CHAPTER 16 Progress in nursing: multidisciplinary and shared care
The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he [sic] would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him [sic] gain independence as rapidly as possible.
We begin this chapter with Virginia Henderson’s classic quote to help you think about what it is that nurses do. At its core, nurses’ work is to care for the sick, however, a more recent definition offered by the International Council of Nurses (ICN) extends this definition, suggesting nurses’ work:
… encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and inpatient and health systems management, and education are also key nursing roles.
Worldwide legislation exists to protect the title of ‘nurse’. Here in Australia the nursing workforce is regulated by a series of Acts of Parliament at a state and territory level which support the function of the seven boards of nursing responsible for monitoring nurse education, examination, and dealing with issues of reciprocity of registration in Australia and overseas (Gerdtz & Nelson 2007). To use the title of ‘nurse’ a person must be registered or enrolled under the Act of the state or territory where they wish to work. These Acts of Parliament provide definitions of who is or is not a nurse.
In Australia the nursing workforce is divided into registered and enrolled nurses based on their mode of functioning. This categorisation differentiates the nursing workforce according to their scope of practice and takes into account nurses’ educational preparation, role activities and professional accountability as defined by legislation. Moreover, registered nurses are differentiated on the basis of the particular fields in which additional qualifications and experience are obtained. Currently, registered general nurses, mental health nurses, midwives and nurse practitioners are identified in nursing registers. Nurses’ boards have the responsibility of maintaining the register of registered nurses working in these categories within each jurisdiction and ensuring that all working as a registered nurse are in receipt of an annual practising certificate. At present the register does not differentiate between nurses working in clinical practice, education or administrative positions (Price et al 1994, Health Professionals Act 2004 [ACT], Health Professionals Registration Act 2005 [Vic], Health Practitioners Act 2007 [NT], Nursing Act 1992 [Qld], Nursing Act 1995 [Tas], Nurses Act 1999 [SA], Nurses & Midwives Act (2006) [WA], Health Services Act 1997 [NSW].
A registered nurse is authorised to practise without supervision and is accountable and responsible for the provision of nursing care. The registered nurse is accountable for assessment of patients and decisions in relation to delegation and supervision to enrolled nurses and unlicensed health care workers. An enrolled nurse practises under the supervision (direct and indirect) of a registered nurse; they remain responsible for their actions and are accountable to the registered nurse for all delegated decisions and functions. In some states, an enrolled nurse may apply to the board for authorisation to work without the supervision of a registered nurse (Nurses Act 1999, SA). A final group of health care workers provide personal care, primarily for the aged care industry. Unlicensed health care workers are also known as nursing assistants or personal care workers. They are not regulated by the nurses’ boards and are not, therefore, legally entitled to use the title of ‘nurse’.
Table 16.1 shows the number of registered nurses (RNs) and enrolled nurses (ENs) in Australia in 2004. Most of the nursing workforce in Australia is comprised of RNs (80.2% of the nursing workforce). The Northern Territory has the highest ratio of RNs to ENs, with 90.2% of the nursing workforce being RNs. Victoria and South Australia have the highest proportion of ENs to RNs, with approximately one-quarter of the nursing workforce in these states working as ENs. In addition, over 49 000 people identified themselves as unlicensed care workers in the 2001 census, accounting for 20.7% of people providing nursing services. This number increased from 18.4% in 1996, suggesting greater use of unlicensed staff to provide care (Australian Institute of Health and Welfare [AIHW] 2003).
Pause for reflection
The South Australian Nurses Act 1999 allows ENs to apply to work without supervision and increasingly they are able to up-skill through further training to diploma level. These developments allow ENs a greater scope of practice. What is the potential impact of this on the delivery of health care services in South Australia given the proportion of ENs to RNs in that state?
How and where nursing occurs is as diverse as the people who nurses care for and the work nurses do. Nurses work in both clinical and non-clinical roles. Clinical roles can include medical/surgical nursing, midwifery, critical care, family and child care, community care, aged care and mental health. The largest speciality for registered nurses employed in Australia in 2004 was medical/surgical nursing (27.5%) followed by critical care (11.8%) and aged care (9.8%). Non-clinical roles for nurses include administration or management roles (5.9%), teaching and education (2.4%) and working as a researcher (1%) (AIHW 2006e). Over half (53.7%) of Australia’s RNs work in hospitals, including psychiatric hospitals. Of the nurses working outside of hospitals, 7.7% work in the community, 7% in rural and remote area services, 2.1% in schools and universities, 10.2% in residential aged care facilities (10.2%), and 3.3% in general practice (AIHW 2006e).
The career structure is a pathway for career progression for nurses. It draws on the ‘clinical ladder’ system in the US and is influenced by the ‘Dreyfus Model of Skill Acquisition’, adapted to nursing by Benner (1984). The career structure or pathway was introduced to provide a framework for career progression and remuneration for nurses based on an individual nurse meeting defined criteria of skill, competence, professional expertise and education. The rationale for implementing a clinical ladder or career structure was, in part, to recognise nurses who choose to remain at the bedside or in clinical practice rather than go into administration and management or education positions (Zimmer 1972; Gagen 1984; Silver 1986a; Walker 2005). In the early 1970s and 1980s many nursing organisations began to explore the possibility of developing a clinical ladder. The Australian Nursing Federation (ANF) in South Australia was one of the first Australian organisations to develop a career structure. The career structure which they developed was piloted in 1985 and implemented in 1987, and provided a model for other states and territories (Koch et al 1999). The South Australian Career Structure Model delineated five levels of nursing professionals based on skill.
The career structure was viewed as providing nurses with a clear career trajectory, professional recognition, encouraging the continual updating of professional skills, improving job satisfaction, performance and the retention of nurses in the nursing workforce (Buchan 1999; Walker 2005). Despite the claimed benefits, nurses’ career pathways still are determined industrially; nurses are rewarded for years of service rather than clinical ability (Moyes 2002). Some of this may be attributed to the lack of recognition of the professional practice roles of those nurses who choose to remain in the clinical arena. Lack of recognition of professional practice has led to ambiguity in defining clinical nurse specialist positions and/or advanced nurse practitioners. The irony is that in order to be recognised and rewarded for their work as a nurse, nurses have had to, and do, move further from the ‘bedside where they learnt their craft’ (Walker 2005: 185).