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Educators defend specialisation

Letting too many nurses concentrate on narrow areas of practice depletes the number of general duties staff, say critics. But educators argue that medical advances make it necessary. Louis White reports.

As a patient, we are both relieved and fraught with nerves when we are told we need to see a specialist doctor. Relieved that there is someone in the field of the unknown illness that our body is carrying, which eases our mind that a cure may be found sooner rather than later.

We are also very nervous that something may be seriously wrong with our health and it may result in a prolonged illness or even death. It is as if our body and feelings are facing a dichotomy.

But where there remains hope, which will always prevail when we know there is a specialist doctor in the field of illness for which we are currently diagnosed, the more positive feeling will generally win through.

While patients take comfort in seeing a specialist doctor, there are mixed feelings within and outside the nursing profession regarding more nurses specialising - in fields such as emergency, aged care, coronary care, midwifery, oncology and palliative care amongst others.

Some see this as a negative, resulting in nurses losing general skills and unable or unwilling to transfer their skills to another section of the hospital or to a completely different area in nursing.

This is because of the difficult processes involved in applying for another job, such as getting the required police and reference checks, interviews and preparation. However, others see it as a positive.

"I have never heard anyone complain that we have too many specialist doctors," says Julie Considine, professor in nursing at the school of nursing and midwifery at Deakin University. "So, I am not sure why people would complain about there being too many specialist nurses?

"Nurses have always specialised but I know a lot of nurses that transfer their specialist skills. For example, I have emergency nursing colleagues who now work in ICU and hospital in the home and they have benefited from the experience.

"Personally, I have always worked in emergency care and relished the challenges that it presents."

Complex illnesses

Considine believes it was inevitable that the medical profession would become more specialised as medical research revealed more details about particular illnesses and diseases.

The more complex a sickness, the more it requires each area within the medical profession to have greater knowledge and that invariably leads to specialisation.

"If I had a cardiac arrest, I would want an expert emergency nurse, if I was having a baby, I would want an expert midwife, if I've had a stroke, I would want an expert stroke nurse," Considine says.

"No one ever suggests that orthopaedic surgeons take over the plastic surgery list."

General medical training has advanced greatly in all areas since Considine started out 30 years ago. "When I trained in the late 1980s, there were still general medical and surgical units, but it was common for surgical specialties to be clustered on the same wards like plastics, orthopaedics, gastrointestinal," she says.

"Now medicine has also sub-specialised and your find medical units with specific expertise in stroke, respiratory problems, diabetes and new areas are developing too. There are many benefits to nurses specialising ... such as patients receiving expert care in that area and the nurses can help out with answering questions, thereby comforting the patient.

"It improves the outcome for the patient and specialised nurses might notice something that a general nurse doesn't. A patient may have broken his or her leg and that is what they are treated for. A nurse who may have worked with stroke victims would naturally look to see if there was any head trauma rather than just treating the immediate injury.

"Of course, there can also be some disadvantages to nurses specialising as it can lead to a less flexible workforce and nurses might become deskilled in areas other than their speciality, which means hospitals have decreased ability to move nurses within their organisation. But I don't see any of these conversations happening about medical specialists!"

The Nursing and Midwifery Board of Australia says there are just under 337,000 registered nurses and midwifes in Australia as of September 2012.

There about 238,000 registered nurses, 59,000 enrolled nurses and 33,000 registered nurse/midwives. These are the three largest categories in the profession.

The biggest worry for Australia is the age of nurses. There are 51,055 nurses and midwives in the 51- to 55-year-old category. In the 41- to 60-year-old bracket there are a total of 178,567 nurses and midwives.

Career progression

Surveys conducted by Monash University, Health Workforce Australia and the Australian Nursing Federation indicate that more and more nurses are looking to leave the profession for a multitude of reasons, including poor pay and lack of career opportunities.

By creating more and more specialist nurse roles it increases the opportunities for nurses to gain broader skills, higher pay as well as more job satisfaction.

"There are often better career progression opportunities for specialist nurses," says Dr Colleen Smith, associate head of the University of South Australia's school of nursing and midwifery.

"For instance, nurses with specialist qualifications can extend their scope of specialist practice by undertaking the Master of Nursing (Nurse Practitioner) program. By offering specialist nursing positions, nurses can undertake that option and study the necessary qualifications to progress in that field."

Smith believes there are far more advantages than disadvantages to nurses being able to specialise and it was inevitable that this genre would open up due to medical research.

"Nurses specialising in particular areas of medicine is a response to an increase in technology and advances in medical and health care knowledge," she says.

"Patient care is much more complex resulting in the need for more specialist nurses to drive the safety and quality agenda and improve patient outcomes."

The reality is that we are an ageing population. The Australian Bureau of Statistics states that 13.5 per cent of the population are currently aged over 65 years.

By 2050 this age group will make up almost 23 per cent of the population. There will be just 2.7 people of working age (15 to 64 years old) compared with five now for each Australian aged 65 years and over.

The risk of having a stroke rises as you get older. Australians are exercising less, eating more junk food and obesity is on the rise, meaning that diabetes will only increase.

As we get older more illnesses and injuries occur and each year medical research makes discoveries resulting in new diseases coming to the fore requiring more specialist knowledge in that area.

This will flow from what children are immunised with to the way people are treated in hospital to the design and care of patients in hospitals in the future.

"The advantages of nurses having specific knowledge is that they acquire in-depth knowledge and skills in their specialist area of practice and provide advice and support within their specialist scope of practice to other health professionals," Smith says.

"Of course there is the disadvantage of specialist knowledge and skills not readily transferrable to other areas of nursing practice, so this could result in the potential to lose skills.

"Overall, their needs to be a sufficient mix of generalist and specialist nurses to ensure a flexible workforce that caters for the needs of the healthcare industry."

Thomas Harding, professional officer at the NSW Nurses and Midwives Association, believes that it has always been a trend for nurses to find a niche and stay there.

"I don't think it is that different from other professions, where you find a niche within your field of expertise and choose to remain there," Harding says.

Technological advances

This school of thought is backed up by the Australian Nursing Federation federal secretary, Lee Thomas, who says that like all occupations some nurses choose to stay in a particular area for many years of their working life.

She says this choice is not unusual and is made generally because of the preference for that type of nursing.

"Skills are broadened and many new skills learned over the years, as medical technology and techniques change. But nurses remain nurses with broad skills irrespective of the areas in which they might choose to spend their working life.

"However, nurses in rural and remote areas, working in the outback and in small country hospitals don't have the same opportunities to stay in one area for many years," says Thomas.

Harding, however, points out that the general public fails to differentiate nurses like they do with doctors.

"Most patients just see a nurse as a nurse," he says.

"That is unfortunate in that all nurses should be recognised for the skills that they bring on board and specialised nurses do extra study and training."

He does agree that processes in place within the healthcare sector don't make it as easy as once before for nurses to chop and change their career path.

"There is no doubt that through all the processes in place these days it is harder for nurses to move from one area of specialty to another or even back to a general nurse once they have specialised," Harding says.

"The reality is that in the future we will need more specialised nurses due to the advancements in medical technology. Doctors too want more specialised nurses to work with.

"While this benefits the city we also need to take into consideration that in the country, with less medical assistance available in all areas, we need more general specialised nurses."
Harding, who previously held a senior position at the Australian Catholic University, says that undergraduate and postgraduate degrees have developed substantially and offer more comprehensive learning, enabling students to better demonstrate their skills and knowledge.

"Nursing degrees offer greater flexibility and improved learning facilities thereby enabling students to have increased knowledge.

"The result of that is students will then want to know more about speciality and there are greater opportunities for them now to undertake such post-graduate courses and training than there has been in the past.

"Of course, this is all determined by labour market activity but the greater skillset one possess the more opportunities afforded to them.

"I don't believe nurses lose skills if they specialise, they just acquire new ones and that is to everyone's benefit."

Professor Ramon Shaban, deputy head of school of nursing and midwifery at Griffith University, actually believes there is less specialisation now than in the past.

"I don't know that I believe that nursing specialisation is more common," Shaban says. "Specialisation has been [this way] for many years, and in fact to some extent there is less specialisation.

"Generally speaking, the growth of some specialty areas of practice has been supported by research and evidence-based practice, along with the move of nursing education from the vocational sector to the tertiary sector. These have afforded the development of specialist, research and evidence-based practice. There is a need for the specialist-generalist."

Shaban says that specialisation offers mastery of skills, professional standing, expert patient and practice care and flexibility for nurses.

"Increasing specialisation, and multiple specialisation, increases professional portability and employment," he says. "In addition, nurses change and expand specialisation as their careers evolve, as their personal circumstances change.

"To some extent they lose skills, but they gain others. Their skill and expertise evolves - evolution is the best way to describe it. All skills and abilities acquired are relevant to future practice and specialisation. It adds to the individual's practice base. Specialisation is fundamental and important."

Expect more of the specialised nurse and less of the generalist nurse in the future, though both are needed all around the country. The more money, effort and time invested into medical research means more discoveries and more knowledge acquired.

We all take relief when we hear that a specialist doctor is available, perhaps we should start doing the same with specialist nurses. After all, we generally end up spending more time with them than the doctor anyway.

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