The Scope of Nursing in Australia: A Snapshot of the Challenges and Skills Needed
- 5.5 Registered Nurse - Psychiatric Hospital
- 5.6 Registered Nurse - Psychiatric/ Private Hospital
- 5.7 Registered Nurse - Nursing Home
- 5.8 Enrolled Nurse - Nursing Home
5.5 Registered Nurse - Psychiatric Hospital
Adam is a registered nurse working in an in-patient mental health facility which forms part of a suburban hospital in Western Australia. It is a 12 bed facility that is always full. The patients in the facility range from 'full blown' psychological disorders such as Schizophrenia, through Bipolar Disorder to lesser mental health issues. The facility is still in the initial phase of being established, and as such Adam has only been employed in this facility for three months. However, the long-term aim of the facility is to nurse the in-patients and then "follow them back into the community" (35:5:93).
Adam is involved in the basic nursing of the physical injuries of patients "if they have got cuts and scratches...... or are diabetic" (35:5:102-103), but he describes his primary role as 'role modelling'. As the only male nurse in the facility, he takes on much of the 'role modelling' and often finds himself acting as a 'father figure'. Adam tries to attend to the needs of his patients in a holistic way by trying to establish behaviours and knowledge which will allow them to function in the community "rather than just making sure they have their medication and dealing with behaviours that come up" (35:7:136-137). While he does try to implement cognitive-behavioural therapies and other set techniques, he describes the majority of his interactions with patients as 'role modelling'.
Adam's typical day begins at 7am when he is allocated his four patients. As the coordinator he then arranges jobs to be done by the staff such as organising patients to go for CT scans. In addition to his coordinating position, he also has a full patient load. Adam tries to have a conversation with each of his patients at least once a day in order to assess what is happening with each of them - if they are hearing voices or having any crises. He will find out what the doctor has said about them, and make sure their medications are understood. He also tries to spend time with the Clinical Nurse Specialist to exchange information. If there are difficult patients, the staff will get together in the afternoon to establish management programs to best suit those patients.
Adam also spends time in keeping his knowledge up to date with medications and evidence-based treatments. He does this by liaison with librarians, contacts with psychological services, and through the internet.
Models of Working with Others
There are four nurses working on all shifts with Adam, these are a combination of enrolled and registered nurses. There are also a number of Personal Care Attendants (PCAs) working at any time and two doctors present at the facility at all times. When describing his interaction with them, Adam says "because they are there you can sit and argue with them over what's going on..." (35:8:182-183). The registered nurses give all medications and concentrate on the behaviours of the patients whereas the doctors are more focused on ensuring the correct medications. There is a psychiatrist in charge of the medications who also has a broader focus than the regular doctors.
Adam describes the model of working with colleagues as very collaborative. The backgrounds of the staff are very broad and so they will collaborate to establish the best treatments for the patients and to share information. Adam also liases with the staff working in emergency because all patients are referred to the mental health unit through the emergency department of the hospital. There is also a physiotherapist and an occupational therapist who work with the unit as part of a broader health service.
Skills
Adam identified the specific skills of being empathetic, diplomatic, and assertive. However, he felt his greatest asset to his work had been gained through life experience in working in a number of different areas, and in entering the nursing profession at a mature age. Through this experience in other mental health positions, he has learned to deal with police, to testify in courts, and just to stand up to demanding patients to achieve a better outcome for the patient, and the staff. He felt that he drew on his life experiences constantly. He also felt that it was especially important to set boundaries with patients, and it was his life experience which allowed him to be assertive enough to do that.
Although he admits the need for a basic knowledge of the physical ailments of his patients, more important was knowing where to find information that he did not know; "where to go to get the right information and the right treatment" (35:14:357-248). Adam also believes there is a need for a knowledge of the broader community and the services available within it so that he could refer the patient to outside help when leaving the facility; "who to ring, what to ring, what people to refer to, or at least push it that way" (35:14:358-359).
Challenges
Adam finds it a challenge to be one of very few male staff in the mental health facility and feels that much of the role modelling falls on him. This is quite challenging to Adam in making him think of things he never had to before relative to how to deal best with patients he is role-modelling for.
There are also challenges which present themselves from the channelling of patients for the emergency department into the mental health unit. The general nursing and medical staff are quite afraid of the mental patients, and of the unit itself, and Adam tries to break down this stigma. Because of this fear, the emergency department want the unit to take on more patients than Adam feels is necessary and there is friction when he refuses to take them.
In being a new facility, challenges also lie in 'keeping up with all the new managers" (35:16:411), and in the changing the culture of mental health and establishing a new model of mental health care. There is uncertainty as to the role of the nurses as the unit gets established. Things that have always been done are no longer, or are done in a different way:
...silly things like being in charge you do the book every time and we list everybody and we don't do that sort of thing now. It's done by computer and the main base is that sort of nursing that its fully integrated...... it's been hard for myself and plus 2 nurses to sort of go and re-look again to see where we are going and what we are doing (35:126:422-430).
Education
Adam feels that student Nurses need to be more exposed to "what it's like to be a nurse on the ward" (35:17:458) from the very beginning of their education so that they are better able to put their knowledge into practice:
...they've never been exposed to what it's like in the day to day staff, they know all the theories of schizophrenia and as one said to me, but they are not reacting like they we're taught, well they are individual human beings and every one has their good days and their bad days (35:17:459-463).
He also felt that this kind of exposure would help with the transition of "student one day and nurse the next, with all the responsibilities that go with it and it awesome to have it dumped on you" (35:17:463-465).
Adam has been involved in being a mentor to many students and feels that it is important to let students input into treatments of patients, regardless of whether you do as they propose. He feels it is also important to have students realise that the anger of the patients should not be taken personally, and to set those kind of boundaries from the very beginning.
5.6 Registered Nurse - Psychiatric/ Private Hospital
Carl is a registered psychiatric nurse working in and not-for-profit community owned mental health service in Tasmania. The service provides alcohol and drug detoxification programs and a full range of other mental health services.
Carl deals with both the physical and mental/emotional problems associated with mental illness on a daily basis, such as in the withdrawal process in drug and alcohol detoxification. However, his principle responsibilities are with the administrative management of the service. This involves promotional and public relations work, liaison between the patient's, their families, GP's and Psychologists/Psychiatrists, medical records department, and the nursing service. He is jointly responsible for most of the major managerial decisions, with other chief executives.
Carl works with a core team of permanent staff as well as a large component of casual on-call staff. His typical day begins at 6:30am and starts by ensuring all necessary resources, and an appropriate skill mix of staff are available. He attends many organisational and administrative meetings, and is involved on a daily basis in; 'pre-emptive' problem solving, liaison with the University, working with consumer organisations, planning of staff development, and interacting with Nursing staff to produce the best possible treatment for patients.
He feels that maintaining staff morale among nursing staff is of major concern, and that nursing education could be most responsive to the mental health area by introducing an 'intern' year at the end of the academic postgraduate years, and better clinical tutors in the workplace.
Models of Working with Others
Carl stated that there was not a bureaucracy. He is involved with all major management decisions with a small group of chief executives including the clinical director. The staff consists of a small core group of permanent staff and a larger group of casual call-in staff.
In his work, Carl interacts with the patients, the patients' families, the patient's GP, their psychologist and/or psychiatrist, nursing staff and medical records staff. In addition, he is involved in liaison with the University, consumer organisations, GP groups, and health funds.
Carl highlighted the necessity of easing the tensions between the nursing staff and psychologists and psychologists and psychiatrists. He expressed his concern over what he called "institutional abuse and professional abuse" towards nurses, and the "lack of respect for nurses and lack of acknowledgement" (15: 5: 190-191) which translates into low staff morale and staff turnover.
Skills
Skills identified as a necessity of Carl's job were:
- Medical skills;
- People skills; listening to what people are doing and talking with them to arrange the best course of treatment
- Budgetary skills;
- Conflict management skills;
- Organisational skills;
- Problem solving ability; "fix it before it gets out of control" (15:4:13);
- Specific psychological and psychiatric knowledge; and
- Business management skills.
Challenges
- Easing tensions between Nurses and psychologists, and psychologists and psychiatrists.
- Changing nursing attitudes from just 'doing what they are told to' to initiating treatments by staff development
- Ensuring a viable business
- Keeping the workforce engaged and happy
- Dealing with institutional and professional abuse of nurses, and the lack of respect shown and the consequent lack of morale.
- Increasing staff morale
Education
Carl believes that while more actual skills based education is necessary in nursing education is essential, reverting to the old 'apprenticeship' scheme should be avoided at all costs. Tasmania has implemented some education schemes which he believes are particularly useful. These include a very close relationship between workplaces and the university to discuss curriculum and student placements, and being involved in accrediting courses. He feels that his organisation needs more time to spend on this and that better clinical tutors in the workplace are imperative.
He states that in their mental health organisation, graduate nurses are employed and paid to ensure a future workforce. In the future they plan to offer scholarships to pay graduate nurse university fees. He believes that this employment allows supportive experience and feels the need for similar programs Australia wide where learning goals are set and assessed within a practical environment. He feels that preceptorship is very useful.
5.7 Registered Nurse - Nursing Home
As manager of a co-located large residential aged care facility in rural South Australia, Sarah, a registered nurse, is involved in more professional nursing intervention and direct supervision than in similar aged care facilities.
At times, she will be the only registered nurse on duty for fifty-one residents. Her nursing encompasses a holistic approach, from managing simple illnesses through to the provision of palliative care. She finds it difficult to juggle her management and practical nursing roles. Sarah's strong supervisory role sees her having to fragment herself in order to deal with so many issues. She has a to be there with the carer to assist with the difficult manual handling or wound management as well as oversee the provision of care by a number of staff. Her typical days are busy and Sarah often spends her time 'chasing her tail' and 'putting out a lot of spot fires' such as dealing with issues and families that have concerns. Sarah also has to assist fellow nurses who are working so hard that they are 'hitting burn out.' A drug round will normally take up approximately an hour and a half of Sarah's time. Sarah constantly has to have the "ability to just pick up and drop things and pick them up as needed..." (21:15:345-7.)
Models of Working with Others
In the course of her work, Sarah interacts with residents, families, volunteers, fellow nurses, carers, clerical support and all the professionals belonging to the allied health services.
As a registered nurse working in residential aged care, Sarah feels undervalued.
In particular, Sarah expresses issues that arise with doctors. She finds it difficult to get GPs to the site because they see their acute care responsibilities as their primary focus. Sarah has a reasonably good rapport with GPs, however she finds that "... sometimes they treat us as if we're second rate nurses as well which is quite sad" (21:24-5:570-2).
In contrast, Sarah works in partnership with the physiotherapist. She describes the physiotherapist as "...wonderful, he sees us as being extremely innovative..." (21:26:598-9). She works in a team setting with other nursing and carer staff and finds that they are really keen to make a difference in aged care.
Skills
- Organisational/Prioritising Skills
- Communication
- Self-learning
- Assessment
- General nurse training
Challenges
- Keeping up with a heavy workload
- Travelling to Adelaide for work purposes
- Juggling numerous nursing and management roles
- Physical exhaustion
- Lack of available staff
Education
Sarah believes that "... people need to come out, when they're doing their placements they need to come to some of these aged care facilities and see what its like, there are some wonderful, positive aspects of aged care that are not portrayed" (21:21:482-5).
5.8 Enrolled Nurse - Nursing Home
Vicky is an enrolled nurse who has been employed in a private aged care facility for seven years in New South Wales. In a semi-rural area, the facility has 72 beds and houses older people from the very frail to some who are relatively active. A typical day for Vicky involves the care of the residents including helping with Assisted Daily Living (ADLs), making beds, showering, feeding, toileting, helping them to be ready for the day by fitting glasses and hearing aids, walking with them, and conducting basic observations such as blood pressure, and blood glucose monitoring, encouraging socialising among residents, helping to care for the terminally ill, and completing required documentation.
The documentation Vicky is required to complete is related to restraint of residents, ensuring they are not restrained for more than 2 hours at any time, location charts for patients who are likely to wander, stating their whereabouts, their mood and what they are wearing every hour in case they do wander from the facility; and sleep charts for residents requiring night sedation. Bowel records are also kept for some residents, and enemas may need to be given in certain instances.
Vicky describes the pace of her work as 'constant:' "you are aware that 5 minutes lost can put you behind in other areas" (27:11:219-220). She believes she would spend an average of 45 minutes a day with a more dependent resident, while only 5 minutes with a less dependent one. She would like to have more time to spend with the residents in talking with them, but realises that the heavy workload of all staff prevents very much of this social interaction from occurring.
Model of Working with Others
Vicky will be the only enrolled nurse in her section on any particular shift. There will also be a registered nurse on shift and a number of Assistants In Nursing (AINs). As the only enrolled nurse on shift, the AINs will often come to her for guidance, especially when the care staff are new, and she will also be involved in a number of managerial duties such as scheduling staff meal breaks, and assigning staff to resident's rooms.
Vicky was very satisfied with her interactions with the registered nurses on staff, with whom she had a very open communication and who will often ask her opinion when making decisions.
Apart from the residents themselves, the only others that Vicky will interact with on a regular basis are the activity staff who attend the facilities on Fridays, and the resident's families. There will also be occasional interaction with a doctor. Most daily care activities for the residents will be undertaken with another member of staff.
Skills
Communication skills were the greatest set of skills Vicky identified as being essential to her position. These communication skills include being able to relate to the residents in a kind and caring manner, and to communicate to the families that their loved ones are being taken care of. Communication skills were also important in dealing with staff conflict, particularly in determining where the break down in communication has occurred.
Vicky also identified time management and the ability to prioritise work as very important. The ability to multi-task was also alluded to; "having your eyes on numerous different things at the same time so that you know when you've got to get x amount of people ready by a certain time that it is a reasonably smooth and coordinated procedure". (28: 10: 212-214)
Vicky identified basic monitoring procedures such as blood-glucose levels, TPR, and blood pressure as central to her role.
Challenges
Having new staff in an environment dictated by very tight scheduling was identified as being quite difficult; 'so you have to be constantly informing other staff members of the routine" (28:10:239-240). More personally, Vicky found dealing with terminally ill residents a strong and ongoing challenge although it only occurred periodically. She felt that any training to deal with death and dying had been seriously lacking in her formal education.
In terms of time constraints, Vicky also found it frustrating to not be able to find the time to spend just in social interaction with the residents, or to give them extra care when it is necessary; "if they have got a cold or flu or even bordering on a chronic illness, you really don't have any more time than just to do the very basics for them and I think that is a bit unfortunate" (28:17:390-393).
Time constraints are also forcing the staff of the nursing home to falsify legal documentation. Vicky referred specifically to the legislation that states that residents must be released from constraints for 15 minutes every two hours. She says that to take 15 minutes out of every two hours to stand a resident and walk them around is 'impossible'. So, the staff will routinely fill in the charts to say that this task has been fulfilled, though it has not. This was a major concern to Vicky.
Vicky felt that taking the time to complete this task or to sit and interact with the residents without performing another task at the same time would lead to herself or any other staff trying to do this to being labelled as 'slow'. For casual staff, this would mean not getting called in for extra shifts, or in Vicky's case, to the loss of her job for not fulfilling the basic requirements of her position.
Education
When asked how nursing education could be responsive to preparing future nurses to fulfil her position, she replied "I think theory needs to reflect practice a little bit more" (28:22:531). By this, Vicky meant that there needs to be more focus on time management aspects, prioritising workloads, communication and interpersonal skills, rather than the more physical anatomy and physiology aspects which are not called upon so much in aged care. She felt that role-playing and being placed in situations where greater empathy and understanding is necessary as important concepts for nursing education.
Vicky felt a greater need for the understanding of psychological aspects of illness. She also felt that education in dealing with the terminally ill was definitely lacking from her education. While she recalled studying Kubler-Ross' stages of grief, she felt she needed greater preparation for dealing with the patient's themselves, the families of deceased residents, and in dealing with her own grief.
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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