Alan Pearson, RN, ONC, RNT, Dip N Ed, DANS, Msc, PhD, FCN(NSW), FRCNA, FRCN
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Adelaide University
Department of Clinical Nursing
Joan Durdin Oration
Paper Series Number 6
2000 marks the sixth annual Joan Durdin Oration.
The Joan Durdin Oration is an annual event initiated and sponsored by the Department of Clinical Nursing at Adelaide University. 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 nurses of South Australia as well as leaders from all fields associated with the health and well being of South Australians to celebrate nursing's past achievements and anticipate the further evolution of nursing in the future.
Professor Alan Pearson has an international reputation as both a nurse and scholar. He is currently the Professor of Nursing at LaTrobe University and Adjunct Professor of Adelaide University, Department of Clinical Nursing. Professor Pearson is also the Director of the Australian Centre for Evidence Based Residential Aged Care a collaborating Centre of The Joanna Briggs Institute.
Professor Pearson holds many degrees in nursing and nurse education including a PhD awarded by the University of London and is one of the most widely published and prolific nursing researchers today.
He is the Editor of the International Journal of Nursing Practice and is an editorial board member of many other prestigious nursing journals. He is an active Member of numerous nursing and health care professional organisations and colleges including the Aged Care Complaints Scheme, Commonwealth Department of Health and Aged Care of which he is the Chair.
His distinguished and diverse career in nursing has taken him from the highlands of New Guinea to ground breaking work with Nursing Development Units at Burford in Oxfordshire. He was the inaugural Professor of Nursing in Australia as the Foundation Dean of Nursing with Deakin University. As Founding Director of The Joanna Briggs Institute and Midwifery he is internationally recognised as a leader and innovator of evidenced based nursing practice.
He is well known to nurses in South Australia as the Foundation Chair of the Department of Clinical Nursing, Adelaide University and Royal Adelaide Hospital. In this capacity he was instrumental in initiating the annual Joan Durdin Oration which has now become so much a part of the nursing calendar in South Australia.
The Adelaide University, Department of Clinical Nursing was established in 1995 in collaboration with Royal Adelaide Hospital.
The Department continues to thrive and grow meeting the needs of the health sector in providing high quality post graduate education to nurses in Australia and through its international teaching programs. Research output through higher degree courses and activities such as The Joanna Briggs Institute and Midwifery, are recognised for their high calibre and relevance to clinical practice. The success of these programs relies on the continued collaboration of the Department and the organisations that provide health care.
Clinical practice remains the major focus of all research and teaching programs, it is therefore fitting that the Department of Clinical Nursing host the Joan Durdin Oration that celebrates the practice of nursing.
"The most beautiful thing we can experience is the mysterious. It
is the source of all true art and science."
Albert Einstein
I am both delighted and honoured to have been asked to deliver this year's Joan Durdin Oration. This annual event serves to celebrate the contribution the profession of nursing makes to the health and well being of Australians and to generate discussion and debate on strategies for the future. I wish to focus on the sometimes uncomfortable relationship between nursing practice and nursing science and to argue that, as both are interdependent on each other, there is an urgent need to develop both much more vigourously if nursing is to take its rightful place as a central component of health services. Nursing is essentially a practice: a caring process that occurs between the nurse and the nursed. Nursing practice draws, however, on an extraordinary array of skills and on a knowledge base that is both specific to nursing and derived from nursing inquiry in its many forms, and draws from a wide range of the sciences, social sciences and humanities. Such a reality is inescapable when thinking about nursing's past, present and, most importantly, future.
In addressing this, I am adopting the view that professional nursing is that form of nursing that contributes to, and bases its practices on, nursing science. This is, in my view, what distinguishes professional nursing from lay nursing - the care given to millions of Australians by their friends and relatives who are not grounded in nursing science and seek advice and assistance from professional nurses.
Since the emergence of modern nursing in the nineteenth century, nurses have pursued a number of different pathways to develop their work (nursing practice) and to generate knowledge (nursing science). Nightingale's reforms centred largely on the management theory of the day and on everyday understandings of caring in both the sickroom and in public health. As the occupation of nursing developed, greater emphasis was placed on management, training or education and the maintenance of the traditions of the occupation. From the nineteen twenties on, practice itself became decentralised until the late nineteen fifties/ early nineteen sixties when nurses in North America began to develop theoretical constructs of nursing and in Australia, Europe and the United Kingdom, the practices of nurses began to be studied and valued. Alongside this, nurses began to realise that a need existed for a radical reappraisal of nursing's developmental direction, and attempts to promote innovation in the clinical arena became apparent. A number of approaches were pursued and the emergence of new roles in nursing such as the nurse specialist and the nurse practitioner; changes in nursing education and training; and the pursuit of evidence based approaches to practice are the present day continuance of nursing's attempt to develop and reshape the reality of nursing.
Until the 1970s, nursing's major developmental interests in most developed countries were directed at the management of the nursing service and the education of nurses. The establishment of nursing departments in the universities in the UK and the increase in university departments in the US, led to a growing interest in nursing as a practice - the direct interaction between the nurse and the nursed. It did not take long for these new pockets of influence to spawn practical developments in health services in their own countries and Australian nurses who went to the UK and the US lead similar developments here. Developments aimed at examining, expanding and valuing the way nurses work with patients or clients are exemplified by innovations at The Royal Marsden Hospital and the Manchester Royal Infirmary in the UK; Rush Medical Centre in Chicago and the Loeb Centre for Nursing in New York in the US; and Royal Adelaide Hospital here in Australia.
The Royal Marsden - a specialist hospital in London concerned with cancer care - pioneered an all qualified workforce, clinical nurse specialist and clinical nurse consultant roles, and an active clinical research program in nursing. The Manchester Royal Infirmary established joint appointments with the Department of Nursing at the University of Manchester within a designated clinical unit titled a Professorial Nursing Unit, led by Professor Baroness McFarlane of Llandaff. In both of these settings, emerging methods of care delivery were piloted, such as team nursing, patient allocation and a modified keyworker or primary nursing system. They also pioneered care planning and patient centred approaches to care and promoted the value of practice-based research (Ashworth and Castledine,1980; Wright, 1983).
The work of Christman, (1978,1988) complemented Hall's work at the Loeb Centre for Nursing at the Montefiore Hospital in the Bronx, New York and involved the unification of academic nursing and nursing service at the Rush Medical Center in Chicago. The Chicago development was enormous in scale and was funded by the Kellogs Foundation. The college of nursing of the associated university was totally integrated with the hospital and health service. The Vice President Nursing - a role similar to a chief nursing officer or executive director of nursing - was also the dean of the college; heads of nursing divisions were heads of departments and professors; charge nurses and staff nurses were also the professors and lecturers of the college. In effect, total unification occurred where practice, management, teaching and research were all combined into nursing roles of varying levels. The concept was admired and respected internationally and the notion of the unification of these four spheres was well accepted. The Chicago development, led by Luther Christman, was seen to be exceptional, however, and its widespread replication did not occur because of its radical nature and the enormous costs involved.
The establishment of the Department of Clinical Nursing at Royal Adelaide Hospital, a joint venture with Adelaide University Medical School and spearheaded by Kaye Challinger, then Director of Nursing, arose out of changes in the post-basic education and training of nurses associated with the establishment of university schools of nursing in Australia. Drawing on the UK and US developments, the hospital based university department of clinical nursing was designed to be a nursing academic and research unit fully integrated into the nursing service of Royal Adelaide Hospital. This initiative successfully unified nursing education, nursing practice and nursing education and the now well established postgraduate education and training programs, evidence based nursing and midwifery research program and clinical research program are characterised by their integration into the core activities of Royal Adelaide Hospital and Adelaide University.
Much of this drive for change in nursing emanated largely from nurses in leadership positions in health service agencies and from those who became academics when nursing departments became established in the institutes of higher learning. Flowing from these moves, governments, health service provider agencies and national nursing bodies now exhort nurses to develop practice based on:
The amalgamation of these concepts have been described as a major reform in nursing (Pearson and Vaughan 1986) and referred to as the 'New Nursing' by Salvage (1990). Alongside these developments in practice, nursing was seriously attempting to be clearer about the nature of its practice and the contribution it makes to the achievement of desirable health outcomes. Much development in the conceptual understanding of nursing and in knowledge for effective, appropriate and feasible nursing intervention has occurred, and there is now a wealth of literature that reflects a growth in nursing science.
Nursing science - and I refer to science here as the systematically developed knowledge of a discipline - is advancing rapidly internationally as nurses increasingly engage in research. Nursing research is still at a very early stage of development in this country, and even though there has been a notable lack of support towards its development by Federal and State governments, as well as the health service community, it is developing rapidly.
In the UK and the US nursing has featured strongly on the health research agenda. Indeed, the current UK focus on Research and Development has increased nursing research funding dramatically in the past five years and funding for nursing research through the National Institutes for Health in the US has seen a similar increase. This is not, of course, the case in Australia, but more of that later.
Nurses have identified (from their experience, practice and research) that we know too little about effectively helping the disoriented person; about how to best feed someone who is unable to do so for themselves; or how best to relieve the constant, nagging pain of chronic arthritic conditions without mind dulling drugs. About the effect of comfort, warmth, colour or noise on recovery from surgery or a life threatening illness; about preventing pressure sores; or about preventing falls in hospitals or in the community.
Nursing science is about these apparently ordinary aspects of life that most of us take for granted when we are in control of them, but which become incredibly important when they move out of our control. It is not as dramatic and worthy of headlines in our newspapers as research into childhood illness, heart transplants, AIDS or other curative endeavours associated with mainstream medical research.
Nursing began as a result of a need in society for an occupational group who would promote healthy living. A group who would engage in providing human assistance to those who needed help to achieve health, or to cope with ill-health or disability, and its very existence depends upon its ability to provide such a service. Nursing is a practice, that needs the support of nursing managers, nursing educators and research activity, but which achieves its purpose through direct interaction between the practitioner and the client/resident. As a discipline, its domain is delineated by the parameters of legitimate practice. Because nursing is so diverse, practice is broad and varied and the focus of legitimate nursing research is best defined in broad terms as:
Elsewhere (Pearson et al, 2000) I have argued that there appear to be five major issues to be confronted if we are to progress nursing science in the future:
While multidisciplinarity is highly valued (and aggressively marketed by funding bodies) there is a plethora of fundamental questions arising out of nursing experience and practice that need to be addressed—and will only be addressed by nurses because they are of little interest to other disciplines. There is recognition within nursing for developing strong programs of research that stem from, and are approached from, a nursing perspective.
The impact of care on outcomes is currently central to government health care, but there is a real need for high quality nursing research in this area. Nursing needs to be much more active in determining how outcomes directly related to nursing intervention can be conceptualised and studied.
There is considerable confusion in this country between the definitions of professional nursing care (a skilled intervention) and personal care (that which can be provided by any caring person) and this appears to lie in misunderstandings of the nursing role. There is also some confusion concerning the relationship between the need for nursing and the need for medical care. Whilst the input of all members of the multi-disciplinary health team are seen as important in the literature, the need for informed, sensitive and skilled nursing in leading the provision of direct care is a recurring theme. The need for research in this area is urgent.
By definition, research into effectiveness refers directly to the relationship between a cause and an effect. In other words, it is concerned with questions of if X is given/applied/carried out, what effect will it have on Y? The worldwide movement of Evidence Based Health Practice is essentially concerned with evidence on effectiveness. A wide range of care practices can be guided by this kind of evidence. Evidence such as:
and are all common problems in health care. Interventions that are not based on the best available quantitative evidence are clearly inappropriate. Evidence Based Health Care Practice focuses on the need for all health professionals to use those interventions that are supported by the most up-to-date evidence or knowledge available on their effectiveness.
This approach acknowledges the difficulties faced by busy practitioners in keeping up to date with an ever growing literature in health care and emphasises the importance of providing them with condensed information gathered through the systematic review of the international literature on a given topic. Pearson (1997) suggests that the current focus on interpretive and critical research in nursing, though critical to its scholarly development, may have led to a devaluing of clinical research which seeks to measure effectiveness. He argues for a balanced, pluralistic approach to nursing inquiry and asserts that this is required if an evidence based practice approach to the delivery of physical care is to become a part of Australian nursing.
Although nurses make up the largest component of health services, consume the largest part of the health system salary budget, and deliver the broadest range of interventions of any health care occupation, funding for nursing research by the making panels and the absence of a nursing panel to review submitted proposals. Whilst multidisciplinarity in medicine means collaboration between medicine and surgery or paediatrics and obstetrics, it is interpreted to mean working with other professions when applied to nursing, but many research questions pursued by nurses are of little interest to other health professionals. Australian nurses have achieved a great deal in achieving a "fair go" for nursing education and for nurses industrially, there has been too little attention paid to the development of nursing science through research.
The Joan Durdin Oration serves to highlight and celebrate the past and to strategise for the future. Australian nursing has a strong, proud history of service, of response to need, of adaptation and of progress in terms of its practice. Although practice and the delivery of a nursing service are the fundamental concerns of nursing as a profession, intervention without evidence; innovation without evaluation; practice without science are unsustainable in this knowledge-rich era. major funding body, the NHMRC, is negligible. This is largely due to the dominance of medicine and health scientists on decision