The Scope of Nursing in Australia: A Snapshot of the Challenges and Skills Needed
1. Introduction
The study aimed at describing what nurses are doing everyday in various practice and work settings, the type of skills needed and their interactions with other health workers. As a descriptive study the intention was one of providing a snapshot of the challenges faced by nurses and skills needed in the course of their everyday work life.
From information provided by the National Nursing Education Review Secretariat, we assume that other projects invited to inform the National Review of Nursing Education are preparing literature reviews and comparative analyses and therefore these aspects do not form a major part of this brief.
The research plan was designed in a way that provides insights, which demonstrate the range of activities that contemporary nursing practice encompasses. In order to do this, we interviewed registered nurses and enrolled nurses from a variety of metropolitan, rural and remote settings throughout Australia in different nursing practice areas.
The information gained from these interviews has been displayed in two formats: short stories, or vignettes, were written about 'a day in the life of' each nurse's experience and a thematic analysis was conducted to illustrate commonalities and issues that emerged from the interviews. Such descriptive snapshots provide insights that facilitate possible challenges to assumptions that may be held about the scope of nursing work in Australia. For example predominantly acute care understandings of nursing practice.
The findings of the study form a basis from which implications for the terms of reference of the National Review of Nursing Education can be drawn.
2. Aims and Objectives
2.1 Aims
The aim of this research project was to produce rich data about different contexts of practice that nurses in Australia work in to inform and provide context for the deliberations of the Nursing Education Review Secretariat. By nurses we mean registered and enrolled nurses (registered nurse Div 2 in Victoria).
2.2 Objectives
The objectives of this project were to:
- Identify participants across the range of work settings delineated by the Australian Institute of Health and Welfare (1998) to gain insights into current understandings about the scope of nursing of registered and enrolled nurses in different areas of practice and locations in Australia;
- Negotiate access to, and collect interview data about, everyday practice, (supported where appropriate with literature based data) framed by specific questions related to the challenges, skills required and ways of working with other health workers;
- Analyse data utilising descriptive and thematic analytical techniques;
- Critically evaluate findings and re-assess current knowledge related to what nurses are doing and type of skills they use, interaction with other health workers and associated skills needed;
- Prepare a final report that details all of the above and applies a critical lens to provide a contextual anchor from which implications for the Nursing Education Review can be drawn.
3. Method
The project was a descriptive and exploratory study that consisted of three stages.
3.1 Stage One - Identify and negotiate access to participants
Participants in this project were registered or enrolled nurses who work in any of 17 key settings identified by Australian Institute of Health and Welfare, either in metropolitan or non-metropolitan contexts.
Figure 3.1 Key Settings for Participants
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Private Nursing Practice Developmental Disability Service School/Child Health Services Tertiary Education Institution Private Sector Prison Medical Service Defence Forces Remote Settings |
These settings were located in Australian Capital Territory, New South Wales, Queensland, South Australia, Tasmania, Victoria and Western Australia. Sampling in qualitative research is directed at finding information-rich cases rather than towards randomisation or generalisability (Patton 1990). Patton (1990:174) identifies that it makes strategic sense to pick the site [State or persons] that would yield the most information. Likewise, it makes strategic sense to select participants who are information rich. Thus the primary consideration in purposive sampling used in this study was 'the judgement of the researcher as to who can provide the best information to achieve the objectives of the study' (Kumar 1996:162).
The research team used a combination of strategies for purposeful selection of participants including, judgement, opportunistic, and snowball sampling (Patton 1990). That is, the selection of the participants was based on the judgement of the research team in terms of work setting, geographical location and the number or status of each nurse, registered or enrolled. Ethical approval to conduct this study was arranged with the University of South Australia's Human Research Ethics Committee. The principles of informed consent, self-determination, confidentiality of information and anonymity, protection from harm, and storage, access and disposal of files were adhered to throughout the study (examples of recruitment materials, assurances and alternative contact personnel are included in Appendix A. Following approval we interviewed 38 nurses purposefully selected across the 17 key work settings. All participants provided written consent. To display or highlight our call for volunteers we disseminated information about the study to members of:
- Council of Remote Area Nurses of Australia Inc. (CRANA);
- Royal College of Nursing Australia (RCNA);
- Australian Nurses Federation (ANF);
- Australian Association of Rural Nurses (AARN);
- Australian and New Zealand College of Mental Health Nurses (ANZMHN);
- Department of Human Services (DHS); and
- Royal District Nursing Service (RDNS).
From these organisations and through the suggestions of other organisations (for example the South Australian Divisions of General Practice), we also provided information to members of:
- National Enrolled Nurses Association (NENA);
- Blue Care Organisation;
- Enrolled Nurses Professional Association (NSW);
- New South Wales Nurses Association (NSWNA);
- Nursing Agency of Australia;
- Queensland Nursing Council;
- Queensland Nurses Union (QNU);
- Eastern Community Mental Health; and
- MINDA Incorporated.
Key senior nurses across States and Territories were approached to alert potential volunteers in remaining target areas to the study. As a result of the extensive recruitment strategy across Australia a total of volunteers to participate in the study was received. Factors that influenced the final selection of participants included geographical location, timing of receipt of participant contact information and duplication of interviews conducted. Only one person withdrew from the study.
The outcomes of stage one were:
- consent from participants to participate; and
- ongoing literature review.
3.2 Stage Two - Articulating 'A day in the life' in-depth interviews
Qualitative interviewing techniques have been successfully used in studies conducted and currently being conducted by Cheek and colleagues to explore aspects of nursing work. Face-to-face in-depth interviews were conducted to explore and describe the nature of each nurse's everyday practice. In-depth interviews are "directed towards understanding informants' perspectives of their lives, experiences or situations as expressed in their own words"(Kumar 1996). The interviews were semi-structured; that is, "a direction is given to the interview so that the content focuses on the crucial issues of the study". The framework for the semi-structured in-depth interviews was drawn from Cheek's work exploring nursing practice (Cheek 1997; Cheek et al 2000). An interview prompt was developed and can be found in Appendix B. Respondents were encouraged to talk about and describe their personal experience of the challenges they face, the skills required and models of working with other health workers they use within the context in which they practice. Of the 38 interviews conducted, 30 were held face to face to ensure rich data was generated. Members of the research team conducted face to face interviews covering the following States and Territories:
- South Australia - metropolitan and rural;
- Queensland - metropolitan and surrounding suburbs;
- ACT - metropolitan;
- Victoria - metropolitan and surrounding suburbs; and
- Western Australia - metropolitan, surrounding suburbs and rural.
The research team also took the opportunity to conduct a face-face interview with the nurse from Tasmania during a conference visit to Adelaide, South Australia.
A total of eight telephone interviews were held with nurses in New South Wales, Queensland, Western Australia and South Australia.
Figure 3.2.1 Number of Nurses in Metropolitan/Rural Settings
As illustrated in figure 3.2.1 above, the sample used for this study directly reflects the proportion of nurses working in metropolitan (69%) and rural areas (31%) in the 1999 National Nursing Labour Force Statistics (AIHW:2001).
Whilst the Northern Territory is not visibly represented through specific participant interview it should be noted that more than one participant indicated they had practiced as a nurse in the NT and drew on those experiences to inform their understandings of their practice area.
While it was the intention of the research team to interview approximately one registered nurse and one enrolled nurse from each of the 17 key areas, difficulties were experienced in recruiting enrolled nurses generally. Consequently, there were no enrolled nurse participants in the key areas of private nursing practice or development disability services. Two ENs were targeted for interview in the area of developmental disability. One was interviewed but subsequently withdrew from the study, whilst the second was unable to meet agreed telephone interview schedules. Given the project timeframe it became difficult to recruit a potential third EN in the area. No EN identified themself as working in 'private nursing practice'. To ensure adequate representation of enrolled nurses in the project, two enrolled nurses were interviewed from both the acute hospital and the private sector areas.
The outcomes of stage two of the study was 38 interviews with nurses working in the key settings.
3.3 Stage Three - Analysis
The interviews, with the consent of the participant, were audio tape-recorded and transcribed. These transcriptions and notes were carefully analysed to elicit themes, challenges experienced, skills needed and ways of working with other health workers in the context of that particular work setting. The purpose of the study was to provide rich contextual material from which to draw implications for the review. With this in mind the analysis had two discrete components.
As part one of the analysis of the transcriptions, the research team compiled individual vignettes for each of the participants interviewed. Vignettes can be defined as "a short usually descriptive literary sketch" (www.dictionary.com).
The purpose of vignettes is to provide an overall sense of the range of responses given (Spiker et al: 2000). In this study, vignettes have been used to illustrate the rich data received, as well as to provide the reader with a snapshot of 'a day in the life' of nurses in the variety of work settings that exist in Australia today. The complexity of maintaining a balance between anonymity and contextual detail cannot be over emphasised in the writing of each of the individual nurse 'portraits'.
The second part of data analysis used a process of theme analysis broad following Ekman and Segesten (1995), involved four phases:
- The entire tape was studied to give a sense of the whole;
- Themes and categories were identified;
- Recurrent patterns were identified; and
- Summative themes and research findings were developed.
To ensure validity, at least two members of the research team independently reviewed each transcript (Becker & McCabe, 1994). Reviews were exchanged and any disagreements discussed and resolved by consensus (Rudman & Verdi, 1993). Themes and issues across interviews were generated and then progressively grouped into categories of similar themes. This is in keeping with Norman et al (1992) who point out that the 'formulation of categories is done inductively by sorting the incidents into clusters that seem to group together'. The theme analysis was an ongoing process that commenced with the first interview and allows a building and layered approach to understandings, which in turn informed the probes used in subsequent interviews. The inductive analysis of the transcripts produced major categories of themes/issues.
The outcomes of stage three were:
- 35 vignettes of nursing in Australia; and
- summary of key themes emerging.
4. Demographics
Demographic information was gained for 35 nurses interviewed. Of these, 15 were enrolled nurses and 20 were registered nurses.
4.1 Age of participants
The age ranges of the ENs are represented in Figure 4.1.1, and the RNs in Figure 4.1.2.
Figure 4.1.1 Frequency of age ranges of enrolled nurses
Figure 4.1.2 Frequency of age ranges of registered nurses
4.2 Nationality and language
Of the 34 nurses interviewed, only one participant cited a language other then English as their first language (Yugoslavian). All participants were Australian citizens, and 28 of the 34 participants were Australian born. One nurse cited Australian Aboriginal as her nationality, while three of the ENs were born in New Zealand, Scotland and Yugoslavia consecutively. One RN was born in Wales, and another in England.
4.3 Years since registration as a Nurse
The enrolled nurses provided a sum total of 309 years experience since their initial registration, with the ENs having completed their EN training on average 19.65 years before the time of interview. The least number of years since enrolment as an EN was 11 years, and the greatest number of years was 31. Registered nurses interviewed had a sum total of 410 years experience, with the average number of years since registration being 20.7. The least number of years since registration for an RN was 4 years, and the most was 35 years.
4.4 Practice Areas
Of the ENs interviewed, the average number of years spent in their current practice area was 6.7, with an average of 3.25 years in their current position.
The average number of years in their current practice area for RNs was 7.2 years, with an average of 3.3 years having been spent in their current position. The participants were asked to name the areas of practice they had worked in, before entering their current practice area.
The most frequently listed areas are illustrated in Figure 4.4.1. 'Other' areas are those areas of practice mentioned by only one participant and are listed in Appendix C. The most common area worked in by the nurses was in surgical wards. Midwifery and medical were the next most common.
Figure 4.4.1 Other practice areas - all nurses
4.5 Education
Fourteen of the fifteen ENs had gained their qualifications through hospital-based training. One participant had gained their EN certificate through TAFE. Five RNs had gained their registration through university, and the remaining fifteen through hospital-based training programs.
4.6 Further Education
Of the 15 enrolled nurses, 11 specified that they had completed some non-university further education such as a certificate or TAFE course since their enrolled nursing education. The list of these courses appears in Appendix D. Only one of the ENs had completed a University degree. This was in a field other than nursing.
Fourteen of the 19 registered nurses had completed further education other than their minimal training for registration. The breakdown of the level of education for RNs is seen below in Figure 4.6.1. The specific areas of education are listed in Appendix D.
Figure 4.6.1 Level of further education completed by registered nurses
4.7 Membership of Professional Bodies
Figure 4.7.1 represents the comparative number of nurses who are members of professional organisations. The organisation which had the greatest number of nurses from our sample were the Royal College of Nursing, Australia, followed closely by membership in a relevant union (dependent on the state of employment), and then by the National Enrolled Nurses Association and the Australian Nursing Federation equally. The specific organisations which make up the groups of 'others', 'unions' and 'continence' are listed in Appendix E.
Figure 4.7.1 Membership of professional organisations
4.8 Professional Development
Participants were asked to state their last professional development activity, and how long ago this took place. The responses ranged from 2 years ago in one case to on-going development occurring weekly. Figure 4.8.1 and Figure 4.8.2 represent the approximate frequency of these staff development activities for ENs and RNs respectively. The subject of these staff development activities varied greatly depending on the area of nursing the participant was involved in. The specific topics of these development activities are included in Appendix F.
Figure 4.8.1 Time since last staff development activity - ENs
Figure 4.8.2 Time since last staff development activity - RNs
ENs most commonly stated that it had been around 1 year since their last development activity. It was less time for RNs, with most RNs stating their last training was around 6 months ago. Cumulatively, from this sample it appears that development activities for RNs are more ongoing, with 89% of RNs who provided responses to this question having undergone some development activity in the last 6 months. This is compared to only 58% of ENs having completed development activities in the last 6 months.
4.9 Interstate, remote and overseas employment
Table One indicates participants' responses to the question regarding other locations of employment other than their current location. Only 9 ENs responses are included, and 16 RN responses. Exclusions are based on difficulties in comprehension of interview transcripts. Some participants had worked both interstate and overseas, providing for the greater number of responses than participants.
Table 4.9.1 Interstate, remote and overseas employment
| Interstate | Overseas | Remote | No other | |
| ENs | 5 | 0 | 0 | 4 |
| RNs | 9 | 4 | 5 | 3 |
Overseas countries worked in by RNs were Saudi Arabia, Scotland, England, Papua New Guinea, and Malaysia.
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