The Scope of Nursing in Australia: A Snapshot of the Challenges and Skills Needed
- 5.15 Registered Nurse - Private Medical Rooms
- 5.16 Enrolled Nurse - Private Medical Rooms
- 5.17 Registered Nurse - Agency
- 5.18 Enrolled Nurse - Agency
5.15 Registered Nurse - Private Medical Rooms
Carmen works as a registered nurse in two general practice surgeries that are run by the same doctors. In these practices Carmen is involved in a great number of tasks. These include specific medical tasks, as well as management focussed tasks such as ordering of stock, rotation of drugs which have expired and monitoring refrigeration temperatures of vaccines.
The more typical medical tasks Carmen undertakes are ECG's, vaccinations, wound dressing, blood-tests for sugar levels and pregnancy, taking blood for laboratory testing, and checking patient's blood pressure. She also undertakes preparation for minor surgery such as removal of moles, and suturing of minor cuts. Much of Carmen's time is also taken in education of patients in regard to their medical condition, and answering phone calls of people with medical questions who are unsure if it is necessary to see a doctor. Occasionally emergencies will arise accidents or falls which have occurred close by, at which time Carmen will be involved in giving First Aid and making Triage decisions.
Carmen's major challenges are related to her educative role within a multicultural community. Often there are language barriers to overcome, and even more difficult are cultural barriers associated with a male patient and a female nurse. She also cites the doctor-nurse relationship as a minor challenge with one particular doctor who believes the nurse's "primary role is to take the patients into his waiting room" (18:8:213-214), and such undervalues her skills as an experienced nurse. Associated with these difficulties, Carmen feels that communication skills and patience are paramount to her position.
Models of working with others
Carmen is one of two registered nurses working within two general practices operated by the same 8 doctors. However, there is only one RN on duty at any given time, with the days spilt evenly between them. In addition to her daily interactions with the GP's, patients and reception staff, Carmen is also involved in liaison with radiology staff, some District Nurses, physiotherapists and the Aged Care Liaison from various hospitals. On fewer occasions she will interact with patient's social workers and carers, and will make appointments with specialists for referred patients.
At the changeover of shifts between the two nurses, the RNs will each count the PBA drugs held within a locked cupboard in the surgery.
Interactions with doctors are generally relative to gaining instructions for the ongoing care of a patient after initial treatment has been given. Occasionally the consulting doctor will ask Carmen for her opinion, but usually the interaction is quite directive. Carmen understands the boundaries between nursing duties and the duties of the doctors and seems to happily accept them. She only cites one problem with one particular doctor who underrates her abilities as a nurse and believes she is really only there to fulfil reception duties.
Skills
Carmen states that the greatest skill necessary in her position is the ability to communicate; "probably the biggest thing is not really a nursing skill, you have to be able to communicate. You have to be able to communicate with a lot of different age groups, a lot of different ethnic backgrounds, a lot of cultural differences." (18: 12: 313-315); "but you have to be able to talk to your patients and be able to assess what level of understanding they might have about things that you need to tell them and choose what sort of language you will use without being patronising." (18:12:320-323)
Further to this, Carmen also expressed the need to be able to communicate on a professional level with the Doctors, reception staff, and pharmacists with whom she had much interaction. Similarly, she emphasised the need for extreme patience, particularly when dealing with older patients with memory difficulties who need to have information relayed to them repeatedly.
On a more specific 'medical' level, Carmen identified assessment skills by visual, physical and verbal observation of the patient, and emphasised the need to assess beyond the presenting problem to other possible issues. She felt this was particularly important because often patients would avoid presenting 'smaller' medical concerns to their Doctor because they "don't want to bother them".
In addition to assessment skills Carmen identified some more specific medical skills such as Cardiac assessment skills and what she considered 'basic' technician skills such as taking blood pressure, examining blood tests for blood-sugar levels, urinalysis, and understanding pregnancy tests. Wound dressing was also addressed.
Time management was imperative to Carmen's position, as was being able to understand and make decisions based on product information provided by pharmaceutical and medical equipment sales representatives. She also stressed the need for a particularly comprehensive knowledge of pharmacology as she is often called by people asking questions about side-effects and interactions of particular drugs. Carmen felt it was also very important to know how to readily access information when she did not already posses the necessary knowledge.
There was also a legal angle to Carmen's skills: "...knowing your limits, not only your personal limits, but your legal limits and where your liabilities lie and where your responsibilities are." (18: 15: 417-419) Relative to this, maintenance of patient confidentiality was also vital.
Challenges
The majority of Carmen's challenges arose from having to communicate on a regular basis with people with a limited knowledge of English, and also overcoming the beliefs of certain cultures associated with the interaction of a male patient with a female nurse. While older people with limited English often bring a family member as an interpreter, Carmen expressed concern over the use of children for this who may have a limited comprehension of her instructions as well. Use of the Commonwealth interpreter is also difficult because of the difficulties associated with coordinating the interpreter, the patient and the doctor for the same time frame.
The only other specific challenge discussed was that of those who 'abuse the system' by repetitive use of the Doctor's services for no particular medical reason.
Education
Carmen felt that her education had prepared her very well for her position as a Registered Nurse within a General Practice; "I think, generally, to meet the needs of the general practice nurse, certainly the course that I did was more than adequate" (18: 20: 577-578). She did feel that perhaps a greater emphasis on paediatrics may have been useful, but that this was not a major issue.
5.16 Enrolled Nurse - Private Medical Rooms
As an enrolled nurse working in a medical centre in Western Australia, Kylie does everything from "...whatever walks in the door, casualty wise to assisting with the procedures with the doctors..." (33:3:62-5).
Kylie's day starts by checking what appointments have been made for the doctors and whether there will be any minor operations or procedures. She will then set about preparing any necessary equipment for the operation and will assist the doctor with ECGs, ultrasounds, making appointments with pathology and conducting aged care assessments. Describing the pace of her day as 'flat out', Kylie rarely finishes her work in the time allocated "...because the jobs they are requiring you to do are huge..." (33:7:187). Given that there are a number of doctors working at the centre at any one time, Kylie often finds she has requests for assistance from more than one doctor at the same time and so prioritising and anticipation are important skills for her to have. Despite the hectic environment and challenges that confront Kylie, she loves the variety of her work and "...the fact that you just honestly don't know what is going to walk in the door next" (33:15:474-5).
Models of Working with Others
Kylie finds her workplace has a good atmosphere and she works well with receptionists, fellow nurses and doctors alike.
A number of work issues have arisen as a result of nursing staff cutbacks and removal of penalties at the clinic where Kylie works. This has created tension among employees and the doctors who are also their employers.
Skills
- Knowledge of wound care
- Organisational
- Computer
- Communication - listening skills
- Assisting people suffering from depression
Challenges
- Dealing with aggressive, verbally or physically abusive patients
- Attending to drug overdose patients
- Knowing the boundaries of an enrolled nurse
Education
Kylie identifies triage, first aid and computer knowledge as areas that nursing education could cover in order to be more responsive to the work that she does.
5.17 Registered Nurse - Agency
Suzanne is a registered agency nurse who works in metropolitan Queensland. She works predominantly in one acute hospital, but on occasions will complete shifts at two other acute hospitals in the area.
Given little time to familiarise herself with the ward, fellow staff and patients, Suzanne has to 'hit the ground running'. She is often given a heavier load of patients than the other nurses who work regularly on the ward because they either want a break, or she is partnered with the team leader who will be busy with other nursing activities. Consequently, Suzanne is left with the heavy showers and sponges for their allocated patients. Fellow staff have a high expectation of assumed knowledge regarding patients and procedures particular to the ward that she is working on. Suzanne is often rushing in her work because as an agency nurse, she has one hour less at the beginning and the end of her shift to get everything done.
Suzanne feels that it is imperative that she is aware of what is happening around her, that she knows who she is and where she fits within the hospital/nursing system. Changing workplace on a shift-to-shift basis requires her to keep in mind how much she can do for her patients in a single shift that might make a difference for them.
Models of Working with Others
Suzanne identified a feeling of remoteness from the other nurses who work regular shifts on the ward. This experience increases in circumstances where she is not introduced to fellow staff or given a ward orientation.
In her work, Suzanne interacts with nurses, doctors, kitchen staff, pathologists, oncologists, pastoral carers, nuns and priests, visitors, orderlies, and police. Suzanne identified both benefits and issues created by her interaction with a wide range of people. She finds it interesting and beneficial that there is such diversity involved in the patient's care.
She hi-lighted difficulties that arise in contacting and communicating with doctors:
...it can be difficult to contact somebody or you know, because it's a private hospital you can two or three specialists involved with one patient, and you're trying to get onto them and they're just not returning their calls or ... umm... you're trying get onto them and they're just not returning their calls or ... umm... you're trying to find out which is the right specialist to contact for this particular thing, for this particular patient umm...so yeah, those kind of things can be a hassle... and I guess the main hassle is with the doctors... historically for nursing it has been umm... and I don't think that's gonna change... (1:4:78-84).
Suzanne also felt that her work with the team leader under-utilised her skills:
...because I'm doing all the sponges and all the showers and it seems like all the junior nurse kinds of stuff... you know like, every so often I'll get to do the pills, but it's the team leader who's doing what...all the extra stuff that distinguishes an EN from an RN ... you know like, the doctors rounds umm... getting pathology reading dong the compute doing the notes ... doing the discharge and admissions...(1:10:274-280).
Skills
Suzanne listed a number of skills that are required of her in the work that she does, including:
- The "basic qualifications and basic skills of any Registered Nurse" (1:14:406);
- General nursing duties;
- Oncology work eg. General medical and surgical oncology;
- Basic patient care - eg. Pressure area care, feeding, bathing;
- Admitting and discharging;
- Medications and doing the paper work
- Knowledge and understanding of various disease processes and medical conditions;
- Knowing how to access information;
- Recognition of patients' confidentiality;
- Communication skills;
- Assessment skills;
- Interacting with doctors; and
- Being a patient advocate. Suzanne perceives caring as being more one on one with the patient.
Challenges
Challenges identified by Suzanne were:
- A lack of ward orientation;
- Not being introduced to staff at the start of the shift;
- Not being placed on the same ward or with the same patients in future shifts,
- The allocation of the heaviest load of patients;
- The expectations that she was supposed to just know things without instruction; and
- The need to be more acutely aware of what is being done around you. Basically getting the motivation to go to work.
Education
Suzanne would like to see:
....a greater amalgamation between hospital and the new training, I want to see them out in the workforce, for the majority of the time and like we did, come back into the school of nursing at the university for blocks of lectures that are going to mix with where they're working so that they're going to get a lot of clinical practice... (1:21:596-600).
She believes that students:
... need to be out there on the wards, working the whole time like we did as hospital trained nurses and still getting that professional university input because I think both are important, I don't think that there should be one at the exclusion of the other... (1:21:606-8).
Suzanne believes that students should:
have a year as a staff nurse before they're actually registered......and then umm... perhaps after that they need to get some experience in agency or something I don't know but.....they need a lot of education about who the staff are, what their roles and how to treat people because nurses are not coming out knowing how they should treat each other let alone how they should treat patients... (1:23:685-90).
5.18 Enrolled Nurse - Agency
Joy is an enrolled nurse working for a nursing agency in Sydney. As an agency nurse her work is quite varied. She provides care in people's homes who are associated with Home Care, Veterans Affairs, or who are Insurance clients. Joy also works in the aged care sector in both public and private arenas, in public and private hospitals, blood banks, group homes, and with Health services Australia which involves screening for migrants.
Joy feels that working for an agency, her major challenges are associated with time pressures. She expressed the concern that the agency was not allowing her enough travelling time between clients, and that sometimes she was scheduled too many clients in too short a time frame. Joy also believed that agency nurses were in great need of more on-going education; having been with same agency nurse for 9 years, she had received only one continuing education course.
In addition, she had often felt that her skills as an experienced enrolled nurse were undervalued and undermined by some registered nurses, including very inexperienced registered nurses. Relative to this, she was very aware that the scope of an enrolled nurse's duties varied between organisations, and such she was sometimes reprimanded for doing tasks of which she felt she was capable and of which she had performed at other places.
While Joy did not really have a 'typical day' as an agency nurse, she does have some regular clients. These include general care of a 13 week old baby of a mother with a mental illness, personal care of a man with severe rheumatoid arthritis, putting a quadriplegic into bed at nights, personal care of an elderly woman who is very frail, and attending to a gentleman with severe muscular atrophy.
Although the skills she will use in a day depend on her clients for that day she identifies a number of generic skills important to her job. Among the more unusual of these included repairing and adjusting equipment needed by clients such as wheel chairs and caring for client's attendant and companion dogs. Joy also identified feeding and bathing, assessment of a new client's condition with little or no background information, understanding of the psychosocial aspects of a client's condition, and knowing how to access other health professionals to undertake care beyond the scope of her position as an enrolled nurse.
Models of Working With Others
Joy works independently most of the time. However, she is involved on a daily basis with the agency staff who communicate to her by phone the clients she is to see on any given day. In addition to the clients themselves, Joy may also interact with home care personnel if she is given a 'double-job' (such as heavy lifting). She is in contact with a range of health professionals on a regular basis to arrange the use of additional resources she cannot provide her clients (such as the client's doctor). On the occasions Joy is employed in nursing homes and hospitals she also interacts with other agency nursing staff and permanent staff of the facility.
Skills
Joy alluded to sometimes having to use nursing skills "going over the scope of practice for an enrolled nurse" (17:6:228-230). The skills she identified specifically as being part of her job were:
- "repairing things that fall apart or making adjustments to wheelchairs and repairs" (17:6:220-221);
- Helping care for "personal care attendant dogs who provide their independence or companion dogs" (17:6:223-224);
- Feeding, bathing, clothing and playing with babies;
- Helping clients with domestic chores;
- Lifting;
- The ability to assess people on meeting them;
- Being able to 'gently' assess the situation and ask the client about their condition, "because some don't want to let you know...and asking them what they want you to do and help them when necessary" (17:8:350-353); and
- An understanding of the psychosocial aspects of a client's condition.
Challenges
A majority of Joy's major challenges came from the time pressures placed on her by the agency. She felt that sometimes the agency tried to 'squeeze in' more jobs than she was able to do in a day. This was due in part to the agency not taking travelling time into consideration when booking clients; "the agency doesn't allow for traffic jams, it doesn't allow you to drive from one side of the city to the other because the girls are unaware of where the clients are located" (17: 7: 285-287). Similarly, she often felt frustrated with the lack of communication in terms of the client's locations, as not being able to find a client's home can take over care time. Joy also felt that often she was not allocated enough time for each client "the time constraints on some of the clients are totally impractical." (17:7:287-288)
Joy also felt that the screening for agency nurses had also declined. Previously agency nurses had to have a minimum of one-year experience and a letter of recommendation from a DON. Now there was no such screening and that left other nurses faced with some incorrect diagnoses, and with a concern for the level of care being received by their client's.
Another concern raised was in regard to instances where the EN was put in a situation where the severity of the client's condition would not allow them to leave. The process to be followed in this situation is to contact Veteran's Affairs or Home Care so that they may approve the EN to stay with the Client. In addition the major carers of the client such as the Doctor or other in-home carers may also be contacted. These carers must be identified by the agency; "You try to get the agency to find out for you. Which is very difficult, they will sometimes acknowledge what is going on but others they will not. I have had success with some clients but non success with others" (17:8:366-368).
The lack of on-going education as an Agency nurse was also a major concern. Joy felt that the agency had a responsibility to provide this, while the agency does not take responsibility. In addition to these difficulties as an Agency nurse, Joy also felt that Enrolled Nurses were 'missing out' on education programs as they were being aimed only at Registered nurses:
A lot of the education that comes through the hospital system or the nursing homes are basically directed to registered nurses. They come into the hospitals but actually don't get down to the floor level so the enrolled nurses are aware of them (17:12: 574-577).
Joy also articulated a conflict between Registered and Enrolled Nurses:
Also you have got the educational differences where your post graduate registered nurses are not aware of the scope of skilful enrolled nurses and therefore there can be some animosity with the junior registered nurses coming on to the floor and creating hassles for the senior enrolled nurses who have been there for donkey's years. You have also got bullying and things like that that goes on between the registered and enrolled nurses but that's been in existence for a while, but it needs to be addressed (17:12:562-568).
Education
Joy felt that too little time was now being spent in the clinical components of tertiary nursing education; "but the clinical components to me, you can't get your feet on the ground in 3 or 4 weeks and actually will be able to learn in that time as well, where my clinical components were I think were 12 weeks in each area. Ok I didn't do midwifery but I think the clinical components need to be looked at so that they get exposed as much as they possibly can." (17:11:536-541)
As an enrolled nurse Joy also felt that trainee enrolled nurses should have senior enrolled nurses as preceptors rather than the current practice of using Registered nurses as preceptors; "For trainee enrolled nurses the use of enrolled nurses as preceptors or as their peer support because we know where they are coming from because we have actually been there" (17:11:541-545).
She also believed that the final block of nursing education should include presentations from various speakers from within the nursing community and professional nursing bodies. This would provide an overview of the 'different criteria's' of various nursing professions.
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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