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Nursing agendas and future directions in 2012

After more than a decade of change, Linda Belardi asks Australia’s nursing leaders to reflect on the shape of the profession and to lay out their policy priorities for the year ahead.

The key players:

Adjunct Associate Professor Fiona Stoker, Chief Nursing Officer, Department of Health and Human Services, Tasmania
Veronica Croome, ACT Chief Nurse
Adjunct Professor Debra Thoms, Chief Nursing and Midwifery Officer, NSW Health
Alison McMillan, Chief Nurse and Midwifery Officer, Victoria
Cheryl Burns, Acting Chief Nursing and Midwifery Officer, QLD Health
Jo Seiler, Executive Director of Nursing, Royal Darwin Hospital, NT
Adjunct Associate Professor Catherine Stoddart, WA Chief Nurse and Midwifery Officer

Q: What milestone or development has most profoundly changed the profession in the past 15 years?

Croome (ACT): The ageing workforce, the rising costs of care, complex technology, undergraduate preparation and specialisation have all changed the profession in the past 15 years. Most changes have been positive for the profession and some have presented us with significant challenges. But if I could only mention one, I would nominate the enhanced role of the enrolled nurse to ensure its relevance to contemporary healthcare environments and to make the role more attractive to employers and the health system generally. In the past 15 years, enrolled nurse education has progressed to a pre-service model and expanded to diploma entry and of course, significant in all this change was the decision to educationally prepare and deem competent, enrolled nurses to administer medication. The impact of this has seen fundamental changes to models of care and the role and function of the registered nurse.

Stoddart (WA): So much has changed for us over the past 15 years. We have bedded down the career structure and long since moved to tertiary education introduced during the 1980s. As a result we can truly call ourselves health professionals. Advancements in technology have had a significant impact on how we do our work. I was reminded of this on a recent trip to Tanzania where a group of student nurses I was with did not know how to shake down a mercury thermometer, having only been exposed to tympanic [thermometers].

To me, the most significant milestone is a recent one, with the introduction of nurse practitioners and eligible midwives and the ability for these professionals to access the PBS and MBS.

As technology advances, and more of us research evidence to support and change practice, nurses and midwives are evolving to more specialised and advanced practice roles. This in turn has led to an improvement with inter-professional education and confidence with how we function alongside medicine.

Thoms (NSW): A major development has been the introduction of extended practice for registered and enrolled nurses, i.e. nurse practitioners and the inclusion of medication administration in enrolled nurse practice. We also have a wider variety of roles for nurses – the practice nurse in a GP setting, the growth in home-based care models and changes in service delivery such as the shortened length of stay for patients in acute settings.

McMillan (VIC): In the past 15 years we have seen enormous shifts in the scope of nursing practice such as the development of the nurse practitioner role, the acknowledgement of the importance of both nursing leadership, and nursing research. This has seen the creation of new models and modes of practice in nursing.

The establishment of the Australian Health Practitioner Regulation Agency (AHPRA) tasked with implementing the National Registration and Accreditation Scheme across Australia is an important milestone in ensuring a flexible and competent health workforce that can meet the needs of the Australian community.

The challenges of recruitment and retention have focused our thinking on some key areas such as an ageing workforce, violence and bullying, diversity, undergraduate and graduate education, professional development, information technology, models of care delivery, and funding models.

Burns (QLD): The nursing and midwifery professions have been strengthened over the past 15 years through the undergraduate and postgraduate education provided by universities and Queensland Health’s review of nursing and midwifery education and training for Queensland. The introduction of the nurse practitioner role to the Queensland health system has had a dramatic impact on contemporary models of care and health service delivery. The nurse practitioner role provides an incentive for our advanced registered nurses to progress their nursing career without leaving the clinical setting. Nurse practitioners improve access to healthcare, enhance patient outcomes, and support departmental performance and educational resources.

Seiler (NT): The past 15 years has seen huge progress and development in the field of nursing and midwifery in the Northern Territory, especially in the evolution of education opportunities for students embarking on a career in nursing, post-graduate programs and career development opportunities.

There are now multiple pathways to becoming a nurse, and also a myriad of options for nurses to undertake training in specialist areas. With the provision of specialist post-graduate training in fields of particular relevance to the needs of the NT such as renal, chronic conditions and remote health we are better catering to the needs of our population.

We have seen midwifery go from a hospital-based training to a graduate diploma through Charles Darwin University (CDU) in 2009 and soon to become a Bachelor of Midwifery next year. These changes all result in aspiring territory nurses and midwives being able to obtain their tertiary qualifications locally.

Stoker (TAS): Over the past 15 years the nursing profession has benefited greatly from increased opportunities for tertiary education and new leadership roles. Nurses have never been so well educated and so much at the forefront of change and this is to be welcomed.

Q: How do you see the role of nursing changing in the next 10 years?

Stoddart (WA): I think that nurses and midwives will continue to grow in their capacity to lead and move into case management, independent practice and senior executive roles previously difficult to break into. I don’t think it will be too far off before we see registered nurses also gaining endorsement to prescribe medication.

We will see more nurses move into primary healthcare. More and more nurses are identifying that they are able to make a real difference by providing education, health promotion, early detection and treatment, and preventative care to people in the community. The emphasis of treatment in hospitals will move more towards critically unwell and complex only patients, with much more care being delivered in patients’ homes for acute, sub-acute and rehabilitation care. The difficulty really is how to change early career nurses’ preferences to the primary care environment rather than acute care.

McMillan (VIC): I don’t see nursing changing significantly in the next 10 years. I think we will continue to see an evolving role with the wellbeing of all Victorians at the forefront of all we do. I believe we will see the introduction of the third tier nursing role, otherwise known as the Healthcare Assistant, or Assistants in Nursing. This role is certificate III prepared and is able to undertake tasks delegated by a registered nurse.

The role of the registered nurse as an advanced practitioner able to co-ordinate the care pathway and undertake complex assessment proposing courses of treatment is a model that is being well utilised internationally and only minimally in Victoria. There may also be a shift to nurses undertaking activities that are usually done by medical staff, such as procedural roles or specialist area roles. An example of this would be an in-reach aged care nurse consultant able to work in the acute setting guiding the sick, aged care patient through from the emergency department in a busy hospital, through their acute episode of care and then back out to their residential environment. These types of roles are proven to reduce length of stay and support the [care] of the elderly patient.

The role of the nurse in the community ambulatory setting will grow with significant redesign opportunities available. The scope of practice of the registered nurse enables this role to participate much more actively in the care pathway. With the advent of new technologies, the ability to monitor patients in their homes rather than admitting them for observation, is being utilised well in the rural setting and may have benefit in the urban setting as the number of patients with chronic disease increases.

Croome (ACT): The profession will continue to change over the next 10 years as more specialised nursing and midwifery roles develop. We have seen legislation introduced to support the role of the nurse practitioner and eligible midwives, and over the next 10 years these roles will become more commonplace and more widespread once access and insurance issues are sorted and other health professionals see the value in these roles.

While the title of nurse specialist dates back many years, traditionally it was something nurses pursued after working in generalist areas. But the early (post registration) and ongoing pursuit of specialisation in nursing is now used as a recruitment and retention strategy appealing to novice nurses to embark on a specialty area of practice early in their career path. Provided nurses do not lose their generalist skills, the impact on the profession should be positive and of course, increasing technology and patient acuity are in effect driving these changes.

Specialisation in professional nursing practice will require the collaborative development of appropriate processes, systems and pathways. Orderly development rather than ad hoc reactionary approaches will ensure that the unique knowledge, skills and attributes of specialist nurses are revealed, thereby empowering nurses and adding depth and breadth to specialist nursing knowledge and clinical practice well into the future.

Burns (QLD): Over the next 10 years registered nurses and midwives will be key in providing high-level clinical co-ordination, critical thinking and decision-making in healthcare.

Nurses and midwives will continue to provide the community with patient-centred care across acute, sub-acute, primary care and residential care settings to support the health of Queensland communities. This will be in diverse service areas such as schools, offender health and community services and in the increased delivery of healthcare through primary care services.

Innovative health service delivery and improved access to care will continue through advanced practice roles including the nurse practitioners and eligible and private practising midwives.

Advances in technology will also change the roles of nursing and midwifery significantly within the next 10 years. The new generation of nurses and midwives will be key to meeting the challenge of driving the delivery of healthcare utilising advanced state of the art technology.

Thoms (NSW): The emphasis on primary healthcare approaches and service delivery will potentially have an impact on nursing. However, nurses are well placed to take leadership roles in this area and manage some of the changes in service models that will be required and are currently being implemented.

Stoker (TAS): Over the next 10 years nurses and midwives may well develop further as leaders in the management of care across the community. This is likely to include primary and preventative care, technical roles that support better screening, extended roles in rural and remote areas and an increasing role in aged care as the population continues to age.

Seiler (NT): Technology will be the biggest player in the continuing development of nursing and midwifery in the Northern Territory into the next decade.

With the rollout of e-health, e-learning and telehealth initiatives just beginning, we are still at the brink of this technological revolution, but the sorts of things that are already achievable are extremely exciting, especially here in the Northern Territory where many of our clinics and even some of our hospitals and health centres are incredibly isolated compared to the rest of Australia.

Many of our nurses and midwives work in extremely remote places and linking in to other health professionals and larger hospitals has revolutionised the way we will be able to practise. In another 10 years I expect to see this technology to develop to allow even greater access and communication between clinicians, health centres and hospitals, allowing for better access to care for our patients.

Q: What would you identify as the three most significant challenges facing nursing in your state or territory?

Stoddardt (WA): One of the biggest problems for us is the distribution of nurses and midwives across geographical settings and areas of work. We have disparity across our state currently, with the greatest number of nurses and midwives concentrated in the metropolitan area, in acute care settings, while many of our rural centres struggle to attract nurses and midwives to their towns for long periods.

Most student nurses want to work in acute care settings, preferable in the major teaching hospitals on graduation, and are only interested in working in our more touristy regional centres. It is also difficult to recruit nurses to aged care sectors, and highly specialised areas.

With the resources boom also comes the issue of nurses and midwives leaving to work in higher paying roles, sometimes in occupational health and safety, but often to non-specialist mining roles.

We also seem to have some resistance in the acceptance of new models of nursing care. Support roles such as the re-introduction of Assistants in Nursing sometimes are threatening to nurses, as we seem to be reluctant to let go of any tasks, even while more extended skills and expertise are being asked of us.

Stoker (TAS): With an ageing population and increasing demand for services, we need to work together as a community to deliver a sustainable, healthcare system which supports people to be active partners in the management of their own health and wellbeing as well as delivering care when it is needed.

In Tasmania, we also need to wrestle control of health inflation, improve efficiency, reduce costs and put health on a sustainable footing to prevent it consuming the entire state budget. Health is impacted by budget challenges flowing from the global financial crisis. Nurses have a key role in reassuring patients that impacts on patient care are being kept to an absolute minimum.

Croome (ACT): I foresee important challenges in the workforce, education and clinical practice areas. In the workforce, recruitment and retention is and will continue to be a crucial challenge and is compounded by an ageing workforce and the continual pursuit of a better work-life balance. A shortage of experienced nurses in many areas, but in particular in critical care, mental health and aged care, will affect the quality of the work environment. [This will] increase nursing workloads and drive up costs with more responsibility falling to fewer nurses.

There are many and varied issues in education, including increased demand for undergraduate placements and supervision, [and] differing agendas and priorities of the academic institutions and the service providers. Information technology demands and access to professional development opportunities both in terms of funding and work release are challenges facing nursing in the ACT.

In the area of clinical practice, models of care need to not only suit the acuity of patients but they also need to match the available nursing skill mix. As more assistants in nursing emerge, particularly from the undergraduate ranks, scope of practice issues will become more of a concern.

Thoms (NSW): An ageing workforce and population will bring challenges which won’t just impact nursing but health services more broadly. We will need to meet the challenge of engaging the increasing number of graduates from nursing programs at university.

Balancing the extension and changing roles and practice, while ensuring core nursing activities continue to be delivered in an appropriate and safe manner, will also be a key challenge for the health system.

McMillan (VIC): Nurses are well-respected members of our community. It will be important to maintain and further enhance this into the future as we are likely to see an ongoing economic crisis internationally, and human resource challenges. We will need to remain vigilant in anticipating and adapting to changing disease patterns and demographics and to ensure scopes of practice for nurses evolve to meet these challenges.

Seiler (NT): The Northern Territory is a unique place and with it comes unique challenges for territory nurses and midwives. Many of our nurses and midwives work in some of the most isolated places in Australia, often in small communities away from their families and friends. While this poses a challenge it is one that our nurses and midwives take on whole-heartedly. It also provides the opportunity of a lifetime, to live and work in the unique environments the NT offers.

A challenge that is a focus in the NT is the recruitment and retention of staff. Just a few years ago in 2009, we had a 57 per cent annual turnover of staff but today that sits at just 15 per cent and the number of nurses and midwives employed has also grown significantly to ensure that Territorians receive the care they require.

Q: What is your leading priority going into 2012 to develop and enhance nursing in your state or territory?

Croome (ACT): Workforce planning, more workforce planning and ongoing workforce planning! The quality of the nursing and midwifery workforce and its sustainability will be a leading priority during my time as Chief Nurse. Nursing is difficult and stressful but incredibly rewarding.

However, there are increasing workloads and ongoing industrial issues, casualisation of the profession, concerns regarding affordability brought about through rising healthcare costs and the GFC internationally, and an ageing workforce with disproportionately increased retirements over the next few years. So, as part of ensuring our sustainability, we need strong nursing leadership, appropriate organisational structures with supported and dedicated staff, performance measurement and motivation, effective communication and ongoing education and development. Workforce planning is a complex business about which we in the ACT need to stay ahead of the game.

Stoddardt (WA): While we are always focused on the recruitment of nurses and midwives into our system, we are increasing work in the area of retention. Recruitment campaigns, such as the one we have running from January to June 2012, is aimed at bringing more nurses and midwives into the system, encouraging those who have left for a variety of reasons to return, and to instill pride and recognition of the nurses and midwives we already have.

We know that there is a limited number of potential students coming into the professions that in years to come will not cover the number of experienced and ageing staff beginning to leave, especially at a time when WA is also embarking on its biggest ever infrastructure program. Better retention strategies can help reduce the gap. We have started working with our older nurses and midwives for them to explore opportunities of how they can remain useful, productive and valued. We have invested in providing financial literacy programs, teaching them how they can continue to work, maybe part-time or casual, and to start balancing life as they transition to retirement.

We are offering nurses and midwives reaching the end of their careers the opportunity to move into professional development, research, or mentoring roles so that their skills and wisdom can continue to be accessed by the younger generation, which aids in succession planning, as well as providing our loyal nurses and midwives recognition for their commitment to their professions.

Stoker (TAS): A key priority going into 2012 is to develop the Tasmanian Clinical Education Network to provide greater collaboration across government, non-government and the private sector to provide clinical training places and to build evidence-based health workforce innovation in nursing.

Thoms (NSW): We will look to continuing our work using transformational practice development through the Essentials of Care Program, which now has over 550 wards and units engaged across NSW. Another key priority will be enabling nursing management and leadership to grow and develop and lead nursing services as they adapt and respond to changes in health service delivery in order to maintain high-quality patient care. In relation to an ageing workforce, we will work to ensure that we are building not only clinical capacity but also leadership for the future.

Seiler (NT): Our leading priority for the next 12 months and beyond is to maintain our workforce and attract the best calibre of nurses to work within the Northern Territory. We will achieve this by offering our nurses and midwives great professional development opportunities and experience and developing our schools to pathway program to foster our aspiring NT nurses to train and stay here in the NT. We are also focused on growing the number of indigenous nurses and midwives in the NT with our indigenous cadetships and the development of nursing and midwifery courses through the NT-based Australian Centre for Indigenous Knowledge and Education, a collaboration between the Batchelor Institute for Indigenous Tertiary Education and Charles Darwin University.

Burns (QLD): One of Queensland Health’s key priorities for the future is providing innovative models of undergraduate and nursing graduate employment. The undergraduate student model introduces second- and third-year students to the nursing role to prepare them for employment.

Interdisciplinary care will continue to be a major strength for healthcare in Australia with nursing and midwifery taking a leadership role in the provision of 24-hour care across most health settings.

Queensland will be responsive to predicted changes in demographics including rural and regional development and the healthcare needs of those populations. We will deliver productivity, efficiency and effectiveness in health services by increasing the capacity of all positions within the nursing and midwifery career structure (from school-based trainee to director of nursing and midwifery level) and using innovative models of nursing and midwifery practice. The fundamentals of care and compassion will continue as a strength and foundation for our professions.

McMillan (VIC): My priorities for 2012 are to motivate debate and developmental thinking around professional nursing and midwifery in the Victorian health sector on matters of strategic and operational significance to the public hospital health system.

Adjunct Associate Professor Lydia Dennett commenced as SA’s Chief Nurse and Midwifery Officer on December 5. She was unable to respond to NR’s request before deadline.

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