The Scope of Nursing in Australia: A Snapshot of the Challenges and Skills Needed
- 5.9 Registered Nurse - Hostel
- 5.10 Enrolled Nurse - Hostel
- 5.11 Enrolled Nurse - Hospice
- 5.12 Registered Nurses - Hospice
- 5.13 Enrolled Nurse - Community Health
- 5.14 Registered Nurse - Community Health Centre
5.9 Registered Nurse - Hostel
As a registered nurse and coordinator in a Queensland hostel, Rebecca's role is both clinical and administrative.
Clinical observation and assessment forms a major part of Rebecca's typical day as she nurses patients in the area of dementia and palliative care. She feels it is important to have a strong knowledge base in the medications that are used and be aware of her patients' needs, as well as their capacity to become distressed or violent. Her position as coordinator also requires her to respond to patient complaints and actively problem solve. Rebecca must manage staffing resources effectively in an environment that relies heavily on government funding.
Models of Working with Others
Rebecca holds a managerial role in relation to her fellow nursing staff members. However she sees her work and ability to best allocate resources as being a team effort. As coordinator, Rebecca considers it to be her responsibility to maintain a harmonious working environment and ensure that staff members feel important and valued.
Rebecca is accountable to the director of nursing, other registered nurses, personal carers, assistants in nursing, members of the allied health profession as well as patients and their families.
Skills
- Listening
- Open-mindedness
- Empathy
- Observation
- Intuition
- Interactive
- Leadership/management
- Computer
- Communication
Challenges
- Limitations of funding
- Understaffing
- Patient behaviours
Education
Rebecca describes graduate nurses as being under trained. She comments that nurses should be taught in the environment that they are going to be working in, and consequently student nurses need to be "...out (on) the wards some of the time (4:17:411-2). "
However Rebecca still sees it as "imperative that the nurses do get a very theoretical background... that they are taught to assess (etc)" (4:18:427).
5.10 Enrolled Nurse - Hostel
Linda works as an enrolled nurse in a hostel in rural South Australia. She is the co-ordinator of the facility and is responsible for the holistic care for all residents, which includes attending to their physical, social, cultural and spiritual needs.
All nursing staff, including Linda, take part in a variety of tasks which include medication rounds, making beds, showers and dressing, vital signs, oxygen therapy as well as preparing, delivering and cleaning up all meals. As co-ordinator, Linda has significant additional responsibilities. She plays a supervisory role over all the care workers and volunteers. In addition to the hands-on work, Linda will also run the management side of the facility, including conducting assessments, duty statements and Resident Classification Scales. Her afternoons will often involve documentation work and responding to residents' and relatives' concerns or questions. Linda enjoys the ability to develop long-term relationships with the residents and on the whole, finds it to be very fulfilling and rewarding.
Models of Working with Others
Linda sees herself as working within a multi-skilled, multi-disciplinary team that includes doctors, pharmacists, podiatrists, physiotherapists and dieticians. She is also in constant interaction with other nurses, residents and their families.
She finds that doctors can be slow in responding to requests. While Linda generally has a good relationship with the doctors she works with, she feels that sometimes they do not listen enough to her concerns about residents or address problems that arise.
Skills
- Time management
- Leadership
- Nursing knowledge
- Persistence, tactfulness, assertiveness
- Developing and nurturing long-term relationships
- Problem-solving
Challenges
- Time limitations
- Budgetary constraints
- Lack of resources
Education
Linda suggests that nursing education should provide its students with good time management, leadership and management skills. She feels that developing students' communication skills is very important and in particular life skills that provide an understanding of the problems that face the aged population.
5.11 Enrolled Nurse - Hospice
Rhonda works as an enrolled nurse in a hospice located in Western Australia. She describes the type of work that she does as "...helping (patients) pass through that phase in their life and [assisting] their family..." (34:6:107-8.)
Rhonda outlines how her work actually involves acute care because the patients' physical and emotional conditions and symptoms will often change. She experiences the tension that is brought about by attending to routine requirements and being available to each individual person that needs assistance at that time. Rhonda illustrates this problem in the following way:
...you're sometimes moving from someone who is actually died and a family that needs support and there is a bell and so you have to walk to that room and it might be something minor but you have to give that person that respect that you know they are not aware and that is not important, well it is important to them, but you know you don't pass on that information, so it is actually, then you are moving back and treating that as that's important as well (34:11:260-3).
A typical day for Rhonda will commence with handover by the night staff, which is normally followed by reviewing notes and a doctors' meeting. Rhonda then assists with the medication round and taking patients to x-ray or oncology appointments. Rhonda's area of work is, however, less task oriented and more about managing oneself emotionally in order to provide each patient with care and create within them a feeling that they are special.
Models of Working with Others
Working within a small establishment, Rhonda feels that nursing staff, occupational therapists, doctors, patient care assistants, physiotherapists and volunteers are team members.
Rhonda sees her role as a patient advocate and sometimes experiences tension with doctors in terms of patient care. While registered nurses do take on more responsibility and as an enrolled nurse, Rhonda is unable to administer schedule eight drugs or give intravenous drugs, she still describes her input as equal with the registered nurse in her area of work.
Skills
- Observation
- Compassion
- Understanding of medications and their side-effects
- Awareness of family dynamics
Challenges
- Providing support for families, dealing with difficult family members
- Being a patient advocate
- Dealing with death on a daily basis
Education
Rhonda suggests that people skills and time spent nursing are what nursing education needs to address. She describes her hospital based training as fantastic and feels that today's students need more clinical support.
However, Rhonda believes that ongoing knowledge that provides education in a specialised field is essential to nursing education. One area of contention that Rhonda identifies is the current lack of career structure for enrolled nurses. She feels that there should be in place a structure that recognises years of experience achieved similar to the structure that currently exists for registered nurses.
5.12 Registered Nurses - Hospice
Angela and Kym are registered nurses who work in the Australian Capital Territory. Specifically, they work in palliative care within a hospice setting. They find it to be an interesting practice area that can be quite stressful and emotionally and physically draining.
Descriptive words used by Angela and Kym to describe the type of nursing they do include 'rewarding', 'holistic' and 'multi-layered'. They highlight the issues of working with patients who are terminally ill. Both nurses feel that to do their job it is important to "know who you are and how you interact .... and where you fit" in order to effectively care for their patients (13:13:617-9). In depicting a typical day Kym states: "There is no typical day. I think we lurch from crisis to crisis but I don't think there is a typical day" (13:11:496-7).
Angela and Kym rate highly the importance of nurses continuing to do the simpler, hands-on tasks for the purpose of assessment:
I have had to give a lot of people showers - I don't have a problem giving that away ... but it still all hinges on your daily work. You can give somebody else a shower but you might have to go and help them and then you know that you do an assessment while you are standing in the shower helping them.... I think the role of the nurse is ...just looking at the whole picture ... we can give it to other people but we still need to know what the information is so we can treat the whole person (13:10:478-85).
They also believe that palliative care is not "just about death and dying" but rather facilitating living:
...it's about caring and sharing, working as a team, communicating all those types of issues, it's about just being you and getting on with living. Self-preservation is probably one of the most important things - that's what palliative care is - looking after yourself to be able to look after others. To do that you need knowledge and you need skills, craft and academic (13:18:910-8).
Models of Working with Others
Angela and Kym see themselves as a member of the team that provides care to the clients. While a number of other allied professionals are involved in the provision of care Angela and Kym feel that they ".... are the people who are there 24 hours a day and know the patients better than anybody else - facilitators who make it all happen" (13:10:486-7).
Skills
- Humour
- Compassion
- Caring
- Knowledge of medications, basic nursing skills
- Communication
- Assessment - listening, intuition
- Ability to work as a Team member
- Pain management
- Culture - an understanding of spirituality
- Self-awareness, self-preservation and distancing skills-"so you don't hurt them and they don't hurt you..." (13:11:xx).
Challenges
- Stress from dealing with so many people in a day
- Time management
- "Just doing what we have to do at that time in a given time..." (13:9:398).
- Emotional intensity
Education
Angela and Kym feel that there needs to be more of a bridge between the clinical and academic components of nursing education. Angela states:
you can educate somebody on pain management - you can't educate somebody on going in and sitting down and talking to that person - some basic skills - its experience its about knowledge and experience of sitting down and talking to that person, finding out where they are at and then dealing with whatever their problem at that time...(13:11:508-12).
Kym also thinks, "death education is really important" (13:17:822) for nursing education because, particularly in this practice area, nurses are dealing with death on a daily basis and they need to have a good understanding of death and grieving in order to work in palliative care.
5.13 Enrolled Nurse - Community Health
Melanie is an enrolled nurse (RN Division 2) who works in community palliative care in Victoria.
In one day Melanie will see five or six clients in their homes, all of whom are terminally ill and have usually requested to die at home rather than in hospital. She will assist the client in hygiene and will provide support to family members. Melanie is left to organise her own day, which is not so task oriented, and enjoys the independence that work in this practice area brings, particularly because it enables her to spend time communicating with clients and their families. Her day starts at the central office where handover occurs and concludes with a debriefing session for the nurses.
The nature of Melanie's work means that there is no typical day and she is often unsure of the environment she will encounter behind each door. Melanie is regularly involved in conflict resolution either between family members or on occasions where clients or their relatives relinquish their frustration and aggression on her. In comparison to other nursing practice areas, she finds the work to be less physically demanding but more emotionally tiring. She finds it difficult to not get too emotionally involved and to also prevent the clients' relatives from becoming too attached to her.
Models of Working With Others
Melanie has a supportive relationship with other members of her nursing team. Because she is in patient's homes everyday she plays a pivotal role for psychologists and pastoral workers who are also involved in the clients' care but often are unable to visit as frequently.
Given that her work environment is the client's homes, Melanie interacts most with the clients and their families, providing them with support and information.
Skills
- An ability to work independently
- Self-confidence
- Time management
- Counselling
- Self-assessment of when to call an RN
- Flexibility
- Patience
- Empathy and supportiveness
Challenges
- Uncertainty of what will be encountered on a daily basis
- Staying calm
- Not getting too emotionally involved, so you don't burn yourself out
- Lack of staff/lack of funding
- Conflict resolution with clients as well as family members
- Time management
Education
Melanie feels that there are insufficient courses in palliative care for enrolled nurses. However, she also recognises that it is a small field and few enrolled nurses are encouraged to enter palliative care work.
In preparing for palliative care work, Melanie found the course she undertook was very useful, particularly the education that it provided on spirituality and bereavement. She found that this information assisted her in her ability to counsel and support clients and their families, which is a fundamental skill for Melanie in undertaking her nursing work.
5.14 Registered Nurse - Community Health Centre
David is a Registered nurse employed within a community based alcohol and drug service in rural Queensland. His client base is around 30,000 people from the surrounding shires, comprised of a number of small communities. In his role, David is responsible for counselling of persons with drug or alcohol addictions, arranging detoxification referral and set-up, and support and education of hospital staff (medical and nursing) involved in the detoxification process, and in constant liaison with local GP's.
A typical day for David will involve starting work at 8am, and possibly attending a hospital first, and ending around 4:30pm. Here he will see if there are any referrals from the local area and if there are any inpatients to see him. He may also need to speak with staff about incidents which may have occurred since he has last seen them, as for example, in regard to the needle availability program. Following this, he will begin his 'client load' of counselling sessions.
For his own safety, David tries to avoid consultation in the client's home. He may consult with them in a hospital, in crisis care or community centres; "I see people on the side of the road. I see people wherever it is convenient for them and whichever suits my treatment regime at the time.....I've seen people in the car, under the tree." (26:14:326-328) In a day, David will consult with a minimum of three clients for an hour each, to a maximum of 7-8, although he tries to avoid this many.
The aim of David's involvement, he says, is based on 'harmonisation'- bringing the client back in control of their life. His is a holistic approach which look s at the client's lifestyle, relationships, past, future, and their physical and emotional functioning. His role is to set up the client's detoxification program in a local area, or to give the person details of facilities in other towns close by.
Wednesdays are of a different nature and is held as a 'team day'. It is a day for a sort of informal team supervision. This day includes clinical updates from other members of the team.
Model of Working With Others
Within the service where he is based, David works in close consultation with a range of health professionals. These include Nurses and medical staff associated with the Methadone program, Psychologists, health promotion, education and research staff, an exercise therapist, senior promotional health officer, a staff education and training officer and a research officer.
In rural areas within his client base David is constantly involved with medical and nursing staff of the community hospitals in providing support and education related to detoxification programs. He will also interact with non-medical staff at these hospitals such as cooks and cleaners because they also have some extent of involvement in detoxification programs. He is also in strong liaison with GP's. The level of interaction with the GP's depends on their isolation, with most interaction occurring with those doctors most isolated from other peer support networks. He also provides a business hours on-call partial service to one shire outside his area. This service is counselling and treatment only, with no health promotion or education roles involved.
In the broader community, David is also involved in working with community centres, domestic violence groups, crisis care accommodation, women's groups, church groups, and local councils.
Skills
Skills identified by David as being central to his type of work include:
- Physical assessment -"good basic nursing stuff for addiction" (26:12:351)-signs of addiction and withdrawal syndromes;
- Psychological assessment - looking at their affect and mood, their social interactions;
- Self-preservation and self-awareness- related to extricating yourself from dangerous situations arising from drug abuse which can lead to violence; and
- Communication skills - talking and listening, the ability to paraphrase to induce understanding, the ability to confront the person about their life, reflecting the person's speech back to them- "assertive and diplomatic" (26:16:398).
Challenges
David identified the greatest challenge as being the lack of services to rural communities:
I can talk to a client and they will agree they need to go in for detox and there is just none there. They might have to go to Brisbane for detox. They may have to wait three days to go to Brisbane for detox because no beds available.........the challenge is for me to try and support that person as much as I can so that they are still able to maintain some sort of abstinence or some sort of lifestyle until they can get into rehab- and some motivation. (26:17:404-412)
Another major challenge lies in trying to break down the stereotypes of people with addictions held by Medical and Nursing staff and GP's in order to gain the best treatment for the client. This is done primarily through education programs, especially with GP's. Time is also a major factor. David finds it difficult to find the time to include all facets of his multi-faceted role including community building, treatment, education, and health promotion.
David also finds a major challenge in one of his educational roles with an acute psychiatric unit of a hospital. The challenge lies in "getting them to look at or modify their practice as far as clients who have a dual diagnosis or come in with a drug induced psychosis" (26:20:485-487).
Education
David is a Level 2 Registered Nurse with a graduate diploma in mental health. He thought that these courses could be more suited to his profession by a greater emphasis on alcohol and drug abuse; "we hardly touched it in my degree and I was told that drug and alcohol nursing was not a part of psych. when I did my psych." (26:21:521-523) David believed that drug and alcohol addiction was more broadly involved in people's lives than nursing staff would believe. He offered the following example; "a lot of older people do have addictions and you bring them in out of their environment and you take away their...half beers a day, their sera pax, or temazipan and they go right off" (26:22:542-544).
David also felt that counselling should have been a stronger part of the curriculum, stating that it had been 'mentioned' but not "reinforced that well" (26:22:571).
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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