The 46th Patricia Chomley Memorial Oration 2012 Emeritus Professor Robin Watts AM FRCNA Nursing’s legacy
Australia’s peak professional nursing organisation
RCNA
23 May 2012 Rcna National Conference Clinical And Corporate Governance
Oration RCNA
The 46th Patricia Chomley Memorial Orator Emeritus Professor Robin Watts AM FRCNA PhD(Colorado) MHSc(McMaster) BA(WAIT) Dip NEd(CoN, Aust) RN
Professor Watts is an Emeritus Professor of Nursing, Curtin University and a Director of the Western Australian Centre for Evidence Informed Healthcare Practice, a collaborating centre of the Joanna Briggs Institute. She has been involved in nursing education for 42 years and served on or chaired numerous national and state nursing education committees, reviews and projects. Professor Watts commenced her basic nursing training at Princess Margaret Hospital for Children (PMH) in 1962. Following her graduation in 1965, Robin undertook her midwifery training at the Royal North Shore Hospital in Sydney before travelling overseas where she gained valuable nursing experience in both Canada and the then war torn Honduras. Upon her return to Australia in 1971, Professor Watts undertook her Diploma of Nursing Education at the Royal College of Nursing in Melbourne and in 1973 accepted an appointment as the Senior Nurse Educator in the School of Nursing at PMH for Children. Following the transition of nursing education to the tertiary sector, she left the hospital in 1976 to take up a Lecturer’s position in paediatric nursing in the School of Nursing at the Western Australian Institute of Technology (now Curtin University). Although promoted to various administrative positions within the university since then, Professor Watts has always maintained a close interest in the quality of health care provided for children in all health care settings in Western Australia and beyond. Professor Watts’ contribution to the nursing profession has been and continues to be immense. Of particular note is her involvement with the Australian Health Ethics Committee, the Australian Council of Deans of Nursing, the National Review of Nursing Education, management of the Shared Health Interactive Practice initiative and her work as the Director of the WA Centre for Evidence Based Nursing and Midwifery. These are current examples of her leadership and ongoing desire to progress the nursing profession.
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the Patricia Chomley Memorial Oration Established in 1966, the Patricia Chomley Memorial Oration has become part of tradition at Royal College of Nursing, Australia (RCNA) and has been presented annually to honour Miss Patricia Chomley, the first Director of the College of Nursing, Australia (now known as RCNA). Appointed in 1949, Miss Chomley was director until her retirement from the position in 1964. During the 15 years of Miss Chomley’s leadership, some six hundred students undertook courses. Many of those nurses subsequently held responsible positions throughout Australia and were instrumental in important developments in the nursing profession and in upgrading the quality of patient care. Miss Chomley passed away on 24 October 2002 and the Patricia Chomley Memorial Oration is a fitting tribute to her leadership and contribution to RCNA. Past Orators 1966
Professor J A Ovenstone – Automation and its implications in Australia
1967
Dr Phillip Law – The changing pattern of requirements in professional education
1968
Professor R A Rodda – Pioneer nurses: Then and now
1969
Miss Patricia Church – After twenty years – A pause for reflection
1970
Reverend Mother Lois – The changing status of professional women
1971 Mrs Joanna Wilkinson – Introduction to the concept of the group care unit into professional nurse training 1972 Mr M H Bone – Lifelong learning: The role of permanent education in the education system 1973
Professor R M Mitchell – Nursing and modern medicine
1974
Miss Beatrice Salmon – Pragmatic axles turn on emptiness
1975
Sir Paul Hasluck – What is the use of history?
1976
Miss Patience R Thomas – The role of women over three centuries
1977
Professor David Madison – Coping with crisis: A challenge for the health profession
1978
Dr John R Sabine – A jug of wine, a loaf of bread and thou
1979
Mr James P Smith – Nursing needs a professional renaissance
1980
Miss Rosalie Pratt FRCNA – A time for every purpose...
1981 Dr Rosemary Crow – How nursing and the community can benefit from nursing research 1982 Miss Patricia V Slater FRCNA FCN (NSW) – The role of nursing organisations in professional education – Challenges for the future 1983
Miss Bartz Schultz FRCNA – Founders of the College
1984
Professor Baronees McFarlane of Llandaff – Nursing – Fit for the future?
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1985
Lady Murray – Women of significance in Victoria’s history
1986
Dr Sandra Stacy FRCNA – Nurses and other people
1987
Dr Margretta Styles – The challenge of excellence
1988
Ms Gillian Biscoe FRCNA – Thought, action readiness and responsibility
1989
Sister Veronica Brady PhD – Primary health care: The challenge for the health profession
1990
Ms Gracelyn Smallwood – Aboriginal health by the year 2000
1991
Miss Joan Godfrey OBE FRCNA FCN (NSW) – Nursing’s heritage: Chains to loosen
1992 Professor B Hayes FRCNA – The voices of Australian nursing: A turning point for the twenty first century 1993
Ms Margaret Robinson FRCNA FCN (NSW) – Reflections of the past...promise of the future
1994
Hon Austin Asche AC QC – Family law and its effect on the family
1995
Associate Professor Sally Garratt FRCNA – Nursing and human service
1996
Dr Kathleen McCormick PhD FAAN FACMI – Guideposts for the 21st century
1997
Miss Merle Parkes AM FRCNA (DLF) – Transitions through time
1998 Emeritus Professor Margaret J Bennett FRCNA – The Humpty-Dumpty Syndrome: Obfuscation or clarification? 1999 The Hon. Justice Michael Kirby AC CMG – Nursing and the law – Maintaining human care in the whirlwind of technological change 2000
Reverend Tim Costello – Wholeness, healing and hirelings
2001 Dr Lowitja O’Donoghue AC CBE FRCNA (Hon) – Healing the wounds: nurses and reconciliation 2002
Sister Paulina Pilkington RSC AM PhD FRCNA (Hon) – Looking back into the future
2003
Ms Val Coughlin–West FRCNA FCN (NSW) – Leadership – Great Expectations
2004
Assoc Prof Joy Vickerstaff FRCNA FCN (NSW) – Leading from the Centre
2005
Adjunct Professor Debra Thoms FRCNA FCN (NSW) – Every Step a Challenge
2006 Professor Sandra Dunn FRCNA – Making a difference: how nurses influence patients, communities and healthcare systems 2007 Professor Jocalyn Lawler FRCNA – Nursing in interesting times: a reflection, an analysis and a reading 2008
Professor Sandra Legg FRCNA – Nursing: A Moderated Love
2009 Professor Anne McMurray AM FRCNA – Empowerment and enterprise: the political economy of nursing and midwifery 2010 Mr Jamie Ranse RN FRCNA – Inspiring, progressing and promoting the profession of nursing in disaster health 2011 Professor Tracey McDonald RN, PhD, FRCNA – Nursing: Our multigenerational work in progress The 46th Patricia Chomley Memorial Oration 2012
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Nursing’s legacy Madam President, distinguished guests and colleagues. It is a particular honour to have been invited to present what will be, given the amalgamation of the two nursing colleges, the final Patricia Chomley Memorial Oration for the Royal College of Nursing, Australia. What an eminently sensible legacy to hand on to the following generations of nurses – a single national professional organisation! As in any year, this year (2012) has some major anniversaries to celebrate. Some of these are of particular interest and/or importance. The Queen for example has reigned over us for 60 years, while Mawson and his men traversed Antarctica 100 years ago. Quite different achievements but both have left or will leave a significant legacy. Terms such as ‘dedication’ and ‘tenacity’, among others, spring to mind. In a recent program on Mawson and his team’s achievements, the commentator remarked: “The men have gone but Mawson’s hut remains and so their legacy lives on”.1 Does Australian nursing have a symbolic ‘hut’? If so, are we tending that legacy so it survives? Is it even a legacy that should survive? Is it rhetoric or reality, or a mix of both? There are some in the profession who argue any efforts we have made, if we made an effort at all, in this regard have been a dismal failure. Kieseker’s recent blunt assessment was that “after being central to the wellbeing of Australians for 200 years, nurses have failed to make a mark”.2, p.11 Others are more positive but whether we, as a national group, could very confidently say that we are perceived as having made a significant contribution to this country is a moot point. I wish to explore these and other related issues tonight. What might we place in nursing’s symbolic ‘legacy hut’? I obviously have some suggestions which I will present in no particular order; you may well have some other ideas. I should also at this point indicate the context in which my more recent observations of what was and is happening in nursing have been made as this inevitably influences my thoughts on this topic. Over the last 12 years I have been, in some ways, on the sidelines of nursing. In the eight and half years I spent in university management, only one day a week was assigned to being a nursing academic (and that was usually Sundays). I then spent another two years full time in the School of Nursing and Midwifery before finally retiring, only to pop up again in an adjunct position. The decision to share this aspect of my personal history with you was generated by a point made by a fellow orator one year ago. She was of the view that nurses who take up positions that lie outside nursing, such as university management roles or participation “in medical research of uncertain relevance to nursing
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Oration RCNA … should not be automatically endorsed by us as representative of our profession”.3, p.18 A quote from another source, with one addition, that is ‘men’, and one substitution, that is ‘senior university managers’ for ‘doctors’, also resonated. This is from Helmstadter discussing nursing leadership at the end of the 19th century: “... the compromise on nursing education these women made with the doctors in order to gain rank and a higher social station placed them in an impossible position in terms of their professional aspirations, leading them into all kinds of inner contradictions.”4, p.189 These two statements led to some reflection on my part but my conclusion was that nursing has always been absolutely core to me and that my experience as a nurse, in a somewhat unique position as executive director of university planning, may well have provided me with some useful insights that I could contribute to the debate. I will leave it up to you to decide whether my observations have any degree of credibility. What immediately comes to mind is the significant numbers of educated individuals nursing has provided Australia with. I am not confining this legacy just to the period from the advent of tertiary education for nurses 38 years ago – as an aside you will note that we are edging ever closer to half a century here. The foundations of this legacy were put in place by a small number of nurses who went to the UK to study for qualifications in nursing education and administration, then built on by the College of Nursing era here in Australia – the oft quoted 600 graduates in Patricia Chomley’s era and many more after that. Add to that the recipients of the Kellogg Foundation scholarships for study in North America in the 1980s. Then there are the nurses who gained higher degrees in nursing overseas and/or university qualifications in other disciplines both before and after the advent of postgraduate nursing degrees. Finally there are those who educated themselves, in spite of the constraints of their training.5 Not bad for nice, kind girls (and boys) who didn’t need to be bright. The impact of tertiary nursing education in this respect is most evident in the number enrolling in university at undergraduate level once the transfer was completed. The most recent figures available – 2009 – for domestic students enrolled in courses leading to initial registration as a nurse were 33 489, an increase of 6.5% for females and 5.3% for males from the previous year.6 Many of these would be the first in their family to have gone to university. Nursing enrolments would also have made a significant contribution to the situation whereby women now make up more than half of university enrolments – 55.6% in 2010.7
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But are these undergraduate students actually being educated? Judging by the content of a number of articles in our national journals,8, 9, 10, 11 this is a very pertinent question. I do not intend to enter into a philosophical discussion here on what constitutes ‘education’. Suffice it to say that the goal of those whose vision it was to have all registered nurses graduate with a degree argued for this revolutionary change on the basis that, in order to provide effective and appropriate nursing care in the future, nurses needed to have, among other abilities, a solid and current knowledge base across a number of relevant discipline areas, critical analysis skills and the ability to apply knowledge and skills meaningfully to their practice. Are we achieving that? A number would say ‘no’. The underlying reasons identified for this dispiriting response are multiple. We all know what they are: rapidly increasing numbers of students with widely varying scholastic abilities and English language skills, ever tightening university budgets leaving less and less money at the teaching level, the privileging of research over teaching, concertinaed curriculum content, decreasing availability of clinical placements, overstretched clinicians with little if any time to support student learning, rapidly decreasing attractiveness of academic positions, etc., etc., etc. We are not alone among the disciplines to be experiencing these negative impacts. One example is the fraught issue of entry standards. A recent study by the Australian Council of Educational Research12 published last month found that nearly every applicant (96%) for university entry in NSW and the ACT was offered a place, no matter how low their school leaving score. And before those in the audience from WA and Victoria start looking smug, your states weren’t all that far behind – in the high to mid 80%. Only in South Australia and the Northern Territory were the figures in the high 70%. However, very low entry scores impact on some disciplines and not others, and some but not all nursing courses. I would think all here tonight would agree with Professor Simon Marginson’s comment on the study’s findings: “... with such an influx of students, unless more money is provided for teaching and learning, quality will suffer as surely as night follows day”.12, p.6 In line with the national government’s push for enrolling more students from the lower socio-economic category, the social class equity initiative as it is termed,13 some additional funding has been provided to universities, but how much of that will trickle down to the teaching coalface through the multilayered levels of university budget allocation? In all likelihood very little, if anything. At one university where nursing is part of a medical faculty the discipline has calculated that it receives a mere 18 cents in the dollar from the funding generated by nursing enrolments. How can anyone be expected to do the job required on that pittance?
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Oration RCNA There have been a variety of responses, both actual and recommended, to these problems. These range from abandoning universities altogether and setting up degrees in the technical and further education sector, to creative ways of learning and teaching, to much bemoaning and wringing of hands, to ignoring the problem altogether and/or just getting on with earning research points. My assessment from my reading and observation is that in general we have been very light on effective action. And I am far from the first person to say that in recent times but I suspect my assessment will probably have as little effect as theirs obviously have had. I have no intention of using up what time I have remaining in this oration to make suggestions as to what might remedy the situation. I would need all that time and a lot more. I will however place on record that I am strongly opposed to forsaking the university system, for all sorts of reasons. We need to actively and quickly seek solutions to either fix the system or work around it to achieve the vision our leaders had five decades ago. We could of course be too late and we will have a ‘solution’ forced upon us. As I was writing this oration the prospect of an early election and a change of government was looking probable rather than possible. If the statements of the federal member for my electorate are anything to go by, the current Opposition have their plans for nursing all ready and just waiting to be dusted off. These plans, as far as I can ascertain, reflect a view of the role of nurses that take us back in time. Before I leave this ‘legacy’ I would like to offer two positive examples of the impact of this educational environment: one from NSW and the other from my home state. Once again, there will be similar examples to be found in other states. The first example involves projects by nurses at the workface designed to improve patient care or improve nurses’ work environment.14 These projects were initiated by the nurses themselves with no funding. The aim of the umbrella project was to collect and analyse these local projects and then present the outcomes to both the state government, and the nurses’ peers and colleagues across the state. The then NSW Minister of Health’s comment at the launch of the project report to government was of particular interest: “What we see in this report is the result of 20 years of university education for nurses”.14, p.1 What was probably of more immediate practical interest to those nurses in the audience was that his speech also included an announcement of funding for further innovation projects of this nature. The second example involves personal observations of clinicians who have graduated from a university program in my home state. In undertaking our work of developing systematic reviews in the WA Centre of Evidence Informed Healthcare Practice, we have a policy of
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involving clinicians in as many aspects of the process as possible. This involvement includes identifying the clinical question on which the review will be based, assisting with the quality assessment of studies for possible inclusion (following a few refresher sessions on research), generating the implications for clinical practice based on the findings of the review and providing feedback on the final draft of the report. Usually, but not necessarily, these clinicians are Level 2 or above so are not neophyte nurses, although in this day and age some at this level have graduated not all that long ago. These nurses have ‘blown my socks off’ with the clinical knowledge and specialised skills they have demonstrated and their commitment to quality patient care. I realise this is a very small sample but I am sure they are not alone and that you would also be able to provide similar examples from your experience. I suggest that a combination of both their undergraduate education and the continuing development they have experienced in the clinical area from their own personal efforts and the educational support of their organisation have contributed to this outcome i.e. we all have to work together to achieve the outcome the nation needs. Let me move on to the image of nursing. What is it about the image of nursing? Why isn’t it obvious to everyone that in this day and age nurses need to be knowledgeable and skilled; we are no longer the doctor’s handmaiden. We’ve done lots of lobbying at various times. Could it be that we have failed to convince the general public of the depth and breadth of our practice and what then must underpin that in the way of knowledge and skills if we are to provide safe, individualised, effective care? Gordon’s15 view is that most members of the public haven’t got a clue what we do. If they understood that then we wouldn’t have politicians deciding they can get votes by ‘sorting out’ nursing. Granted it is difficult to get someone to appreciate the more subtle, less obvious aspects of skilled nursing care in its entirety or to even realise that it has occurred. Patients who have been seriously ill and their families are probably in the best position to gain this understanding, provided they have skilled and knowledgeable nurses caring for them. But the general public’s image of us is primarily generated by the media. Despite some improvements in recent times, we are still seen primarily as merely carrying out doctors’ orders with a few other plot lines thrown in to make it interesting – personal issues, sex, life threatening errors, etc. During the time I was writing this paper I watched several episodes of ABC Compass – Hospital Chaplains.16 There was one particular female chaplain serving the intensive care wards at Royal North Shore Hospital who I thought conveyed the complexity of her role extremely well in an authentic, direct way. I sat there thinking I wish we could get something similar made to portray nursing this well. The series produced by SBS several 8
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Oration RCNA years ago RAN: Remote Area Nurse17 did a good job of not only portraying the professional side of their challenging role but also the personal aspect in a balanced way, avoiding stereotypical representations. Trouble is, how many of the general public watch the ABC or SBS – less than one in five. All this sounds ‘glass half empty’. Let’s look at the ‘glass half full’ version of nursing‘s image. There are I believe some positive signs that the portrayal of nurses and nursing is becoming more professional and reality-based. David Stanley,18 a former colleague of mine, concluded, after conducting a qualitative analysis of 280 feature films produced between 1900 and 2007, that more recent films increasingly portray nurses as strong, capable, intelligent, independent and self-confident professionals. This was in contrast to early films which pictured nurses as self-sacrificial heroines, sex objects and/or romantics. However, I’m sure you all share my view that the portrayal of nurses in television ‘soapies’ still has some significant catching up to do. According to numerous polls, the public trust us; we’re seen as honest and ethical. In 2011 nursing again topped the Morgan poll19 seeking public perceptions of 28 professions – that made it 17 years in a row. Trust is essential to the work we do but is it sufficient? No, according to Gordon15 – not if the public don’t really grasp what our practice entails. Gordon talks about the ‘trust trap’ – that it can lull us into thinking that because we are trusted then there is no need to inform people about our work, but trust does not equal knowledge and understanding. Her suggested corrective strategy is for nurses “to talk, in detail, about what they do in their daily work”,15, p.1 not just a once off but on a continuing basis. Perhaps we all need to do that with our local parliamentarians as a starting point. How do other health professionals perceive us? The results from a series of surveys20 the Curtin School of Nursing and Midwifery conducted in the last decade of graduates, one year and three years after commencing employment as a nurse, provide some insights in how clinical nurses might answer this question. Between the first and third survey – a period of seven years – the respondents were significantly more likely to report respect and appreciation from other health professionals – an increase from 34% to 50%, and 33% to 49% respectively. But this is barely a ‘glass-half’ – full or empty. Their perceptions of whether the nurses were well regarded and respected by the public in the three surveys ranged from 49–66% and 52–70%. However, their rating of nursing as a prestigious profession ranged from 12% to 28% agreement. I’m not sure whether to include, from the image perspective, the advent of nurse practitioners in this ‘glass half full’ section. By all reports the public who attend accident and
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emergency departments in WA hospitals where they are employed have taken to them in a very positive way, even if the AMA hasn’t. A number of studies21, 22, 23 have found that client satisfaction with nurse practitioners in a number of different clinical settings is consistently high. But the question is: Do the public perceive them as delivering nursing care or, despite the title, perceive them as a mini-doctor? In the academic world my personal experience has been that nursing’s image, or perhaps more accurately the image of nurse academics has changed quite significantly but this assessment is based on an ‘n of 1’. It had to change – we were coming off a base of less than zero in the mid-1970s. Let me illustrate this claim. On arriving at work one day in my first week at what was then the Western Australian Institute of Technology, we were greeted by large sheets of brown paper plastered over the walls of the Architecture building, in which our basement offices were located, inscribed with comments such as: “Go back to your hospitals and bedpans”. Needless to say this had the opposite effect – we were staying put no matter what. I look back now from a point where we have nurses across the nation in very senior university positions, including a Vice-Chancellor, as chief investigators on large research grants, undertaking research assessed as world class or above, and winning national teaching awards for innovative teaching and learning strategies, and I marvel at the changes. But that change was the result of courage, persistence, lots of hard work and learning from our mistakes in this totally different culture. A third area I would like to touch on is the relationship between research and clinical practice. Until relatively recently the general consensus was that there was an almighty void between the two that appeared to many to be unbridgeable despite their efforts. My observation is that in the last decade we have managed to bridge that gap, albeit the bridge might be lightly constructed and a bit wobbly but with more support will carry more and more two way traffic. The destination is evidence informed nursing care. I base the claim that I’m about to make on observation but I think it is still a reasonable claim: the two health care professions in Australia that have adopted the concept of evidencebased practice and then applied it most widely are nursing and midwifery. I also suggest that both these professions have made a very significant contribution to broadening the concept from that adopted by medicine with its focus on effectiveness of treatments assessed, quite rightly, by randomised controlled trials (RCTs). Given the scope of nursing and midwifery practice, we had other clinical questions that required answers in terms of available evidence and these can be best answered by research designs other than RCTs. Australia, through organisations such as the Joanna Briggs Institute and its international network of collaborating centres now numbering well over 60 across all continents, has
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Oration RCNA provided international leadership and practical support in this development. This isn’t because other health care professions haven’t taken up the concept, but it seems to be taking longer to embed across the board or they have been later adopters than us. The most measurable evidence of the extent of the uptake of evidence-based practice by nursing in this country lies in its widespread incorporation into nursing policies and the modification of protocols to align with current evidence. These policies and protocols have translated the evidence to facilitate its application. But the key question is: Is this evidence being applied to meet individual situations and needs? Evidence-informed practice has a triangular base: the best evidence currently available, professional judgement and expertise, and, at the peak of the triangle, the individual receiving the care. To my knowledge we don’t yet have a solid base of evidence that indicates the extent to which individualised application is happening, although I’m sure we could all provide anecdotal evidence either in support or otherwise. What follows is an example of individualised application in practice. But first, some contextual information. Despite laboratory evidence that fever aids the body’s response to fighting infection,24 the medical research literature is replete with references to the objective of ‘fever clearance’ in children.25, 26 Therefore fever must be ‘treated’ as if it was the disease i.e. all efforts must be made to get the child’s temperature down to normal. That is not to say that all medical practitioners hold this view, but judging by the advice and prescriptions given by GPs, many do. A number of course may feel pressured by parents influenced by very cleverly targeted advertising, to prescribe antipyretics, as with antibiotics. Epidemiological evidence is also now appearing that exposure to acetaminophen (paracetamol) in the intrauterine environment, infancy, childhood and adolescence is associated with an increased risk of asthma.27, 28 So the currently available evidence is telling us to minimise as much as possible the administration of antipyretics. This advice is, however, complicated by the fact that these febrile children may well be in pain or in real discomfort associated with their illness and so need analgesia – managed by the same drug – along with other non-pharmacological care. A two year old boy is admitted to hospital following a diagnosis of pneumonia. He is miserable, not eating, doesn’t want to be cuddled, etc. He is ordered, among other medications, analgesia. The graduate nurse administers the medication and then takes time to explain to the mother that this has been given to relieve her child’s pain/ discomfort, not to bring his temperature down. She further explains, in non-technical terms, the role of fever in fighting his infection and why the hospital had a policy of encouraging parents to minimise the giving of antipyretics to children. This child was my The 46th Patricia Chomley Memorial Oration 2012
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goddaughter’s son. She, a social worker, and I had had several conversations about this topic in the context of how can we get the message through to parents. So it was with great glee she related this story to reassure me that the message had got through to at least one nurse, not only about minimising antipyretic use but also individualising the application of evidence. Turning now to our legacy of political activity. There is no doubt that nurses have been politically active – we wouldn’t be where we are today if a number of our predecessors hadn’t been politically savvy and strategic. However that activity hasn’t always been obvious to all and sundry. To my knowledge no nurse has resorted to the suffragettes’ tactics – hunger strikes, etc., although Sister Paulina Pilkington did indicate in her oration in 2002 that a suggestion along these lines had been made to her. And I quote: “When the debate regarding the future of nursing education was taking place in the seventies, the late Dr Sidney Sax was of tremendous support to those of us who were trying to bring about change. On one occasion, when I was deploring the inactions of government regarding our recommendations, Sid asked me why we didn’t chain ourselves to the gates of parliament house in protest?” 29, p.8 But many nurses across Australia did find their voice and their marching boots in order to win that battle in the face of very strong opposition, some from within nursing itself. The latest example of overt political activity is the Victorian nurses’ uncompromising stand on patient ratios which finally, after nine long months, was successfully negotiated on March 16 this year.30 However, examples such as these are not the norm in nursing. Our long history of being patronised has seen to that. In 2008, more than two decades after the completion of the transfer of nursing to tertiary education, Walker and Holmes’ summary of the situation was that: “… nursing still struggles for an equi-authoritative voice at the decision-making tables of those concerned with the future of healthcare and that much, if not most, of what nurses do is simply taken for granted and what nurses have to say is politely acknowledged but, all too often, largely ignored.”4, p.108 Shield’s31 analysis of a recent publication Health of the Nation by a national newspaper suggests that the situation hasn’t changed. This report covered topics such as the country’s
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Oration RCNA health system, its effectiveness, costs, economics, and accessibility. In the 22 page supplement the word ‘nurse’ only appeared three times. If, despite all the efforts that have gone into making submissions to endless inquiries into health care, we haven’t been able to make a significant impact on the system, we need to figure out how we can change that. We do after all, comprise 55% of the health care workforce31 and we have a lot to contribute given our experience. I was again reminded of this analysis very recently by two newspaper articles, one in a national paper32 and one in our daily state paper.33 These articles were reporting on the projected shortfall in the number of nursing and medical practitioners by 2025 based on modelling undertaken by Health Workforce Australia:34 109 000 nurses and 2700 doctors. Despite the significantly larger problem looming with nurse supply, both articles allocated a number of column inches to the AMA’s response to the report with no comments included from any nursing organisation, although the WA AMA did refer to the impact the nursing shortage would have on health services. Did the newspapers not consider seeking a response from a nursing organisation or make use of media releases, or did a decision have to be made to not use the response given space available? Whatever the reason, the message to the reader is that what we have to be really concerned about is the supply of doctors; nurse supply fades into the background. As an aside, I did find the report’s focus on nurse retention measures as the primary strategy for reducing this gap somewhat comforting; for once the solution doesn’t appear to be focused on significantly increasing intakes, although no doubt there will be some pressure there. That is not to say retention will be an easy issue to address to the extent required – it too comes with its own unique challenges and need for some radical changes in the work environment. However we need to remember that there a number of ways of acting politically which don’t involve wearing a red vest, waving placards and marching down the main street. Although we know that part of the role of our professional organisations is to lobby, we probably don’t appreciate just how much time and effort goes into that activity. A recent success was the amount of additional funding proposed for increased salaries for nurses in the aged care sector in the Australian Government’s response Living Longer, Living Better35 to the Productivity Commission’s report Caring for Older Australians.36 We did of course have very vocal support from the aged and their families on that score. Another area where significant political activity goes on, although those involved could never admit to this, is in the chief nurses’ offices in health departments. From what I have observed, without this backroom work, bringing the nurse practitioner concept to fruition might not have been achieved. Yet another activity that could be classed as political activity is individual
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nurses talking purposely about what their practice entails, in order to raise the public’s and politicians’ understanding of our role and responsibilities. So, back to our symbolic ‘hut’, “what contributions have we made that we can place in there for the future of nursing in this country?” I suggest the following; you can add to these: Education as opposed to training Adaptation, adoption and application of evidence to inform our practice. There are several others that I have explored tonight that have potential but need more work and strengthening: Improving the public’s understanding of the complexity of nursing practice Ensuring involvement of nurses across the board in ongoing political activity, in its various forms, to ensure the profession survives and prospers. Further strengthening of productive partnerships between the clinical areas and academe; partnerships that are active, respectful and mutually beneficial. These are all in a sense fragile and need tending, that is without care and attention they could all wither and die, or easily disintegrate. Some need more immediate action than others to avoid this fate. As Sara Henderson, she of outback fame, advised (and this is a slightly modified quote given the occasion): “Don’t wait for a light to appear at the end of the tunnel; stride down there … and light the @#$! thing yourself.” 37, p.10
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Oration RCNA References 1. Barlow K. Mawson’s hut reveals history frozen in time. ABC 730. 2012 30 January. 2. Kieseker P. Status and symbols of power. Nursing Review. 2012:11. 3. McDonald T. Nursing - Our Multigenerational Work in Progress: Royal College of Nursing Australia 2011. 4. Walker K, Holmes C. The ‘order of things’: Tracing a history of the present through a re-reading of the past in nursing education. Contemporary Nurse. 2008;30(2):106-18. 5. L awler J. Nursing in Interesting Times: A reflection, an analysis and a reading. Sydney: Royal College of Nursing Australia 2007. 6. DEEWR. 2009 Higher Education Student Statistics - Nursing Students Canberra: Australian Government. 2010. 7. DEEWR. Summary of the 2010 Higher Education Student Statistics. Canberra: Australian Government; 2011. 8. Walker K. Curriculum in crisis, pedagogy in disrepair: A provocation. Contemporary Nurse. 2009;32(1/2):19-29. 9. M adsen W, McAllister M, Godden J, Greenhill J, Reed R. Nursing’s orphans: How the system of nursing education in Australia is undermining professional identity. Contemporary Nurse. 2009;32(1/2):9-18. 10. Shields L, Purcell C, Watson R. It’s not cricket: The ashes of nursing education. Nurse Education Today. 2011;31:314-6. 11. McAllister M, Madsen W, Godden J, Greenhill J, Reed R. Teaching Nursing’s history: A national survey of Australian schools. Nurse Education Today. 2010;30:370-5. 12. Hare J. Warning standard slipping at unis. The Australian. 2012 24 April:1&6. 13. Department of Education Employment and Workplace Relations. Higher Education Participation and Partnership program - Social class equity initiative Canberra: Australian Government; 2011 [cited 2012 3 April]; Available from: http://www.deewr.gov.au/ HigherEducation/Programs/Equity/Pages/HEPPPrograms.aspx#2. 14. Chiarella M, Parker V, Patterson K. Foreward. Contemporary Nurse. 2010;35(2):131-2. 15. Gordon S. Nurses Again Win Public Trust 2010: Available from: http://www.suzannegordon.com/?p=472. 16. Doogue G. Hospital Chaplains: It’s a tough job. ABC Compass. 2012 15 April. 17. Caesar D, McKenzie C. RAN: Remote Area Nurse. Australia: Special Broadcasting Services (SBS); 2006. 18. Stanley DJ. Celluloid angels: a research study of nurses in feature films 1900-2007. Journal of Advanced Nursing. 2008;64(1):84-95. 19. Morgan R. Image of Professions Survey 2011. Roy Morgan Research; 2011 [cited 2012 27 April ]; Available from: http://www.roymorgan.com.
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20. N owak M, Thomas G. Employment Directions of Curtin School of Nursing and Midwifery Graduates 2005 and 2007. Perth: Curtin University of Technology 2009. 21. C arter A, Chochinov A. A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department. Canadian Journal of Emergency Medicine. 2007;9(4):286-95. 22. Wortans J, Happell B, Johnstone H. The role of the nurse practitioner in psychiatric/mental health nursing:exploring consumer satisfaction. Journal of Psychiatric and Mental Health Nursing. 2006;13(1):78-84. 23. Wilson A, Shifaza F. An evaluation of the effectiveness and acceptability of nurse practitioners in an adult emergency department. International Journal of Nursing Practice. 2008;14:149-56. 24. Kluger M. Fever revisited. Pediatrics. 1992;90:846-50. 25. H ay A, Costelloe C, Redmond N, Montgomery A, Fletcher M, Hollinghurst S, et al. Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): randomised controlled trial. BMJ. 2008;337(a1302):1-9. 26. M eremikwu M, Oyo-Ita A. Physical methods versus drug placebo or no treatment for managing fever in children (Review). Cochrane Database of Systematic Reviews. 2009(2):1-16. 27. B easley R, Clayton T, Crane J, von Mutius E, Lai C, Montefort S, et al. Association between paracetamol use in infancy and childhood, and risk of asthma, rhinoconjunctivitis, and eczema in children aged 6-7 years:an analysis from Phase Three of the ISAAC programme. The Lancet. 2008;372:1039-48. 28. B easley R, Clayton T, Crane J, Lai C, Montefort S, von Mutius E, et al. Acetaminophen use and risk of asthma, rhinoconjunctivitis, and eczema in adolescents: International study of asthma and allergies in childhood phase three. American Journal of Respiratory and Critical Care Medicine. 2011;183:171-8. 29. P ilkington P. Looking Back into the Future: Royal College of Nursing Australia 2002. 30. Bennett J. Victorian nurses settle dispute. ABC News. 2012 16 March. 31. Shields L. ‘Invisible’ nurses have to find their voice. Nursing Review. 2011 December:10-1. 32. Cresswell A. Nurse shortfall to hit 100,000. The Australian. 2012 28-29 April:10. 33. O’Leary C. Predictions for 2025: Alarm over nurse shortages. The Weekend West. 2012 28-29 April: 11. 34. H ealth Workforce Australia. Health Workforce 2025 - Doctors, Nurses and Midwives- Volume 1. Adelaide: Health Workforce Australia2012 March 2012. 35. Department of Health and Ageing. Living longer. Living better. Canberra: Australian Government; 2012. 36. P roductivity Commission. Older Australians: Overview Report No.53 - Final Inquiry Report. Canberra: Productivity Commission 2011. 37. Gemmell N. Rules of the game. The Weekend Australian Magazine. 2012 24-25 March:10. 16 RCNA The 46th Patricia Chomley Memorial Oration 2012
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