The Scope of Nursing in Australia: A Snapshot of the Challenges and Skills Needed
5. Vignettes
Set out below are the 35 vignettes compiled by the research team that illustrate a snapshot of nursing in Australia across 17 key practice areas in which nurses work. The vignettes provide the following:
- A brief description of the area that the nurse works in;
- The work environment and tasks involved for the nurse;
- A brief outline of the skills and challenges identified; and
- A summary of the responses given to how nursing education could be more responsive to the work that the nurses do.
For confidentiality purposes, the names of the participants have been replaced with pseudonyms in order to reduce the likelihood of participants being identified.
Where direct quotes have been used, reference has been made to the transcript number, page and line number of the passage.
The majority of the vignettes represent the responses from an individual nurse, however, due to the similarities found in the interviews of two nurses working in the same key area, one vignette reflects the responses received from two independent interviews. Participants varied in the depth of their reflections on their practice area.
5.1 Enrolled Nurse - Acute Hospital
Deborah is an enrolled nurse who works in a Victorian acute hospital. Her work involves caring for medical and surgical patients, predominantly in the area of paediatrics, but may also include any overflow of adult patients.
A typical day will vary greatly depending on the types of patients that Deborah has been allocated to for any given shift. Her day will begin with handover and the allocation of patients whereupon Deborah must prioritise, plan and manage her shift accordingly. Deborah is regularly dealing with a high turnover of patients, so that in any one shift, she will be dealing with a number of admissions and discharges of patients. Where there are a number of surgical patients, a morning shift will require Deborah to prepare each patient for admission and theatre. Deborah will monitor and assess any medical patients, organise physiotherapy and provide post-operative care. As an enrolled nurse, some of Deborah's tasks include doing observations and giving oral medication, as well as medicating Ventolin for asthma patients. Overall Deborah works in a busy environment where she must deal with anxious and sometimes aggressive parents and other family members. In addition to her workload, Deborah feels a responsibility to maintain a good working environment, and provide conflict resolution. Deborah encounters conflict on a regular basis, she often finds that she is the target for aggression and so must have strong conflict resolution skills.
Models of Working With Others
Deborah interacts with the nurse in charge of each shift, registered nurses, doctors, a range of allied health professionals, as well as patients and their families. She feels that she acts as a caregiver for her patients, while she often finds herself to be the information/reference point and giver of support to patients' families.
Deborah experiences issues in terms of her position as an enrolled nurse. As a senior staff member, Deborah finds herself to hold great responsibility when she is working with a junior registered nurse. She feels frustrated because she will be seen as a senior member of staff and her skills are utilised when necessary, but other times she is treated like a junior member of staff by registered nurses.
Skills
Deborah makes reference to the following skills:
- Organisational skills;
- Time management;
- Broad nursing knowledge base;
- Assessment;
- Interpersonal;
- General nursing skills; and
- Research skills.
Challenges
- Challenges include:
- Maintaining an up to date knowledge base;
- Working the system to get the best outcome for the for patients;
- Conflict resolution;
- Co-ordinating a constantly changing and heavy workload;
- A varied position within the team as an enrolled nurse; and
- Lack of resources.
Education
Deborah thinks that nurses need a lot more practical experience as part of their education. She believes that "...there should be a better balance of the old system and the new system...." (8:21:502-3). She states that ".......... what you see on a video.... and what you see online, is not necessarily what you will encounter on the ward...." (8:23:548-9). A general foundation of medical and surgical nursing knowledge is imperative so that when nurses specialise, they are able to expand a good basic knowledge of nursing.
In regard to interpersonal and conflict resolution skills, Deborah feels that such topics need to be covered in nurses education, but a large proportion of those skills will come on the job.
5.2 Enrolled Nurse - Acute Hospital
Sally is an enrolled nurse who works in the accident and emergency department of a rural hospital in Western Australia. The hospital doesn't have resident doctors and while there is always a doctor on call, Sally recognises a need to have her skills constantly updated in readiness for whatever comes through the emergency doors.
The rural work environment is most obvious to Sally over the weekends and after hours when access to resources is severely diminished. The lack of available mental health nurses, shelters for the homeless and children's services on weekends creates a challenge for Sally and other emergency nurses. Her work also involves taking emergency calls for the ambulance service whenever the officers are out answering another call.
Sally's work environment is often congested, stressful and fast paced. What is required of her on any one shift is unpredictable. "There is no set routine for the day," (32:9:219). Sally's job requires her to respond to situations as they present themselves.
A typical day for Sally will commence with a brief handover. She will then check that all bays in the emergency ward are fully stocked. If a major emergency patient enters the hospital, Sally will hopefully know in advance by a call through from the ambulance officers, if not however, it is a matter of "just dealing with it.... and hopefully have the staff amongst ourselves to deal with it.." (32:8:184-5.) Sally regularly attends to patients who require injections, nebulizers, blood pressure checks or dressings. There is also a minor theatre associated with emergency and Sally will on occasions set-up and assist the doctor during the operation.
Sally identifies the most challenging circumstance is the real emergency situation where the patient arrives unconscious and it is difficult to know exactly what the problem is and how to treat it. Often Sally has to deal with aggressive patients. She encounters verbal abuse on a daily basis. While Sally carries a duress alarm at work, there is no security staff at the hospital and she feels a need to be constantly aware of her surroundings and the safety of herself and other patients and relatives in the department.
Sally finds that the limited resources in the emergency department creates good team work among the staff as each member must be aware of the other's ability and rely heavily on one another.
A lot of Sally's interaction with patients extends to communicating and comforting anxious parents or families dealing with traumas. She finds this can be quite emotional work but feels "...it's nice then when you've been able help them as well and give them a bit of time" (32:13:337-9).
Models of Working With Others
Sally finds that the limited resources in the emergency department creates good team work among the staff as each member must be aware of the other's ability and rely heavily on one another.
A lot of Sally's interaction with patients extends to communicating and comforting anxious parents or families dealing with traumas. She finds this can be quite emotional work but feels "...it's nice then when you've been able to help them as well and give them a bit of time" (32:13:337-9).
Skills
- Basic nursing skills
- Assessment and treatment
- Promotion of awareness and education of patients
- Social work
- Flexibility
Challenges
- Emergency environment
- Limited staff and resources
- Safety of staff and other patients
- Coping with verbal abuse and aggressive patients
Education
Sally believes that too many enrolled nurses "...come out totally unaware of how aware they need to be" (32:17:471-2). She is appreciative of her work training on professional assault response but feels that this is an area that is extremely important and currently lacking in nursing education.
She feels that you need to be a little bit more mature to cope with the first line of the public and need to be a particularly experienced enrolled nurse to work in an accident and emergency department. However, Sally still feels that clinical practice is a critical component in the development of nursing education.
5.3 Registered Nurse - Acute Hospital
Sue is a registered nurse who works as a Clinical Nurse Consultant in New South Wales, specifically in the area of continence care. The aim of her work is to improve quality of life for people with incontinence issues. It is a multi-faceted role with a focus in education. Sue is primarily involved in the education of community groups, other registered nurses, and primary nurses caring for those suffering from incontinence. Sue also tries to maintain a level of nursing research. As is necessary in her highly educative role, Sue spends a great amount of time in updating her own knowledge surrounding continence research and treatments, and in updating the resources provided for those she teaches.
Sue also has a clinical role in consulting with clients with incontinence issues. Although she has few clients of her own because of her strong leadership role, Sue is involved in consulting with other continence care nurses in various community heath clinics, hospitals, and in people's homes. She works closely with a great number of allied health professionals because of the numerous and varied causes of incontinence. She feels very satisfied with the respect given to her from the many specialists she works with and feels that there are 'no barriers' between them.
Models of Working with Others
The greatest amount of interaction Sue undertakes is with other Clinical Nurse Consultants. These CNCs come from aged care and orthopaedics, cardiology, intensive care, neurology, and paediatrics. In addition to nurses, Sue works closely with a group of neurologists, gynaecologists, paediatricians, nutritionists, and physiotherapists. One day a week, Sue meets clients of other nurses who are acting as continence nurse advisors. This will occur at one of 23 community health centres, hospitals, gynaecology, cardiology clinics, or orthopaedic clinics within her catchment area. Often she will also accompany a community nurse to people's homes.
Skills
The skills identified in Sue's written job description as a nurse continence advisor are:
- A Nurse continence advisor certificate
- 5 years experience as an RN
- Relevant tertiary education
- A broad knowledge of continence issues and care
- Ability to educate both professionals and the public
- To be able to carry out research projects from proposal through analysis
- Computer skills including use of Excel and spreadsheets
- Ability to create rosters
From her own experience Sue pinpointed the following skills as being integral to her role:
- Need for a broad knowledge base of a great number of areas which can
all be related to incontinence including:
- Disease;
- Fractures;
- Dementia; and
- Pharmacology.
- 'People skills'
- the ability to empathise without being patronising or over-sympathetic;
- to be able to be a friend but retain emotional distance so as to remain as an advisor; and
- the ability to motivate people to stick to their programs when they want to give up.
Challenges
Sue was adamant that the greatest challenge was getting funding. As a non-acute, non-life-threatening area where positive outcomes are delayed rather than immediate, continence is not considered important. "So that's the biggest challenge of all of this- getting funding to get more nurses to do assessments" (19:11:527-529).
Sue also expressed some frustration with young nurses in training who didn't consider continence care a nursing role. She believed that nurses didn't want to take on a role in Continence care because it meant that people were "on the way out" (19:11:540), although Sue also deals with young children and young women who have just had babies.
Also related to her interactions with nursing staff, Sue identified the challenge of trying to convince directors of nursing to make continence assessment and intervention "part of the system" (19:12:549). Rather than just "treat(ing) it palliatively-(and) put(ting) a pad on it" (19:12:554) she feels that continence care should be a core care issue for the benefit of the patient, and of the health care system in the long term. The cooperation of the DON is imperative because it has a filter-down effect on nursing staff. If it is not made a regular part of the system, the nurses, partly through a lack of time will not consider undertaking continence care and assessment.
Sue expressed that a lack of time for conducting continence care was caused by a declining ratio of registered nurses and enrolled nurses to patients, and to the vast amount of documentation having to be done by nurses and carers which was detracting from 'care time' with patients.
In dealing with the clients themselves Sue states that it is also a great challenge in initially getting people to admit that they have a continence problem; "people don't want to talk about it, they would rather suffer in silence" (19:11:546-547).
Education
Sue is involved with the first year of the nursing degree at one of her local universities. She believes that this university "is trying" to incorporate continence care into the curriculum. In terms of nursing responding to changing health care needs, Sue felt that the major issues to be addressed were:
- that in the future health care will be undertaken more in the home and the community than in the hospital; and
- that older people are going to live longer as they are getting better care, and such will need more ongoing care.
In responding to these changing needs Sue made the following suggestions for responsive education:
- nurses will need to be trained as more independent workers as they will no longer be encased within a hospital setting with other medical staff;
- nurses will need greater training in the skills of aged care rather than care for younger people;
- education needs a greater focus on the social aspects of a persons life relative to their decline in health rather than just the biological/physiological aspects;
- separate from aged care needs, nurses also need a greater understanding of modern health issues such as youth suicide and men's health; and
- nursing education needs to foster an increase in nurse's involvement in health promotion.
In addition, Sue also felt that nurses-in-training needed greater practical experience with formal guidance from experienced nurses:
...for the next 5 weeks your going to work as the extra person here .......with this experienced nurse who will show you the ropes and help you through all the hard things to start off with. I think that's important rather than a 12 hour orientation which you hardly ever get... (19: 14: 703-708).
In support of greater ongoing education of nurses, Sue also expressed the need for greater flexibility in rostering to allow for nurses to attend university lectures, and complete higher education. The difficulty in this is back-filling these nurse's positions with equally experienced staff with such a shortage of nurses in most hospitals and aged care facilities.
5.4 Enrolled Nurse - Psychiatric Hospital
Peter is an enrolled nurse who works in a psychiatric intensive care unit in Western Australia. The unit is a secure ward and will admit all types of mentally ill people. It can vary from a relapse of psychosis to drug induced psychosis.
There is "never a typical day" for Peter (38:8:172). The pace of his day can vary dramatically within a shift. The day starts off with hand over and medication round followed by patient interviews with visiting consultants. Peter finds that it can get quite complicated sometimes when a patient comes in "...and you don't know who they are, and they can't tell us who they are and sometimes we've had two or three days before we've been able to find out who this person is...you have to be a bit of a detective sometimes to work here..." (38:10:221-6). Safety is a constant issue for Peter and other staff members. Peter recalls: "...a couple of weeks ago actually, where we had to call security and police because a patient was about to take everybody apart and the ward with him..." (38:6:131-3). After a patient has a psychotic episode, he will be involved in debriefing other patients to ensure they are okay.
Peter communicates with his patients by meeting them on the same level, which often means using street language. Most importantly Peter finds that he has to sell the service that they're providing to the patients and explain that they are not brought to the hospital to be punished. This can be challenging when some patients, suffering very intense paranoid delusions, incorporate members of staff into their delusions. Peter's experience in mental health nursing has enabled him to be aware of his surroundings, anticipate problems and be proactive in his nursing care.
Models of Working With Others
Peter describes his working team as a cohesive unit.
There is a constant flow of staff on the ward, including nurses, psychiatrists, registrars, consultants, pharmacists, as well as police and ambulance officers. Each morning, a number of medical officers arrive for the ward meeting where Peter will make his contribution as a respected fellow team member. At the meeting:
....decisions are made and then sometimes from that meeting they're handed onto the actual teams then and a couple of the team whether they consider they want to follow that line of treatment or whether they have completely different ideas altogether. Sometimes there is a bit of a clash between consultants but generally they work pretty well together... (38:9:200-4).
Skills
- Working knowledge of medications and their side-effects
- Communication
- Knowledge of individual patients and their backgrounds
- Awareness of safety issues and anticipation of violence
Challenges
- Dealing with aggressive, violent patients
- Stressful situations that challenge personal safety
- Caring for psychotic patients
Education
Peter thinks more students should be given an opportunity to work in areas like psychiatric hospitals and intensive care units in particular. He suggests that people need to be on the wards, working with the people to gain experience in his area of work. Peter believes communication skills are most important and nursing education should concentrate on teaching those skills to nursing students.
Any comments or queries should be sent to: highered@dest.gov.au
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last updated on Tuesday, 04 December 2001
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