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May 12 is International Nurses' Day, in tribute to nurses and the role
they play in delivering health care. In Australia, the nature of this
role has changed significantly over the past three decades. The
momentum for this change has come in response to forces from both
within and without the profession: the women's movement of the 1970s
dramatically altered expectations of work for this once almost
totally female workforce;1 in the 1980s, tertiary
education was introduced; and in the 1990s, nursing has not escaped
the impact of deregulation of the labour market, multiskilling and
the drive towards greater efficiency and productivity in the face of
economic pressures.
Impact of tertiary education
Newly qualified nurses are now the product of a liberal education,
quite different from the hospital-based education of the past.
Indeed, all nurses have embraced the tertiary opportunities that the
transfer of nurse education has provided. The demand for places to
convert certificate or diploma qualifications to degrees remains
strong in the 34 universities with faculties or schools of nursing in
Australia.2 So, too, does the demand for
places for graduate diplomas and higher degrees; about half the
schools of nursing offer doctoral programs3 and the number of nurses who
have gained doctorates is increasing. This has in turn led to the
creation of more chairs of clinical nursing (18 as of March 1996, with
more pending [Professor S McKinley, Secretary to the Australian
Professors of Clinical Nursing Association, personal
communication]).
As well as providing education, universities have promoted and
stimulated research that is contributing to the developing
knowledge base for nursing practice. This work, together with
hospital-based research and that of newly established nursing
research centres, is crucial to the evolution of the nurse's role and
to the provision of evidence-based care unique to nursing. In fact,
increased scientific knowledge and resulting new technologies and
treatment methods are increasing the complexity of nursing
practice. And in the constant interplay between education and
research, education to maintain and develop new practical skills has
become a critical necessity.
Other influences
Influences apart from those of education and research have led to
further developments in the role of nurses. At times, blurred
boundaries with the roles of other health workers have resulted, with
accompanying dilemmas. For example, economic forces have led to the
increasing employment of less skilled workers who have taken on some
of the work of nurses, mostly outside the regulatory framework that
governs nurses -- grave questions about accountability and duty of
care need to be answered. For example, to whom and for what are personal
care attendants, with no knowledge of drugs, accountable in
administering prescribed medications without supervision?
Indeed, the general decline in resources and the restructuring of
service delivery systems will continue to impact on the role of
nurses. Advancing technology is also associated with
yet-to-be-resolved legal and ethical dilemmas in the role of nurses
(as for all health practitioners) -- dilemmas, such as euthanasia and
assisted suicide, that are no longer remote but immediate and
omnipresent.
Expanding roles
The expansion of the nurse's role is challenging the existing
statutory limitations on nursing practice. For example, nurses in
intensive care units are at the cutting edge of technological
innovation and often undertake activities once thought to be the sole
province of medical practitioners.4 Nurses in remote areas have
long been expected to act outside the boundaries of the nurse's role
and have articulated the case for an expanded role (e.g., the right to
prescribe some medications or to order pathological
tests).5,6 Further, nurses in
women's health services in most States and Territories find the
absence of such rights (including also the right to refer clients to
specialist services) prevents delivery of optimal patient
care.7 A review of existing nursing roles with new and expanded boundaries is
almost complete in New South Wales.8 The Nurse Practitioner
Review, sponsored by the New South Wales Health Department, started
in November 1993 and has included 10 pilot projects to evaluate three
models of nursing roles with expanded responsibilities: Nurse
Practitioner Remote Area, Nurse Practitioner General Practice and
Nurse Practitioner Area and District Health. Within the context of
each practice, extra responsibilities include ordering diagnostic
procedures, prescribing and receiving or making referrals. The
scope that the nurse practitioner role offers for advanced practice
in nursing is a major attraction for nurses. And, given the
developments in their preparation and the growth of nursing
knowledge, it is a role that nurses are ready to fulfil.
Within the wider context of all health care professions, nurses wish
to work collaboratively, as team members, and to be consulted about
their views on people's health care needs. They wish to be
acknowledged for the contribution they make to patient recovery and
to maintaining people's health and for the care and support they give
to the dying; nurses are arguably the health professionals most
intimate with people's lives and they recognise their resulting
position of privilege and trust. And, in the challenging climate of
change continually impacting on so many aspects of the nursing role,
at least one aspect will persist: nurses will continue to support the
values of caring and comfort that have always underpinned their
practice.
Elizabeth C Percival
Executive Director, Royal College of Nursing, Canberra, ACT
Helen M Hamilton
Project Officer, Royal College of Nursing, Canberra, ACT
- Beaumont M. The professional role of a national nursing
organisation. In: Gray G, Pratt R, editors. Issues in Australian
nursing 2. Melbourne: Churchill Livingstone, 1989; 247-261.
-
Report of the national review of nurse education in the higher
education sector: 1994 and beyond. Canberra: AGPS, 1994: 143.
-
Royal College of Nursing, Australia. Directory of higher
education nursing courses. Sydney: New Hobson Press, 1996.
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Bucknall T, Thomas S. Clinical decision making in critical care.
Aust J Adv Nurs 1995; 13 (2): 10-17.
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Kreger A. Remote area nursing practice: a quest for education.
Report to the Council of Remote Area Nurses Inc. CRANA, 1991: 57-60.
-
Buckley P, Gray G. Across the spinifex: registered nurses working
in rural and remote South Australia. Adelaide: School of Nursing,
Flinders University, 1993: 143.
-
New South Wales Health Department. Role and function of nurse
practitioners in New South Wales. Discussion paper. Sydney: NSW
Health, 1992: 7, 13-17. (NSW State Health Publication No. [NB]
93-120.)
-
New South Wales Health Department. Nurse Practitioner Review
Stage 2. Vol 2. Sydney: NSW Health, 1993. A1/1-A5/1-20. (NSW State
Health Publication No. [NB] 93-120.)
©MJA 1999
© 1999 Medical Journal of Australia.
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