How The Nursing Profession Has Changed Over The Years

Emeritus Professor Rhonda Nay has agreed to write for The Nurse Break about how the nursing profession has changed over the years, answer tough questions about the state of nursing education and give us down-to-earth perspectives on how to improve! With 50+ years of experience, she has been pivotal to the careers of so many and led significant changes to how nursing care is provided today, this is well worth your attention and reading!

Read Part 1 “Career Spotlight: Fighting for justice for older people and those with dementia for 50+ years”

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The “old hospital system”. Since those times, how has the evolution of nursing improved (or not) in your eyes?

Well, that depends on who you ask! I was always a protagonist. Medicine and Allied Health were considered worthy of a university education. Why not nursing, the largest of the health professions? Well, we had a long history of being witches (burned at the stake), damned whores or God’s police, and then doctors’ handmaidens. Our training was grounded in religion and the military. We followed orders; we dare not question. We stood when a doctor entered the room. We stood back to allow anyone senior to step ahead of us. We were predominantly women and thus by definition lesser beings!

The 60’s

The 60s changed things up for women. By the 80s it was past time we changed things up for nursing. Unfortunately, although nursing was eventually ‘allowed’ a university education, some were not prepared to argue for the education nursing required and settled for less. This resulted in a 3 year degree, rather than 4 that some knew to be the minimum required to prepare a nurse for practice. To complicate matters further the Federal Government based the funding of the UG Nursing degree on a flawed study that examined what it then cost to prepare a nurse (in 3 years), rather than what it would cost if the education was appropriate (4 years).

Further compounding this was the reduction of weeks in a university semester. So, what was, in hospital training 3 years, became 6 semesters of some 13-17 weeks. At the same time more and more was crammed into the curriculum and clinical places became harder to source. It was determined that any nursing work undertaken as employment could not be counted as clinical hours, lest labour replace learning as the priority. University nurses and clinical nurses had little respect for each other: clinical nurses saw academics as airy-fairy without street cred and academics saw clinical nurses as lacking their ‘superior’ knowledge. I am generalising, of course not all were like this, but it was a common scenario.

Crammed Curriculum

University education is essential if patients are to have RNs who base their practice on the best available evidence and are in a position to advocate alongside other health professionals. BUT, those courses must be of a standard that prepares them for the real world, with similarly educated health professionals and in a position to lead and influence policy and practice. I do not believe in general we have delivered at the UG level.

Some have achieved a 4 year degree, some have entered into clinical school partnerships with health organisations and some academics and clinicians respect each other’s contributions. Many still have a long way to go.

For those students who progress to PG studies and beyond then a big YES we have Some specialities demand that clinicians working in the area have PG education. Unfortunately, aged care does not and many nurses working with older people in community and acute care are not sufficiently skilled or knowledgeable in older people nursing. There should be more compulsory older person nursing content in the UG degree, but there is no room in the already too short, crammed curriculum.

Is it too easy for students to get into nursing at university?

The short answer is nurses should be equal to medicine and allied health and have equivalent and some shared learning if we are to offer the best in interdisciplinary care.  A lower score sets students behind the eight ball from the start.

Of course the Enter score does not adequately predict student ability to succeed but it is used across the university sector and thus students and parents take it as a reflection of the course: higher score= higher demand=more prestigious and therefor must be the course to aim for. It is also no surprise that students with low scores usually struggle, especially with the sciences.

The universities need the funding large nursing courses attract so they are reluctant to set, what I would argue are essential, ENTER scores equivalent to that of Medicine and Allied Health. Such scores could reduce student numbers and associated funding. So, students are accepted with far lower scores. The result is nursing students are seen as the poor cousins and requiring special ‘dumbed down’ science courses. So, students came into nursing with less academic confidence their course confirmed this and they graduated at the bottom of the health professional pecking order. Any wonder they complain/ed they ‘have no voice’.

 Nursing needs to learn from medicine and acknowledge that we will only realise the educational, practice and policy potential of nursing when we shake the cage, demonstrate we deserve a voice and provide the evidence that we make a huge difference to patient outcomes. Too many bitch and complain about not being valued and having a voice, while being too fearful to speak and demonstrate the value nursing adds. Why is it after all these years we still are not prepared to demand a degree and Enter score on a par with that of other professions?

My suggested compromise is that we acknowledge funding appropriate nursing education as it stands is way more expensive than funding the smaller professionals. So, let’s re-engineer the nursing workforce. (see answer later on)

Similarly, is it too hard for lecturers and universities to fail students?

I can’t speak for all academics/universities on this, and I am not aware of research on the topic. In my experience, while it did become too easy for students to appeal, in the end, if the university had appropriate quality systems in place, the academic had adhered to quality protocols, done his/her job and was able to justify the fail, the student would be failed.

What are some tips you would give nurse lecturers, to make sure education and research are relevant to end-users (the students)?

The most important tips I would give are:

Work collaboratively with stakeholders from conception of idea, through development and in the practice field. Stakeholders should include consumers/patients as well as groups such as the Nurses’ Board, Health Care organisations, students, past students, representatives from other professions etc. Expert advisors from other universities can also add great value. Don’t think when the research/education programmes are completed that the job is over. Constantly network and review. Learn to see critique as essential and use it to improve.

The ‘decision-making table’ and nurses

I was obviously very lucky because I was ‘always’ at the decision-making table. Often I was appointed as a ‘token woman’ but I made sure I was taken seriously. I did my homework, arrived at any meeting on time and well prepared and contributed to any relevant discussion.

I learned from the men that one could argue vehemently about an issue but not take it personally or outside the meeting. Perhaps because history has excluded us too often from public debate and decision-making, women are more likely to take and make it personal.

I’ll admit in the beginning it took courage to speak in a room full of senior men, but the vast majority were supportive once they tested me a time or two. I also learned that humour changes minds and behaviour more efficiently and effectively than anger, taking offence and/or complaining to some committee.

It is important to fight for your position on a topic but to know and accept that at times you will lose. Being a bit more provocative, I would say for some it is safer and easier to complain about not having a voice then it is to have something of value to say and stand up and say it.

RNs and ENs

The current RN is neither fish nor fowl. The education is insufficient to prepare a health professional significantly distinguishable from a skilled and knowledgeable EN 

Professor Nay

Any health workforce should be driven by the needs of the Clients/ Residents/Patients (CRPs) in my view; not by politics or who is the best lobbyist.

(1) establish predicted health care needs;

(2) determine skills and knowledge required to meet those needs;

(3) determine type and level of education  necessary to prepare care providers and

(4) predict workforce numbers to meet needs. 

Imagine a triangle; common sense indicates that the base of the workforce will be large and prepared to assist with/provide many of the everyday care essentials (Health Assistants [HAs]); these staff would receive 12 months broad-based educational preparation and be able to assist (under supervision) nurses, doctors and allied health professionals. The next level would be equivalent to the current EEN, have a Diploma and work independently within their scope of practice but supported by the next level, which would be NPs.

As the ‘Top’ level, NPs would be fewer and thus an appropriate education and wage would be fundable. Enter scores to university would be much higher and education could then be a Masters level preparation with a number of interdisciplinary subjects (eg. Health Systems, physical and social science, communication, law and ethics) shared with doctors and allied health. NPs would be and feel confident clinical leaders.

WHO provides care should not be based on ‘tasks’ but the health status of the CRP and the purpose of the task For example, a shower may be provided by a HA if the health status is stable and the purpose is not assessment. Where health status is severely compromised and/or the purpose is assessment, then the appropriate care provider would be EN or NP where the EN requires expert clinical support/ advice. Obviously, the triangle would be inverted where health status is critical and unpredictable.

What nursing education deficits are under-preparing our nurses to care for older people?

Older people are not valued in our society, and this is reflected in health care. There are many reasons: we fear loss of independence and death and older people remind us this is possible; the media worships youthfulness and we are socialised to accept that value; major companies have invested trillions in age-defying treatments and work constantly to convince us young is beautiful; etc.

Historically nursing older people has been seen as ‘the pits’ of nursing, where failed nurses work to pay off the ‘white goods’. This view is reflected in the way aged care nursing has been taught in universities: often the least capable academic was given the subject to teach and the first clinical experience of students – considered basic – was undertaken in a nursing home, where there was generally a dearth of clinical experts who could teach students all of the skills required to adequately nurse people with multimorbidity.

Many of the staff were never taught comprehensive assessment skills. Most do not have post-graduate education in aged care/dementia (THIS should be a pre-requisite for RNs).  Consequently, unless there was another senior gerontic nursing subject, students believed that you ‘do’ aged care to learn how to make a bed, do a shower and take a BP/temperature then you move on to real nursing with drips, drains and machines that go beep.

Regulated AINS / PCAs

I was involved in a Review of Certs III and IV and although some were excellent, some used articles from New Idea/Women’s Weekly as the evidence base! My view is that Cert 3s need a major review and AINs/PCAs should be regulated.

Some of us had some success in addressing the curriculum deficits at the university level such as:

• the Victorian Nurses Board adopted  recommendations that included universities having to provide evidence that academics teaching aged care had the qualifications to do it, RACFs who took students could demonstrate they had the expertise and environment to adequately support the students and there was a senior gerontic nursing subject in the BN curriculum;
• the Commonwealth Government funded a project which resulted in all universities receiving Principles for aged care in the UG Curriculum; and
• the Clinical Schools models that involved university/ aged care partnerships

What inspired you to develop the trusted textbook: “Older People: Issues and Innovations in Care”? What are some key elements that are raised?

I was concerned that there were insufficient resources available that were Australian and could support academics and students to develop knowledge and skills around working with older people. Initially my wonderful colleague, Sally Garratt,  and I published Nursing Older People. It was well received and we were commissioned to do three further editions.

To reflect our belief that the best care was provided by interdisciplinary teams, we changed the title Older People: Issues and Innovations in Care. TheBEST experts in care of older people agreed to provide chapters and the rest is history. The book won awards for ‘AJA Best Publication in the Field of Ageing’! Perhaps if Sally hadn’t died and I hadn’t retired we would be doing another edition…

Central to the book and care of older people is focusing on THE PERSON, not the disease or task. All authors:

• believed in PCC,
• were committed to evidence-based practice,
• were leaders in their field,
• adopted interdisciplinary practice,
• impacted research, education, policy and practice; and
• all had street credibility!

What red tape exists that you would remove tomorrow if you could – that is impeding our development as a profession?

I’m not sure the issue is red-tape as much as courage, commitment and loud, convincing,  persistent voices. Look at the groups who usually get what they demand and learn HOW they go about it. Fractured voices won’t cut it. We need to be united and have the evidence to back our claims and then be able to present it in a variety of formats depending on our audience: will they be convinced by statistics, tragic stories, fears of not being elected etc.

The red tape preventing the full potential of NPs and ENs being available to the public certainly  has to go and I am impressed with the work Kylie (ACNM) is doing on this front.

What are your final 5 pieces of advice & wisdom to up-and-coming nurse leaders/educators?

1. Be passionate about your CRPs (Clients/ Residents/Patients) rights and your area of expertise; remember the CRP is the expert of their health and you are there to provide support and information NOT to take over ‘cos I know best’!
2. ALWAYS keep learning; if you learn something new every hour you will still not keep up with all the developing knowledge and skills.
3. Respect and collaborate with CRPs, interdisciplinary teams, all staff (gardeners, cleaners, cooks, managers etc often have so much to teach you)
4. Only knock a change/suggestion if you can offer something better
5. Be prepared to take risks (so long as they won’t kill someone!!); innovation comes from risk-taking and preparedness to ‘fail’ – but you haven’t failed until you give up.
6. If you want to be heard/have a voice then make sure you have something of value to say and say it loud enough and well enough that it will be heard and valued. Know your audience and speak in language they will understand. Remember it is not about you – it is about something you want to communicate convincingly.
7. Finally
   • Speak For CRPs;
   • Speak for NURSING; not for your ego, not so you will be popular, and
   • Be prepared to be dis-liked, vilified, embarrassed and everything in between because some do not like what you say; the only way to avoid this is to stand for nothing and even then you will probably be categorised as spineless!
   • Lead from the front – don’t ask staff to do more than you are willing to do. If you want 100% give 150%. Don’t be offended – be resilient. Laugh every day, it is good for your health and the health of those around you.