The Scope of Nursing in Australia: A Snapshot of the Challenges and Skills Needed
- 5.19 Registered Nurse - Private Nursing Practice
- 5.20 Registered Nurse - Development Disability Services
- 5.21 Registered Nurse - Day Procedure Centre
- 5.22 Enrolled Nurse - Day Procedure Centre
- 5.23 Registered Nurse - School/Child Health Services
5.19 Registered Nurse - Private Nursing Practice
Michelle is a registered nurse who works in Queensland in the area of health education. For the last two years she has had her own health and fitness practice where she practices as an exercise physiologist. In this practice she devises health and fitness programs for clients with a pre-existing health condition, and acts as a personal trainer to clients not wanting to attend a gymnasium. Michele also works in the field of midwifery conducting post-natal home visits, and is very active in various areas of health promotion. For example, she works for a health insurance company devising their health promotion programs.
As well as her clients, Michelle interacts on a daily basis with allied health professionals such as physiotherapists, naturopaths, occupational therapists, and medical doctors. Her clients are gained through referrals from these professionals.
Michelle states that no day is really typical in her position, and her tasks are dependent on the day of the week. However, her more typical activities include consulting with clients in developing their health and fitness programs, either at her practice or in the client's home, promoting her practice by writing to or visiting doctors or developing fliers which are left at various places. On other days she will attend her office at the medical insurance company where she will do customer service, and spend around five hours a week completing work from the insurance company. This type of work includes phoning people, or writing letters to people who have requested information.
In her consultation with clients requiring a health and fitness program, Michelle will conduct health assessments involving aerobic threshold, body fat analysis and heart rate, examining their gait, balance and flexibility. Based on this assessment she will then create a program incorporating fitness, nutrition, and other issues dependent on the client's condition- eg: stress management.
Models of Working with Others
Michelle works independently in her practice but is regularly involved in interactions with:
- Physiotherapists;
- Naturopaths;
- Occupational therapists;
- Medical doctors (GP's); and
- Nursing students.
Skills
Skills that Michelle felt she used on a regular basis were:
- Counselling skills;
- Education/Teaching skills;
- Accounting;
- Management;
- Writing;
- Marketing;
- Health assessment skills (heart rate/body fat/blood pressure etc.);
- Understanding of confidentiality; and
- Interpersonal skills - "that skills of building a rapport with people so that they will trust you and talk to you about how they are feeling. A lot of people have issues that they don't want to discuss, they do want to discuss it but they don't know how to." (16:6:246-248).
Challenges
Of the question regarding challenges in her work, Michelle states, "I am challenged everyday. It's difficult because it's so broad."(16:6:156-157) However, some specific challenges she identified were:
- Understanding the vast variety of health conditions she is faced with (physical and mental);
- Staying focussed on the client's holistic health (nursing and fitness);
- Recognition as an 'exercise physiologist' by other health professionals (doctors, specialists), and health insurance companies; and
- Lack of recognition from other nurses that Michelle's work in health and fitness constitutes 'nursing practice'.
Education
Michelle felt that there was not one particular tertiary pathway that was suited for her profession. She encouraged the initiative of QUT to combine degrees in Exercise Physiology, Nursing and Human Movement in order to streamline education into her field. She felt that as an exercise physiologist she was limited in the amount of medical information she received in her formal education, and that more was necessary.
Having been involved with teaching clinical skills to student nurses, Michelle thought that tertiary education in Nursing and Medicine should teach more in terms of health promotion, in order to promote holistic health in their patients. In relation to this she stated, "nursing could certainly know more about how your health does revolve around how fit you are- to improve your health you should be fit" (16: 8: 357-359).
5.20 Registered Nurse - Development Disability Services
Matt is a registered nurse working in South Australia in development and disability services.
As a registered nurse, Matt is responsible for administering medications to patients that reside within the separate units that make up the service. Each unit has its own environment that can vary greatly between a calm quiet setting to a very noisy dementia unit and Matt has to quickly adapt as he moves through the units on medication rounds. Matt deals with challenging behaviours of patients on a daily basis. His assessment skills are vital to caring for patients, particularly because many patients are unable to effectively communicate:
You have to do all with your assessments to be able to work it out exactly with them moaning or crying or something, why they are doing it is it because they are sad or is it because they are in pain and so on and we need some time to spend with them and to have a really good start to be able to assess all those problems and their needs. (10:3:33-7).
Matt's medication rounds take up a substantial part of the day and need to be well co-ordinated, as certain patients require medications at certain times before or after meal times. Matt finds that emergencies and other events will often interrupt medication rounds. He feels that his situations in his work environment change daily and he needs to be quick to respond to these changes. Matt's work also requires constant research, training and acquiring information For example, about medications and their side effects.
Models of Working with Others
Matt relies heavily on written and oral information provided by the registered nurse from the preceding shift about his allocated patients. They have an extended handover, which allows for the two registered nurses to work together as a team. Similarly, Matt works in close collaboration with a number of care workers and mental deficiency nurses, as well as a number of doctors and allied health professionals who are also employed by the service.
Skills
- Nursing skills
- Psychiatric nursing knowledge
- Interpretation of medication and side effects
- Research skills
- Time management
- Adaptability and flexibility to changing work environments
Nursing skills are of greatest importance for Matt in his area of work because of:
... people's mental ability - most don't communicate their needs and their problems and you have to look for the signs and symptoms to be able to work it out exactly what you have to do. Some other staff notice happening connected with behaviour or with pain - need time to collect all the information (10:7:158-161).
Challenges
- Challenging behaviour
- Lack of time
- Fulfilling government requirements regarding documentation, accreditation
Education
Matt identifies that there is a lack of clinical experience to enable graduate nurses to feel comfortable wherever they are working. However, he feels that he has gained significant knowledge from education programs that are run on site by his employer.
5.21 Registered Nurse - Day Procedure Centre
Stacey is a registered nurse who works in the theatre of a day surgery in the Australian Capital Territory.
Her work environment is very confined. She spends long hours on her feet and finds the pace of theatre work can be very busy, with quick turnaround times between patients. Her work as a theatre nurse sees Stacey 'scrub in' and assist the surgeons with instrumentation. She is responsible for setting up the operating theatre at the start of the day and preparing all the equipment, which includes sterilisation. During operations, Stacey will provide instruments to the surgeon and often anticipate his or her needs. At the end of each operation, Stacey has "... about a minute turnaround time, so you have got to pack up your trolley, separate the sharp and dirty instruments and count off how many needles and swabs are there, get that out into the CSC area, ... and then straight back into the room" (11:9:175-9).
Models of Working with Others
Stacey works in conjunction with the anaesthetist, recovery staff, and anaesthetic and scout nurses, but is primarily involved with the surgeon. On occasions, Stacey will experience conflict with some doctors, as a result of their direct sexual comments and innuendo.
If under a local anaesthetic, Stacey will communicate with the patient throughout the operation by "asking them if they're okay and telling them periodically what's happening." (11:7:140-1).
Skills
- Adaptability and flexibility
- Having a sense of humour
- Sterile skills
- Anticipation and assessment skills
- Social skills and diplomacy
Challenges
- Time pressure
- Conflict resolution
- The physical environment, heat and dehydration experienced while in theatre
- Sexual harassment
Education
Stacey believes that to work in her practice area student nurses need "... some background in understanding of the sterile field and I guess it helps if they have had some previous experience in scrubbing up..." (11:12:243-4) She refers to the skills as qualities that student nurses need acquire for education to respond to the type of work that she does.
5.22 Enrolled Nurse - Day Procedure Centre
Sonia is an advanced skills enrolled nurse working in the day surgery of a community hospital. Sonia has been working in day surgery for 8 years, although she has only been employed in her current place of work for one month. Sonia described her place of work as "very busy, very futuristic and currently we do two-thirds of all day surgery in this place" (36:5:85). Her shifts are from 7am until 3:30pm, 10am-6:30pm or 12-8:30pm.
On a regular morning shift, Sonia arrives at around 6:45am. The patients begin to arrive around this time, Sonia will go and introduce herself to her patients and do her best to relax the patient and any family or friends who are in attendance. She will get their details, then do baseline observations, ensure consent forms are signed and will then orient the patient to the wards. Sonia may repeat this process a dozen or more times each day for different patients. The orderly then comes to take the patient to theatre and Sonia will go with them to do a hand over with the ward nurse.
When the patient is done in theatre, Sonia is called for and will take hand over back from the ward nurse if she feels the patient is recovering well enough to return to the ward. On return to the ward, Sonia will do observations for several hours while the patient wakes, and then will arrange for them to have food and drink if they want it. Pain management is also a major role for Sonia. The staff avoid the use of narcotics for pain relief because it prolongs recovery time, therefore she will try other means such as positioning and talking to the patient, but will them request narcotic pain relief if necessary.
If the patient is recovering well, Sonia will contact the family or other contacts to come and get the patient to go home, and discharge them. There is much documentation involved in this whole process, documenting observations, drugs given, whether they have eaten and drank, if a doctor has been contacted and the consequent conversation, and discharge of the patient. After all patients have left the day surgery, Sonia is involved in tidying up and getting ready for the next day by restocking, and general 'house work'.
Model of Working With Others
On a daily basis Sonia interacts with the patients and their families, with her immediate peers who are all registered nurses, with medical staff from theatre, and with other staff such as domestic services for people with particular dietary requirements, and sometimes with religious workers who visit the hospital. Although the nursing staff are required to work quite independently, there is also open communication between them if they feel the need to discuss problems or help in making decisions. Sonia would also inform the coordinator of theatre if there were potential problems.
Sonia will make decisions to administer patients with pain relief medication but is legally unable to give injections. She will make a recommendation for medication and an RN will check this. If the medication is oral she will administer it, or an RN will administer any injections. Sonia also interacts with the surgeons who will often visit before and after surgery, and she will inform them of any problems she has observed. If the surgeon is unavailable, then she will call a ward doctor. For the majority she feels that the doctors recognise her as a professional and feels there are very few of the 'old school' who have issues with nurses.
Skills
The skills Sonia identified as central to her position were:
- Clinical skills: blood pressure, pulse, oxygen saturations, when to apply oxygen therapy, dressings, taking drains out, taking the drip down, IV infusions, setting up ECG;
- Emergency skills eg: CPR;
- Communication and public relations skills: talking and listening, understanding body language;
- Interpretation of physical actions to documentation;
- Being able to set people at ease and reduce stress by using a relaxed manner;
- Technological skills and the ability to update skills to use new technologies;
- Visual observation/sight surveillance/vigilance: the ability to tell if something is wrong and needs to be checked by just looking at a patient, being able to do this with several people in one room, being constantly vigilant of these visual signs.
Challenges
Rather than identifying challenges which were an obstacle to her work, Sonia identified challenges inherent in her work which she thoroughly enjoys; "the challenge for me is making a smooth transition through the operation, they can feel safe and comfortable about, obviously coming out successful and limited pain support and not being too scary for them"(36:12:292-294).
Emergency situations were out of the ordinary and a challenge for Sonia, although she felt that she didn't recognise them as a challenge until after the event. However, public relations presented the greatest and most common challenge to her in her constant interaction with patients and families. This particularly related to dealing with aggressive people. Through her experience Sonia now feels that she is quite adept at dealing with aggression, and feels it is largely through feelings of discomfort and stress that prompt the aggressive behaviour.
Another positive challenge is in teaching new staff and student nurses who come into the outpatient ward. These include TAFE enrolled, postgraduate nurses, and registered nurses also who are new to the position.
Education
Sonia stated, "I can't stress how important public relations is in the day surgery" and felt this was an important thing to stress to students and new staff who came to her to learn. In terms of responsive education, Sonia felt a stronger need for day surgery training; "we so have a same day association that we go to, it is usually quite popular..... a lot of them tend to think that day surgery is just taking obs. and meeting them and taking them to theatre but it is a lot more than that. I think that education could teach that there is a lot more to it than that" (36:14:346-351).
Sonia also felt that it was important to teach nurses to be able to thorough but quick; 'like walking into a room and not focus (on one person)...... teach them to scan the room, look at the drips and drains quickly, look at their colour, look at their eyes and whether, you know different things you can teach them as being more observant"(36:14:355-360).
5.23 Registered Nurse - School/Child Health Services
Jill is a registered nurse who works closely with 2 other Level 2 RNs in a Child health service. The service is located in a metropolitan shopping area as to be more accessible to clients. The majority of infants Jill is involved with are 0-3 years, although the clinic caters for children up to 12 years of age.
Generally, the clinic is an information service for parents. Most commonly, Jill is involved in 'wellness' assessments of infants at key developmental stages. These assessments involve examining the child's growth, and their physical, mental and behavioural development. These assessments are aimed at gaining early intervention for any developmental abnormalities suspected. Jill will refer the child and the parent to a medical officer or a GP if she feels there may be an issue beyond her scope as a nurse practitioner.
Jill is also a lactation consultant and thus deals with mothers who are having difficulties with breast-feeding. She may also become involved with other more social family issues, such as those that arise with very young mothers, and domestic violence and postnatal depression. With these social issues, Jill will aim to gain an insight into the general background of the family, and refer the client to other suitable services.
Jill also spends much time in following up the progress of her clients with whom she has developed intervention strategies. She tries to maintain some ongoing education, and has been involved in the development of information for parents.
Models of Working With Others
The structure of the organisation in which Jill works is currently undergoing a great deal of reform. She referred to a great number of 'teething problems' to do with these changes, and also to the increasing difficulty in accessing allied health services as a result.
On a daily basis, Jill works closely with two other nurses within the clinic, and a clerical person, and addressed both the advantages and disadvantages of working in such a small group:
...we do support each other as peers also, and if we've got any queries about practice or issues that come up, we will quite often speak to each other and we do de-brief, we do do that very easily, but it's not quite as easy not, I mean you've got a smaller network so the dynamics of the team has changed, it's now, you've only got like 3 nurses so I mean if the dynamics are not getting on very well, it would be very unpleasant. (23:10:271-276)
A team manager is also housed within the same location, but their duties are spread between two locations. Formerly, Jill's team had had very close connections with an early intervention worker and two social workers, but under current reform their services had become much more difficult to access. Their access to the organisation's physiotherapist had also decreased. The Physiotherapist is currently employed 2.5 days a week, but this access is shared.
Skills
Jill identified certain skills as an integral part of working in such a small group. She referred to these as the 'tools of teamwork'. These included conflict resolution skills, and the ability to confront.
Clinically, Jill referred to the skills involved in 'normalising' in childcare; normalising feeding and settling of the child in order to help parents who are having difficulties in these areas. Formally, all Nurses in the clinic are required (in addition to their qualifications as a Registered Nurse) to have either a graduate certificate or prior training in child and adolescent health. Relative to this is a strong need for a sound knowledge of normal physical and behavioural development.
In addition to this, there is also a need for the understanding of more social aspects of the family, and of other family-related issues such as domestic violence and post-natal depression.
Challenges
Many of the challenges Jill described related to the difficulty in accessing allied health professionals for referral. A decrease in access to early intervention co-ordinators and social workers meant that the ongoing care normally undertaken by these professionals was now falling back to the Nurses themselves. Speech pathology was one particular area of difficulty, with none being employed within the organisation, and the region severely lacking speech pathologists in general.
Allied health professionals were having to "share themselves" around more and more. The medical officer employed by the organisation visits the clinical only one-half day a week. At other times it was difficult to contact them for consultation referrals.
Other challenges were more related to the social aspects of the job; "it can be quite draining and because of the social issues you have to be really aware of not owning the problem, taking a step back at times." (23:3:28-30) Particularly difficult were those cases were Family and Youth Services (FAYS) becomes involved. Often clients would not come back to the service following their involvement:
... they don't want your involvement anymore, they get angry, and even though they are not really supposed to be told and you've got that choice of whether you let them know that you've notified or not, sometimes they put 2 and 2 together and sometimes they think that it's you, and it's not, so it's hard (23:9:222-227).
Relative to this, there is also the ongoing challenge of trying to work within the confines of Confidentiality legislation when dealing with other organisations such as FAYS, when there is conflict between loyalty the client and the role as a mandatory notifier.
Liaison with GP's was also difficult. Jill expressed the recognised need for, and the on-going challenge of trying to promote their work with GP's. After referring clients to other services, Jill and her colleagues need feedback to understand the ongoing situation. This feedback was rarely given to them from GP's and with their strenuous workload it was difficult for them to 'chase it up'. Also relative to GP's and other health professionals was Jill's concern that there need to be more cooperation between them to limit the amount of 'doubling up' which frequently occurs. However, this cannot be decreased until Jill and her colleagues are recognised as competent child -health practitioners.
Education
Jill felt that the greatest education gap for her current position was in the area of infant feeding. To fill this gap Jill states, "they need to be an RN and they do need some postnatal, midwifery training, definitely and they do need the child as a postgraduate..." (23:19:566-567). She also identified a problem with bringing RN1's into the organisation where an RN2 was really necessary
[I] think it's hard for us too to provide an RN1, to provide that gap in the organisation, because once your in the organisation your under the pressure of service delivery. If the RN1s could work with us, if it was programmed based, maybe if we had a program that was family and baby program and we worked in that program a level 2 with an RN1 and a level 2 with an RN1, I could see that working, as long as you work in a particular area doing that specific thing for a period of time, they would develop skills in that area because they learn, a bit like a teaching and learning. (23:20:585-591).
Jill also felt it was a good idea for those training to be midwives to gain experience in their organisation to gain more community experience.
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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