Associate Professor Brenda Wilson
RN, CritCareCert, DipAppSc (Nursing), BBus (Health), MBA, FCHSE, FRCNA
ISBN Number: 0-86396-596-2
The University of Adelaide
Department of Clinical Nursing
1997
Joan Durdin Oration
Paper Series Number 3
The Joan Durdin Oration is an annual event initiated and sponsored by the Department of Clinical Nursing at the University of Adelaide. It is intended to serve as an occasion of celebration of nursing's past achievements and to focus on visioning the future. Orators are distinguished nurses who have made a major contribution to the development of Australia's vibrant nursing profession.
As well as focusing on nursing as a profession which is central to effective health service delivery, the Oration honours the contribution of Joan Durdin, a South Australian who has played a major role in uncovering the historical legacy of nursing and in the advancement of nursing through the development of advanced education in the higher education sector.
The Joan Durdin Oration brings together all nurses of South Australia as well as leaders from all fields associated with health and well being of South Australians to celebrate nursing's past achievements and anticipate the further evolution of nursing in the future.
Brenda Wilson has been a registered nurse for more than 20 years. Her formal qualifications include a Master of Business Administration, Bachelor of Business (Health Major), Diploma of Applied Science (Nursing) and a Critical Care Certificate (Nursing). Brenda completed her training at the Royal Adelaide Hospital and went on to hold a variety of positions at the RAH. In 1989 Brenda was appointed the Assistant Director of Nursing at the Hampstead Centre and was promoted in 1990 to Director of Nursing and in 1992 to CEO. In 1994 Brenda held the position of Director of Nursing Lyell McEwin Health Service and presently holds the position of Executive Director, Nursing and Outpatient Outreach Services at Flinders Medical Centre.
The Department of Clinical Nursing was established in 1995 in collaboration with the Royal Adelaide Hospital.
The Department is unique in Australia focusing exclusively on postgraduate studies and high quality research in nursing practice. It has one of the largest doctoral enrollments in nursing and has one of the highest per capita staff publication rates. The Department has a well established team of research staff and an extensive funded research program.
The Department of Clinical Nursing also incorporates The Joanna Briggs Institute. The Institute is a major international research and development group based at the Royal Adelaide Hospital and is linked to centres in Queensland, New South Wales, Victoria, Tasmania, Western Australia, New Zealand and Hong Kong.
"When to the sessions of sweet silent thought I summon up remembrance of things past." Marcel Proust 1907.
I feel both honoured and privileged to have been invited to give the 3rd Joan Durdin Oration which provides an opportunity to celebrate Nursing and our contribution to raising the health status of our consumers. Nursing is a profession to which I am proud to belong and one which I have no doubt has been greatly influenced by Dr. Durdin's work.
I began student nurse training at Royal Adelaide Hospital (RAH) in March 1973. This was a very exciting time for me as I had the opportunity to help people who were "sick" and was able to earn money and live in the Nurses Home. University courses for nurses were not an option in South Australia and ninety five percent of my class were women, many of whom came from privileged backgrounds.
Sr. Durdin had just returned to RAH to take up the position of Supervisory Sister after an absence of 10 years when she previously held the position of Tutor Sister.
It was soon after this (1973) that Dr. Durdin left RAH to join the Staff of Sturt College (now part of Flinders University of South Australia). I have strong memories around this time of being informed by my Tutor Sisters (Fromm and Burnell) that the training I was undertaking would be superseded by the Diploma of Applied Science at "Sturt". I was devastated, not only because I was embarking on something which was soon to be obsolete but I had the notion that in terms of study three years was long enough. I had also learned that the title "Sister" was also to become obsolete and I would be called "Nurse". It was pleasing to learn that others felt the same way, enforced change is hard to take, and so I did become Sister Wilson for some time. This meant that no-one needed to know or remember your name and to refer to us as "Sister" was easy and kept one at a distance. I remember a similar experience when working in the United Kingdom when a doctor referred to me as "Staff". It took me a couple of seconds to realise he was referring to me!
Interestingly, it was at this time the Royal Australian Nurses Federation (RANF) as it was called then, was working hard to introduce programmed days off (1973). This was also the era where on occasions two nurses were allocated to one "bay" of six patients. This was a time of plenty and from memory my biggest stresses were combining study and work with my hectic social life.
When I completed training in 1976 I could not wait to get into a white uniform and wear a white cap with a green band. At last the "ice-cream cone" could be dispensed with. For those of you who are not RAH trained I am sure are able to recount similar memories. This was the cap worn by student nurses. It was shaped like an ice-cream cone and designed to be worn on the top of your head. This was of course if you wanted to look smart and professional. This was not the look of the seventies and one which we thought we would change. We chose to wear it half way down the back of our necks with long strands of hair falling out from either side. I cannot imagine what our patients must have thought. I suspect however we could probably ask them today as the hair styles and clothes appear to have more than a resemblance to those we wore in the seventies.
This was the first year (1976) that Junior Sisters were not required to wear a different coloured uniform to demonstrate we were novice "Sisters". In previous years a shade of grey was introduced before you were able to wear white. I have occasionally wondered about the significance of these colours. We were junior Sisters for one year during which time we undertook an advanced nursing course, now referred to in this State as the Graduate Nurse Program. My last placement was in the Intensive Care Unit at the Royal Adelaide Hospital (RAH) where I began to really consolidate my earlier learning experiences and gain confidence to manage patients in a range of settings.
At the end of this year I was keen to become a Critical Care Nurse and developed a thirst for knowledge which has stayed with me. In my view this was where I could really contribute and work in an environment which was truly interdisciplinary. Doctors, physiotherapists, social workers, technicians and nurses all worked together in the interests of patients and their families. Nurses were considered to be part of the team and we were respected for our knowledge and skills. We thought we were OK too. "Super nurse" I remember was the term applied to this phase in our "development"
This was the first year (1976) that nurses undertaking critical care and theatre training were not allowed to wear "shovel" caps on their heads. This was a progression from an ordinary sized cap to something much taller and more powerful in appearance. For someone who is 5 '3'' this would have been a major advantage. For many of us change was happening too quickly and we could not believe how unlucky we were. I was however privileged at this time to be taught by expert clinicians such as Lorraine Butler, Joy Gilbertson and Margie Khaw in the intensive care module, Helen Geyer in the coronary care module and Kaye Challinger in the cardiothoracic module. These nurses many of whom are known to you provided learning opportunities which I will always remember.
The next time I experienced the work of Joan Durdin was when I attended Sturt College a couple of years later and I am sure there are many nurses in this room who have either been directly influenced by Joan's work or benefited from the strong foundation which was laid years earlier and which Joan greatly influenced.
Since those earlier years I have been fortunate enough to broaden my nursing experiences. In particular I am referring to the five years I spent at Hampstead Centre a Rehabilitation Centre nine kilometres North of the City of Adelaide and an "annex" of RAH. It was here that I began to more clearly understand the valuable role that nurses play in contributing to improving the lives of people who have been spinal injured, people who are learning how to manage after a stroke or orthopaedic injury and people coming to terms with dementia. The highly skilled nurses working in these areas have learned how to empower their customers by standing back and assisting them to help themselves. This approach was quite different from rushing in and completing the days work before 10 am and teaches us how to empower our customers rather than taking control of them.
One of the few regrets I have in my nursing career so far, is not to have undertaken midwifery training. I see this as an area of Nursing which has progressed much further in gaining autonomy of practice which I believe is a major element in gaining job satisfaction. I was advised by my "Supervisor" at the time that nurses were no longer required to collect certificates and become "triple certificated" but that tertiary qualifications would be more useful.
As I embarked on the daunting task of preparing this oration I began thinking about other areas of Nursing practice and the unique contribution each makes. In the area of psychiatric nursing we have nurses who have special skills in counseling and dealing with the mentally ill. I believe many of these skills could be transferred to other areas of the health system for example the acute sector where many of our patients also have some form of mental illness.
The role of the triage nurse in Emergency Departments is quite exceptional. This nurse is relied upon by doctors and nurses and of course patients and their families to quickly and accurately assess the state of health of patients entering the department. This is an onerous responsibility placed on highly skilled clinicians.
Nurses permeate the health industry in traditional and non traditional roles and for some occupy positions which are related to policy, budgeting and finance or management. Nurses have involvement with the care of people with physical impairment and disability, the homeless, prison services, refugees and migrant health, immunisation, palliative care and home nursing. We work in acute health centres and the community in a broad range of settings.
We should therefore celebrate the enormous and varied contribution we make.
I believe many of the issues facing nurses today are different than in the seventies. The Health Care System is more complex and provides more demands than previously experienced. There are however some similarities. Nurses still struggle to combine their leisure time with study and work commitments and for students of nursing this also means supporting themselves and their families financially throughout their education.
The environment in which we live and work today is constantly changing and for those of us who like change and the challenges which come with it will survive. These changes are occurring much more frequently and nurses will be required to become increasingly flexible and adaptable.
I remember when Team Nursing was introduced at RAH in about 1973. This appeared to be a big change from Task Nursing but we had a long time to get used to it. Today we introduce one change and another is already waiting to be implemented. Evaluation of these changes is often scant and changes are implemented widely without validation of their usefulness.
The current environment provides us with many challenges and I believe many more opportunities which we are only beginning to explore. We are required to face these challenges in an environment which has placed greater emphasis on health care expenditure, where there is an increasing demand for scarce resources, where we are experiencing difficulties with measuring derived benefit from increased expenditure and where we emphasise the need to undertake economic evaluation for monies spent.
As health care providers we are continuing to seek greater remuneration for the work we do. In particular there are examples in the USA where Chief Executive Officer's of large health care organisations are commanding salaries of up to $2m. Whilst this situation has not yet presented itself in Australia, rising salaries of doctors and nurses in this country combined with other factors will contribute to increasing the costs of health care generally. We do however have some distance to go before we spend as much on health as the United States. In Australia in 1996 we spent 8.5% of Gross Domestic Product (GDP) or $41,742 million on health which equates to $2,294 per person compared with the USA which spends approximately 14.0%. GDP represents the aggregate volume of all the goods and services produced (output) within a given economy (e.g. Australia) in one year.
Of particular concern to me is the low entry requirement for acceptance into Bachelor of Nursing courses at all Universities. This primarily occurs because of the large number of places offered to students of Nursing each year. I suspect we can all cite examples where people have told us that they have entered Nursing because they didn't get their first preference and this is more than disappointing. The incident of the top student in SA last year who had selected Nursing as her first career choice but when her academic results showed she attained the highest aggregate score was advised to enter Medicine. It is my view that we need to deal with this issue strategically. Not only are we all tired of hearing "I did it because I didn't get into OT" but the long term impact this will have on our customers and their care is an issue which requires special attention.
Not much has changed in the area of gender. Nursing still remains a female dominated profession. Medicine on the other hand has almost an equal split of men and women entering the workforce but has other issues of gender which have not been addressed.
Nursing work remains demanding both physically and mentally and we are getting older. In the past women left nursing if they got married and they certainly left if they got pregnant. Today we have policies in place which provide greater opportunities for women (and men) and aim to encourage women to remain in the paid workforce after childbirth if they choose to. This of course is excellent in terms of retaining knowledge and skills within the industry and is fully supported. It does however pose a different set of problems for employers and employees. Employers need to place greater emphasis on the health and safety of nurses. In particular we need to ensure that adequate lifting equipment is easily available and used as this accounts for the greatest number of injuries to our nursing workforce. Ageism which occurs when the talents of older employees are disregarded has become a particular problem in the US especially with the emphasis on downsizing. Older employees need to ensure that we "retain our marketability" through ongoing education and training.
Undergraduate training requires ongoing modification to ensure the product meets industry requirements. We need to prepare nurses to enable them to operate in an environment which is constantly changing and where alternative models of health care delivery are being implemented. Whilst the major teaching hospitals continue to employ the greatest numbers of graduates it will be essential for nurse leaders and clinicians in these settings to continue to work with academics to ensure nursing students are appropriately educated.
I believe nurses today are managing extremely well in an environment which is undergoing rapid change, where the average length of stay in hospital has reduced from seven to three and where consumers continue to demand more and improved quality.
As we approach the year 2000 and beyond our challenges will continue to focus on the cost effectiveness of service delivery, that is providing the best quality care at the lowest possible cost. This will be essential before we attempt to ration health services. We will be committed to continually examining how and why we deliver services to ensure that where changes to models of service delivery lead to efficiencies and that health outcomes are improved or maintained. This will be one of the greatest challenges facing health care providers and is often not able to be measured in the short term, sometimes we have to best guess.
There will be a strong emphasis on improving access to health care and choice in the services offered in particular in rural and remote Australia.
Most people believe that ageing and technology will combine to place extreme pressure on the industry and this will be the impetus for increased rationing of health resources. We will continue to observe our customers demanding an increase in the quality of the services we provide and in the way those services are delivered.
It will be essential for health service providers and universities to continue to work closely together to ensure we skill our graduating nurses appropriately and reduce costs of production and areas of duplication. We need to concentrate on what products we are trying to produce not how much power and status we can gain along the way.
We will see a greater emphasis in the use of clinicians as role models and educators. Clinicians recognise the benefits to patient care and the important role they play in assisting students to learn. This is a satisfying role for most clinicians and as many nurses as possible should be involved in the teaching role. When I was a "charge nurse" we ensured all nurses on our unit participated. Not only did this share the load but also offered students exposure to different approaches to patient care.
We need to value and develop our workforce and ourselves and I believe this is an area in which we can greatly improve.
We need to work with policy makers to ensure we direct energies to disadvantaged groups to ensure we provide similar opportunities for raising the health status of all Australians. It will be particularly important to work with other welfare agencies such as housing and education to ensure our goals are congruent.
Obtaining our customers perspective on the quality of care received will be vital. With high quality customer feedback we are in a more informed position to shape improvements in health care.
I believe the work environment plays an important role in the health status of nurses and we need to foster an environment which encourages learning and growth and which is welcoming to new students and staff generally.
We need to ensure that nurse managers are highly skilled and sensitive to the competing demands on the lives of nurses and acknowledge we are unique in the hours of work we cover and the nature of the work we perform.
We need to ensure that the environment is safe and that the health status of nurses is protected. As eluded to earlier this will be particularly important with the aging population of nurses and the demanding nature of our work. It will be essential to provide adequate lifting apparatus which are easy to use and available so that nurses are more likely to use thereby contributing to protecting their own health.
We will see a proliferation in nursing research as we employ increasing numbers of Chairs in Nursing not only in hospitals but also in the community. As this proliferation occurs we will see an increase in the specialisation of Chairs, rather than requiring them to be all things to all people. We need to ensure these nurses who are called "professors" and who do not come cheaply actually add value to Nursing.
In theory if we practice nursing by providing care which is well supported by rigorous research then we should contribute more favourably to raising the health status of our community. We need to embrace this concept and choose people who have a range of skills. These skills are not confined to research but also encompass the ability to work within a team, to have well developed communication skills, have credibility with clinicians and have a voice which enables them to clearly articulate nursing views which will contribute to shaping health policy and the direction it takes.
Chairs in Nursing will play a vital role not only contributing to the body of knowledge of nursing but also ensuring that research which has been undertaken is applied where appropriate. This will contribute to ensuring our customers get the best possible care.
I believe nurses need to move further away from "institutionalised" nursing which is quickly learned by new graduates entering the workplace. We need to consider moving away from the wearing of uniforms as I believe they provide a barrier between us and our customers as did titles such as "sister" which I now know are no longer useful. We are already able to observe examples in the workplace where uniforms are not relevant. I am referring to the psychiatric, palliative care and birthing centre arenas. I would like to move away from the "flight attendant" argument that I have heard aligned to nurses. That is, that the corporate image of the airlines is maintained by the wearing of uniforms and inspires confidence in the passengers. White coats are now obsolete in health centres and I think when our customers are introduced to doctors they know who they are. It means that we are required to take more care when communicating. We will see a greater emphasis on health care providers enabling patients to take more control of their own health. This model as I described earlier has been used effectively in rehabilitative nursing and in my view needs to be applied more vigorously in the acute setting.
I also believe we have an obligation to encourage nurses to be increasingly creative and flexible thereby removing the black and white rules and regulations which were previously applied.
For those of us who have given lip service to working in an interdisciplinary environment in the past will need to change. As eluded to earlier rehabilitation and intensive care units, and community health centres provide excellent models of interdisciplinary health service delivery. Nurses work very closely with their medical colleagues and the roles of physiotherapy and social work are well integrated. It is in environments such as these that nurses gain job satisfaction and value the work they do. It is essential for these models to be replicated across other settings and for health care providers who have concerns about power and control to recognise working as a team is not only more rewarding for all concerned but results in the best possible care for our customers. This integration of service delivery will ensure the patient receives maximum benefit.
In the future we may see the emergence of new categories of staff as we strive to lower costs of production. Care must be taken to cost options such as this to ensure that in the long run we do not increase costs. We will see nurses taking on roles which were previously undertaken by medical staff and this will enable doctors to do more of the work for which they were trained. Nurses should embrace this opportunity as it presents.
In order to improve patient satisfaction and the cost effectiveness of our services we will continue to examine ways of streamlining practice to identify areas of duplication e.g. in checking drugs and taking histories and identifying opportunities to perform work which adds value.
We will stop defending ourselves as a profession and focus on our strengths. We will move forward and consolidate our profession which is growing in its own right. We will be able to clearly acknowledge our contribution.
We will develop strategies which attract men to our profession at the same time ensuring that women in the profession compete equally for leading positions and that we do not see a concentration of male leaders disproportionate to women.
We will become increasingly flexible as models of health service delivery change and we will be required to work smarter not harder to achieve the same or greater outcomes.
We will see an increase in specialisation and the traditional roles of medical and surgical nursing will become more defined and specialised. As specialisation increases it will be important to draw upon the strengths of each of the specialties and ensure each pervades all areas of nursing practice. We will become increasingly aware that each specialisation adds a uniqueness to the body of knowledge of nursing, recognising that all areas of nursing work are valued.
We will become more supportive of each other and encourage growth and development.
We will continue to avoid the situation in the USA described by Jocelyn Lawler where the role of nurses is often ignored and unacknowledged. To survive and flourish we will continue to be highly skilled clinicians who are creative, energetic and adaptable to change with a gender and ethnic balance which is reflected in the community.
We will see an increase in the numbers of highly skilled managers of nurses who provide flexible rostering to meet family and competing needs. If we do not we will see an increase in the numbers of nurses leaving our profession and looking for more palatable alternatives for work. It is our responsibility to ensure nurse managers are equipped with these skills.
I believe the Nurse Practitioner role is one of the most exciting opportunities facing nurses today. This role will enable independent practice and autonomy of work. This I believe is largely missing from clinician roles in Australia today and in my view will lead to increased worker satisfaction and improved patient care. Much collaboration will be required to work with doctors, educators and health service providers to ensure these roles are given the support required to succeed and that nurse practitioners have the appropriate knowledge and skills to perform this expanded and unique role. We will require expert clinicians to provide teaching and learning opportunities for nurses and to draw on a wide range of knowledge and skills from other disciplines which will be integrated into nursing practice.
We will see stronger collaboration between health care providers and universities as we seek to maintain the skills and expertise of nurses and students in a rapidly changing environment. Universities will seek to strengthen the relationship with providers as they seek to ensure their product is one the industry wishes to purchase. This relationship will become mutually enhancing as we strive to ensure undergraduate and postgraduate learning opportunities are enhanced.
Nurses play a pivotal role in the coordination of patient care and discharge practice. We have seen an increase in the role of social workers and "discharge planners" in relation to discharge practice and while I am supportive of an interdisciplinary focus in patient management I believe nurse clinicians understand the needs of their patients better than most other groups. I believe documentation of these processes will clearly define each disciplines role in ensuring we do not miss appropriate care for our patients. The unique role each member of the interdisciplinary team provides, needs to be more clearly defined to ensure duplication of effort does not occur and that our patients receive the best possible care at the lowest possible cost. I am of the view that we do not need to create new roles to manage this process but enabling nurses to continue managing this process will ensure continuity of care is enhanced.
We will see an increase in the number of nurses contributing to the development of health policy at all levels. This will be essential in contributing to raising the health status of our community. Nurses have an obligation to become politically aware with the ability to identify and work with major stakeholders.
We will identify ways in which we can ensure we have strong leaders in the future This will require the ability to identify future nursing leaders, exploring options to promote and educate them and ensuring succession planning processes are in place.
I believe the nature of our work will make it difficult for nurses to follow the medical model of integrating research, practice and teaching into one role unless we are given the resources required to do this. This problem will be exacerbated in an environment where the research dollar is shrinking. Further there are greater numbers of nurses with varying capabilities and aspirations. It will therefore be impossible for all nurses to achieve this goal but will be the domain of a few.
We will continue to observe forms of managed care introduced in this country with some benefits. In the USA, we have seen a decline in the care of the poor and in teaching and research dollars. Nurses need to contribute to managing this process more carefully in Australia to ensure situations such as this are avoided.
Nurses must contribute to deciding what and how health services are measured. We are all aware of the pitfalls of benchmarking but at the same time should not lose the opportunity to demonstrate how well each of us is performing when compared with our competitors. We must ensure we are all counting the same way and comparing "apples with apples".
Australia is one of the most culturally diverse nations on earth and this is well recognised by nurses. Further work is required to focus on ways of reducing the barriers to recruitment of both Aboriginal people and those from other culturally diverse backgrounds. Nursing leaders will be required to work with Education and Housing and Development to ensure long term solutions are put in place to address these issues.
In summary, we need to strive for autonomy of work practice, the value to which cannot be underestimated. We need to work towards ensuring we have equal numbers of men and women within our profession, who reflect the varying cultures of Australian society. We need to work towards ensuring people entering university choose nursing because they want to join a profession with a positive future and which successfully contributes to improving the health status of our community through involvement in policy making at all levels.
This will further enhance Nursing as a profession to which we can be proud to belong.
Thank you.