The Scope of Nursing in Australia: A Snapshot of the Challenges and Skills Needed
- 5.31 Registered Nurse - Defence
- 5.32 Enrolled Nurse - Defence
- 5.33 Enrolled Nurse - Remote Setting
- 5.34 Registered Nurse - Remote Setting
5.31 Registered Nurse - Defence
Helen is the nurse unit manager of an outpatients department for a defence hospital in New South Wales. Her job is to 'look after' defence force personnel in an outpatients' treatment area on the military base. Helen will see personnel for scheduled check-ups and assessments. She will also, attends to 'sick parade', will attend to 'walk-ins' who feel unwell and present for assessment, may referring them to a doctor or to the hospital, and also conducts preventative health programs. Preventative health programs include education of military personnel in lifestyle, diet, and smoking.
Helen describes her clients as "healthy patients. Healthy, wonderful, motivated patients." (29:7:120) She may remove plasters and sutures, and conduct ECG's as part of the medical check-ups. As a nurse manager, much of Helen's time is also spent in dealing with administrative problems related to rosters and safe manning in other buildings from where she has her treatment clinic.
Although scheduled to work from 7:30am until 3:30pm, Helen generally doesn't leave work until around 5pm. She feels that is part of her leadership role to be the 'last out-turn the light out'. Helen spends this extra 1 ý hours in tidying her 'messy desk', looking up statistics and collating them for the physiotherapists injury prevention program, talking to doctors about 'interesting cases' and liasing with the ward staff.
Models of Working with Others:
In the department, Helen manages there are four doctors housed within four consulting rooms. She also manages two other related medical facilities, and a specialist centre where outpatients clinics are held. In her daily work, Helen interacts with specialists, GPs, officers and soldiers, other clinicians, physiotherapists, hand therapists, psychotherapists, clerical staff, and administrative staff. There are no on-call or agency staff, so the medical and nursing staff will aid in other areas if need be. Helen will work on the wards if they are short of staff.
Skills
Good communication skills are first on the list of skills that Helen feels are central to her position. She describes the necessity of being able to communicate with other staff and the patients without intimidating them, and being able to know what questions to ask. As part of a military organization, Helen also felt it was very important to gain credibility by understanding what is involved in the jobs of the officers and soldiers. She feels that felt she has gained this credibility by serving in uniform herself "otherwise they just think you're a dumb civvy" (29:10:209). Assertiveness was also an advantage in Helen's position, as were "honesty, integrity and professionalism" (29:12:304).
Helen also discussed the need to look at the patient holistically and understand the support structures, or lack of, which might be in place in their social life:
... you might be looking at someone who comes in, with a very high fever and you don't think he can self-care so you throw him in a ward to be observed and helped out, stuff that wouldn't be admitted to a normal hospital (29:11221-224).
Relative to this, Helen cites assessment skills as being also very important, and believes that her own are highly developed.
A broad knowledge base and the ability to triage a situation is also very important, "from one end of the spectrum to the other......strapping for an ankle...preventative stuff right through to when to dial 000" (29:12:294-297). As a leader, Helen also believes that loyalty and the willingness to 'roll your sleeves up' is also very important (29:12:307). Also from a management perspective, Helen believes that honesty in letting workers know when they are not performing adequately is important, as is listening to their opinion.
Challenges
Working as a contractor, rather than an 'employee' of the military presents a set of challenges. Helen is not paid sick leave, annual leave or superannuation, and as such doesn't feel that her loyalty to the organisation is recognised, and is also concerned about her future, which is unstable.
Keeping a 'harmonious relationship' with such a variety of personalities is also a challenge that presents to Helen as a Nurse Unit Manager. This is relative to a great range in age and demographics associated with the military. On a personal level, Helen finds trying to balance work and family quite difficult, especially when she is called upon out of hours to deal with work problems.
Education
Financial assistance would be useful to Helen in trying to gain continuing education:
it would have been easier if I didn't have to pay quite as much in fees to do a course. At the moment I have to argue with the business manager to get them to pay either for the course or my salary for those hours of attendance (29:16:402-405).
Helen in no way condoned the way that she was taught when gaining her Nursing education, referring to self-taught blood taking on her flatmate, working them like 'Trojans', spilt nights off, and 12 weeks of constant night shift, but she did feel there was a greater need for more clinical skills in modern nursing education.
5.32 Enrolled Nurse - Defence
Mary is a civilian enrolled nurse working for the defence force in Western Australia. She works predominantly with outpatients, seeing the patients before they the doctor attends to them.
The environment is very unique to Mary's practice area. The medical centre is impeccably clean and orderly. While the pace may not be as busy as it is in previous civilian workplaces, Mary does experience a variety of tasks and challenges in her work. Mary takes blood, conducts ECGs and inoculations under the supervision of a registered nurse. A typical shift for Mary will commence with seeing outpatients, followed by conducting preliminaries for upcoming medicals and attending to any dressings. Minor operations are also conducted, whereby Mary will be required to assist and ensure that all equipment required is in order. Mary is also receiving training in a number of tasks unique to her job, including search and rescue training which involves her being winched out of a helicopter. If an emergency occurs on the base, then Mary will be among medical staff that provide assistance and administer first aid to the injured.
Models of Working with Others
Mary interacts with doctors, nursing officers and other medics, the majority being members of the defence force. She describes her interaction with these staff as comprising of teamwork, however she indicates a distinction between the civilians and defence members with an increase in tension due to the possible increased intake of civilian nursing staff whose wages are significantly lower than their defence counterparts.
Skills
- Extensive nursing skills that enable taking bloods and giving injections
- Ordering stock
- Providing preventative mechanisms for an already healthy population
Challenges
- Improving skills
- Knowing the boundaries
- Working within the chain of command
- A civilian working in a military environment
Education
Mary feels that enrolled nurses could be given more extensive training and involvement in the community. To make work more interesting for enrolled nurses, she would like to see training in skills such as taking blood and doing ECGs.
5.33 Enrolled Nurse - Remote Setting
For two years Jodie has been working as an enrolled nurse in a small 20-bed hospital in a remote, rural area of South Australia. The area in which she works has a very large catchment area and has a large aboriginal component, as well as a large number of people from other cultures.
Jodie describes the work she does as "general medical", in which she is involved in every aspect of nursing from the most basic of wound dressing to major trauma from road and mining accidents. Although she is an enrolled nurse, the remoteness of the hospital means that Jodie has to perform many duties enrolled nurses are not called upon to perform in metropolitan hospitals.
In a typical day then, Jodie may work as the Triage nurse, initiating emergency care is some cases, sometimes assisting doctors in minor theatre once a month, taking blood, facilitating student nurses, stabilising emergency patients, and doing general showering and observations of inpatients.
In the case of major emergencies such as mining accidents, all medical and nursing staff available may be involved in the emergency department. In this case, one member of staff will have to leave to care for the inpatients, otherwise the DON may be called to take on duties in the ward.
Model of Working with Others:
On a typical day, Jodie will be involved in interactions with other nursing staff at the hospital- both enrolled and registered, medical staff, and with visiting allied health professionals such as a physiotherapist. Agency nurses may also be employed at the hospital periodically. There are a number of community health workers involved with the hospital including mental health workers, a social worker, and a women's health nurse. There is also a visiting female doctor who deals with women's health issues for three days every six weeks.
Staff of the remote hospital are in regular liaison with the Royal Flying Doctor Service, and also videoconference with specialists from a major metropolitan hospital when needed. Jodie also describes use of out-of-hours remote services such as drug-and-alcohol counsellors and domestic violence hotlines.
There is a one to one ratio of enrolled nurses to registered nurses in the hospital where Jodie works. She describes her interaction with the registered nurses as "indirect supervision". By this she means that she acts autonomously within her legal boundaries, but will always inform the registered nurse on shift of any treatment she undertakes independently.
When rostered as the triage nurse, Jodie will often have to work alone in the emergency room, with other nursing staff being involved with working on the wards. In this instance, Jodie will instigate a number of treatments herself, or may call upon the registered nurse if she feels the need to triage a person very highly.
Skills:
The small number of staff employed in the hospital where Jodie works, the one to one ratio of registered nurses to enrolled nurses, and the remoteness of the hospital require that Jodie is very multi-skilled and that she be able to perform duties not generally associated with being an enrolled nurse. The skills Jodie pinpointed as being central to her nursing role were:
- Triaging skills - deciding in what time frame a patient needs to see a doctor, instigating ECG's;
- Communication skills - the ability to be a 'front person' for the hospital and deal with grievances from patients and families as there "is not always somebody to palm it off to" (27:11:228-229);
- Confidence in her own judgement and nursing abilities;
- Setting up and assisting minor theatre (preparing patients, setting up trays, cleaning up, re-setting, and sometimes scrubbing in and assisting;
- Taking blood; and
- The ability to work medical equipment such as monitors and pumps.
At the time of interview Jodie was soon to be assessed to gain approval to be able to cannulate. She emphasised that her strong need to be multi-skilled required that she was always adding on to her skills, either by participating in set accreditation processes, or through her own research.
Challenges
Jodie identifies her greatest challenge as the unpredictability of her work; "you never know what is going to come through the door" (27:14:320). She also cites the remoteness of the area as a particular challenge in emergency situations:
... if we have got something that is really acute, high risk that comes through the door we have to stabilise that patient and we are at least 1 1/2 hours before we can get a flying doctor plane in, sometimes its 2 1/2 hours if we need to get a retrieval team to come.....You have to wait that time. You really feel the remoteness in those situations (27:14:321-326).
A high incidence of alcohol abuse from within the community also presents a major challenge for Jodie as a nurse. The challenges are particularly associated with people entering the hospital while intoxicated and becoming abusive. Often this results in police intervention. She also describes how often people will often present to the hospital with feigned injuries in the hope of gaining a bed for the night.
Working with agency staff also presents some challenges for Jodie. This was associated with trying to explain basic information such as where things are located to the agency nurses. This is a problem because of the small number of nursing staff available to work with the agency nurse, especially in emergency situations.
Education
To be sufficiently prepared to work in her position as a remote area enrolled nurse, Jodie felt the need for quite vast experience. She states:
... to at least have done some acute medical surgical stuff. To be aware of what the drugs are, what could go wrong with things especially the cardiac side of thing, more preparation for accident and emergency (27:22:541-544).
She again reiterated the need for multi-skilling.
Jodie discussed the need for the 'melding' of what is learnt in university and what is used in the hospital. She felt there needed more time to be spent on learning and practising clinical skills. While she supported formal academic schooling, she felt that physically being taught by someone was more important. She supported the model of education she experienced 14 years ago when doing her nursing education at TAFE:
... you did that initial block then you went out in the hospital for 3 months and you worked on the wards as one of the team and you put into practice everything you had learnt in that first block........then you did another block at TAFE and then you went out and practiced until your time was up (27:26:623-628).
Jodie also felt that generally enrolled nurses were undervalued and deserved more credit. She felt that registered nurses needed to be given the opportunity to develop their skills, and that the responsibilities of her position had allowed her to do that.
5.34 Registered Nurse - Remote Setting
For the last ten years Jenni, who currently works in remote Western Australia, has worked as a remote-area nurse. She spoke of a number of these roles, many of which dealt primarily with Aboriginal health. Often she was the only medically trained person in the community, or one of two. She described the skills she required in these positions as needing to be "a master of all trades" (25: 12: 247).
As a nurse in a number of very multi-cultural communities, Jenni expresses the need for a knowledge base vastly different from that needed in mainstream emergency settings. This is because of the exposure to and susceptibility of an entirely different set of diseases arising from an entirely different background relative to climate and genetic predisposition in a remote and sometimes tropical setting.
The facilities in which she works are often one-roomed facilities, which are frequently cut off from power and water because of problems with the power-supply. Jenni emphasised the focus on trauma nursing, especially that arising from alcohol and other substance abuse and related violence. Jenni spoke of a typical Saturday morning in one of her sole charge positions:
...you spend the whole day repairing trauma, anything from someone with seven stab wounds in the back to a dead person because a besser block crushed their skull, to that one is probably dead because the wire is still hanging on the tree, to I've got pain sister to oops I have got a baby (25: 17: 420-424).
On a day such as this, Jenni may see up to 40 patients in a day on her own.
Any patients needing overnight care will be flown out by the Royal Flying Doctor Service. Being so isolated, Jenni will be called upon to perform procedures beyond the normal scope of the registered nurse. These include intubation and drug therapy with the guidance of a doctor by phone.
Health promotion is also a major concern to Jenni in her work where what would be considered basic sanitation and nutrition could be lacking in these isolated communities:
We provided everything free to the people right down to hoses, toilet paper, bleach. They needed to be able to clean the toilets, clean the floor-they had poor housing. That stopped a lot of dysentery and diarrhoea.. (25: 14: 330-333)
Other predominant health related areas that Jenni deals with in a 'typical day' are paediatrics, malnutrition, liver damage, imuno-deficiency presentations, and renal disease. In the case of dialysis, the patient will return to Jenni's clinic everyday for the first few months because 'self-management' in the community is almost impossible within the home setting. She also undertakes about 40 hours of driving a week in order to service the surrounding communities.
Model of Working With Others
In Jenni's first sole-charge remote area position she received back-up support from regional 'Aboriginal Medical Services'. From this service she gained pharmaceutical, medical, and sanitation supplies such as bleach and toilet paper, and baby formula.
Skills
Jenni described the need of being a 'master of all trades' (25:10:247). The first skill that Jenni was taught as a remote-area nurse was four-wheel-driving. The location and isolation of this position makes this a necessity. Jenni talks about having to learn the skills of plumbing, being an electrician and learning to be "a bit of a motor mechanic" (25:8:161).
Other skills she described were environmental, communication and assessment skills. Jenni placed an emphasis on 'top-to-toe' assessment skills because "when you rang up a doctor you have to have systematically-top to tail gone through everything" (25:20:525-526). In addition, she described the importance of public health, health promotion, primary health care and emergency type skills. On a budget of $220,000 a year, Jenni also needs excellent budgetary skills.
Due to her isolation, Jenni often performs medical duties usually undertaken by a doctor. Examples of this include cannulation and intubation, where a doctor would stay on the phone for the duration of the procedure.
Now working in a remote area of Queensland, Jenni also describes the skill base needed for working in an extremely multicultural community.
...we have about 13 different cultures. Just having worked in a cross cultural environment and just knowing where they have come from and what their background is and where they have travelled and what to look for.......Hansen's and rheumatic hearts.......knowledge about what to look for when they see a person who comes from Cocos or Christmas Island- they have their own set of risk factors..(25:15:359-370).
Challenges
Despite all the challenges involved in working in a poor, and remote community, the challenge that drove Jenni out of remote practice was the legal restrictions on remote practice. As legislation became increasingly restrictive of what Jenni was allowed to do without a doctor's permission, she felt that she was no longer able to practice properly in the interest of the patient.
In some communities you just have to get in and go for it and you can't-not unless you are getting Doctor's orders to do everything. You may give the Oxygen, you may out an?? angine in under the tongue, but then you must have phoned the doctor. You can cannulate but you wouldn't be allowed to run the fluids unless you had the doctor's order (25:20:533-538).
Some days you had acute asthma or acute bronchi with kids and often through the night, because that's when kids get the sickest. Often the RFDS were really busy. They had huge workloads. The doctor might be on duty all night. You might be phoning up 20 times a night. They were finding that pretty tiresome of course. We were only allowed to give two Panadol without doctor's orders. When you are on call at night in a community that is packed with trauma, gets a bit wearing and that is what in the end burnt me out of there. I just thought I can't practice properly (25:21:551-560).
Another challenge relates to violence, especially when working in isolation at night:
...we had one time petrol sniffing. And when young kids from the age of 4-18 are roaming in gangs petrol sniffing its like living in a war zone. They would literally charge the clinic with weapons. We would really just hide (25:26:709-712).
Education
Jenni described the difficulties of having different standards for nursing education between states and between Australia and New Zealand. This means that it is impossible to assume that a graduate nurse has certain skills and knowledge. She felt that there was a general lack of background knowledge in pharmacology and microbiology which was important to her position.
Jenni stressed the need for both a strong theoretical background and an equal amount of hands-on clinical experience. As a nurse in a somewhat unique setting, she also felt it was necessary to "expand our view of what a nurse is going to be doing" (25:26:668), because not all nurses will be working in a hospital setting.
She also emphasised the need for a focus on holistic practice with a "background of science and technical skills ...making you a really accountable nurse in today's society" (25:26:674-765). As part of being holistic, Jenni stresses a need for nurses to also practice health promotion, public health and primary health care, rather than just taking a curative role.
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last updated on Tuesday, 04 December 2001
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