carrying such a heavy workload can mean that nurses work either double shifts or work beyond their agreed shift time on a regular basis. As one manager illustrated, "I do work long hours, I tend to get here at 7 in the morning, because officially the centre opens at 9 ... I have two hours to get a lot of paperwork done" (2:6:124).
Many participants considered the expectations that organisations and employers have of nurses are too high. Consumers of health care and nursing services also have high expectations regarding what nurses can do for them in any given timeframe.
Rigid models or structures
Whilst participants described at length the need to be flexible in their practice to use problem solving and be innovative, they also told of rigid models or structures that are barriers to nursing. Examples of such barriers include the restrictions placed on nursing practice between States, the degree of restrictions to practice between settings and the incongruence between metropolitan and rural practice.
Nurses spoke of being competent and experienced with aspects of practice but because they had moved States they were not allowed to carry out such work. Remote nurses can also be restricted and placed in difficult positions regarding immediate management and monitoring of patients or communities in their care.
Of the snapshot of nursing provided by the nurses in this study, it is clear many nurses move around Australia. Rigid legal or policy structures negate development and mobility and subsequent diversity of practice. Nurses in the study often function independently in rural areas and without ready access to medical or support services. Enrolled nurses in particular express concern over the challenges of being able to administer medication in one setting but not another, even when they have been assessed as having the appropriate experience and knowledge.
Structures such as defence with civilian nurses on site or the prison service where nurses have little or no input or influence over those who employ them inhibit and stifle practice but also can create tensions between work processes for nurses. Where a medical model is applied to a practice context nurses can feel restricted for example in child health.
Being undervalued or not respected
Being a registered or an enrolled nurse continues to be a role that is undervalued by many who work not only alongside nurses and the community but also by the organisations who employ them, as illustrated by one nurse who stated:
... there is institutional abuse and professional abuse as well and from the patients there is abuse as well. Probably for me that is one of the biggest things - after 25 years it just gets you down, it gets everybody down. It's the biggest thing..staff morale (15:5:189-98).
Whether this is a perception or not, nurses feel undervalued and that their input, judgement and experience is not respected. The negative effect of this is seen in low morale for nurses, increasing turnover of staff and eventually nurses who leave nursing for a what they see as a more worthwhile job. For example, one participant said
... nursing itself is such a rewarding career but at the present time and the climate internationally as well there's just not enough of us around and I think that becomes, that's come that way because we're not valued as a professional. I think people don't see a nurse as a professional and the whole thing is we're losing our staff to go and work at Woolies and to find work elsewhere because they can earn just as much money, not as much pressure and they feel valued in their work and I don't think nurses feel valued anymore (21:31:731-40).
Nurses in the study noted that nursing is not well marketed, and at times nurses do not value their own professional worth suggesting they are 'just a nurse'. In addition, nurses can stereotype what nursing is or should be, as exemplified by a private exercise physiologist:
I still do home post natal midwifery visits, I still work in health promotion and I have absolutely no qualms about signing off my registration and saying I actively work as a nurse because I do. As far as I am concerned health promotion is a part of nursing, but you do get a lot of nurses who do say you are not working anymore because I am not doing that hands on, put a bed pan under someone (16:9:407-412).
Agency nurses felt undervalued and not respected by the nurses with whom they work leading often to a lack of continuity of care or under utilisation of skills and experience.
6.3 Working With Others
RN and EN boundaries
Enrolled nurses suggested that their practice was very similar to that of a registered nurse except for 'paperwork and medication,' although some enrolled nurses have greater input into both aspects of the registered nurse role in some settings. Of concern to enrolled nurses within the study is the apparent inconsistency almost daily in what they are allowed or expected to do. Variation in expectations and role function occurs between registered nurses on a shift and can occur between wards or units within an institution. One nurse explained that:
...sometimes it's not that easy to manage because within the system you are a junior member of staff ... as in an EN but by experience you're actually perceived as a senior member ... they'll utilise your skills as a senior member when it's necessary and when it's not necessary you're actually put down a lot as a junior member of staff and I find that very frustrating (8:18:424-9).
Links between different roles in nursing, for example the indirect supervision of enrolled nurses relies on an acceptance of competence. As this enrolled nurse describes:
You've gotta be fairly happy to work on your own, so you've gotta be fairly self confident I suppose... and also willing to acknowledge when you're out of your depth and knowing the times when I need to ring the div 1 (registered nurse) (5:5).
Many enrolled nurses do not want to become a registered nurse and value their role as it stands although more enrolled nurses would like to be able to extend their practice and be valued for example as has occurred in Western Australia with Advanced Skilled Enrolled Nurse status.
Team work, autonomy and collaboration
In this study nurses told of working with many and varied groups of health professionals and service personnel in the course of their daily work. Strengths and positive gains for consumers were felt to occur when nurses were able to collaborate with others, to be recognised as part of a team with equal input. Many nurses gave examples of flexible working structures that sees the nurse based in a number of venues with a diverse client group perhaps community based yet have acute facility input. In these examples nurses have developed ways of working positively with other health professionals and at times take on a strong leadership role. Nurses also work in teams with unregulated workers such as PCAs or AINs who provide a continuity with the patient and support for a nursing role. In community health centres, the prison setting or emergency department in rural areas nurses work with greater degrees of autonomy, although they may not be recognised for such independent practice.
Collaboration within and across settings and networks seems the most productive way for nurses to work with others. The nurse practitioner role was mentioned by some nurses as a model that offers potential for nursing practice in the future. Roles and boundaries within health care seem to be blurring and nurses, especially in this study, are maximising some possibilities to improve their practice.
Working in isolation
Some nurses practice in isolation from a team or their peers on a daily basis but remain part of a larger group which facilitates vision and direction for the service. In remote settings the physical presence of other nurses or health workers can be limited. Nurses in this study shared experiences of great satisfaction at being able to make a difference and a contribution to the health and lifestyle of not only individuals but also communities. Working in isolation demands a degree of flexibility and the development of new skills. Nurses working in prison services or in general practice surgeries also experience a sense of being isolated from other nurses. Agency nurses although flexible and multi-skilled often feel disconnected from nursing through a lack of team membership.
An alternative view of isolation is one of feeling isolated from the 'nursing norm.' For instance, one nurse stated:
I feel very isolated in what I am doing which I don't like - it would be nice to think that there was a little bit more support and to give that support from nurses - I don't know how you feel but I have always felt that because I have always wanted to do something a little bit different or a little bit by the side of that I found largely and this is certainly not everybody, nurses as a group they tend to say - well what do you want to do that for? (16:9:391-6).
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