A Christmas Message for Nurses

For the Christian world its nearly Christmas. Its time to think of others. When I think of family I also think of my nursing colleagues all around the world.

Nurses truly are a global village. We come from all races, countries, religions and beliefs. We are Christians, Muslims, Jews, Hindus, Buddhists, Sikhs, Taoists, Atheists. We celebrate Christmas, Ramadan, Hanukkha, Diwali, Maghi and so many others around the world. We are women and men, young and old. We are parents, siblings, children, relatives and friends.

We wear theatre scrubs, nuns habits, the hijab and military uniform. We work in large city hospitals and small remote villages. We work in wealthy, prosperous communities and in poverty stricken refugee camps. We work in the most harsh and remote places. We practice in clinical settings, education, research, health policy, management and the law.

We practice in peace times and in war zones. We are there at birth and at death. We  relieve pain and promote healing, fight sickness and advance health. We have access to the most advanced technology in western medicine and we make do with the most basic resources in developing countries. We care for the very young and the very old, the disenfranchised and diseased. We care without imposing judgment and we advocate for those without voice.

We are teachers and philosophers, councellors and confidantes, mentors, experts and leaders. We are team players and negotiators, we are unwavering in ensuring our clients right to self-determination and choice.  We care about humanity, the environment, social justice and freedom of speech. We are lobbyists and conscientious objectors. We are often stereotyped and we are frequently objectified but respond with dignity and professionalism. We are run off our feet but will sit quietly by the bedside of someone who needs our time and our caring.

To all nurses everywhere. I wish you health and happiness. I hope you are safe.  And I hope wherever you are, you receive the respect and acknowledgement you deserve. 

With love and recognition

Allison Willis, A Nurse

www.thehealthobjective@blogspot.com

Nursing stereotypes...what do we do to change them?

All you have to do is type ‘nurse’ into Google images and you will see every stereotype of nurses from angel to devil. Are these stereotypes really ever dispersed? What do the public really think of nurses? We are no more angels of mercy than we are naughty nymphets. Nurses remain misrepresented in and the public remain ignorant of the important contribution nurses make to health care.

We have reality talk shows like Dr Oz (Nov 2011) showing a line-up of naughty nurses  dancing provocatively with him, wearing high heels, retro nurses' caps and white dresses with red lingerie showing.  We have popular TV dramas like Grey’s Anatomy representing nurses as largely absent from the provision of care (performed mainly by doctors) and portrayed as 'kind but dumb' nymphets. How can we even hope to change the perception of the public?

Nurses are as negatively stereotyped today as they ever were, even though the profession has become a highly educated and technologically expert field of health science, along side its healthcare colleagues, and there is innumerable evidence that where nurses provide care, morbidity and mortality rates decline.

I suppose we should ask ourselves, are these stereotypes deleterious to nursing? Do the public believe them or are they just a bit of fun? 

Not all stereotypes are negative in nature. The image of the Angel of Mercy is one of a self-sacrificing, morally superior, noble nurse, selfless, altruistic and a reliever of suffering - based on the origin of nursing in the religious orders. The Heroine is the depiction of a brave, tirelessly dedicated nurse with its origins of war time nurses, virtuous – the good nurse ideal.

The trouble with these stereotypes is that they are no more accurate of nursing today than the negative images. The problem for nursing is that the common stereotypes are unrelentingly negative and totally removed from the reality of nursing. 

If public does not understand the complexity of nursing practice, it can’t support nurses fight for the necessary resources and infrastructure that enable nurses to do their work.  If the role of nurses is discounted and demeaned by these images then the public will not recognise the importance nurses play in meeting their health needs nor cry out when nursing numbers decline with the ever declining health dollar.

Although the public continue to hold nurses in the highest regard in relation to qualities of honesty, kindness and caring, the public have more faith in the doctor's knowledge than the nurse's knowledge. Although the public hold nurses in such high regard, it is deeply concerning that they do not have equal belief in the nursing professions level of professional knowledge and expertise. This view appears to be supported by the Gallop Polls (refer Nursing Autonomy Part 3).

But do nurses work at changing this perception or do they passively accept the stereotypes?

Have a look at the first images below. When I show these two images to nurses I ask them to describe who they see in the pictures. In the image on the left nurses routinely describe these as - a female doctor with two males nurses behind.  Nurses routinely describe the image on the right as - three doctors. When I ask them to explain why -  they rationalise that the first image shows the women in different scrubs and standing in front of and taller than the two men, hence this position of seeming authority must mean she is a doctor! They're rationale therefore that the subordinate positions must therefore be nurses!

The second image shows the same three people but now dressed identically and at the same height. When I ask nurses who these people are the most common response is - three doctors. When I ask why they couldn’t  be three theatre nurses the usual rationale is they were three nurses, there would be no doctor present and therefore unlikely!   I am astounded that nurses identify with these images in this way and seem to accept (and foster) the subordinate stereotype of nurses. 

Have a look at the images in the next slide. These are all generic stock photographs found on the web. What do you see these images representing? Be honest with yourself. Do you automatically identify with the subordinate images? Do you see the male roles as more likely to be a doctor? Do you see the person giving information as the doctor and the person listening as the nurse (taking orders)?

The next image is a poignant example how nurses are portrayed in the media (to the public) and how detrimental this is to our profession.  

The two photographs are from the Minister for Foreign Affairs, Mr Kevin Rudd’s, official website. The caption for the first image identifies the medical officer by name and even summaries the nature of the conversation he has with the Minister “....he relays the typical medical conditions presenting at the Camp Cockatoo Health Centre."  Mr Rudd attentively listens to what the doctor has to say.

The second image is captioned “Mr Rudd meets two Australian nurses with the AusAID civilian team” and even included in brackets “(names not known)”  We see two nameless, faceless nurses, Mr Rudd shaking hands with as he walks past. Did the nurses have an audience with Mr Rudd as he did with the doctor? Did he ask or was given their names? Did they have the opportunity to discuss nursing issues in Camp Cockatoo? Did the photojournalist take the time to ask the nurses their names so he could reference this information with the photographs (as he did with the doctor)? I somehow doubt it.

So how do we want to be represented? What images do we want the public to see when they Google us? Aren't these images amazing?

Isn't this what we want the public to see..to know, about nurses?

          

 

Nursing Autonomy Part 4: Visibility, Viability and Voice

Each year the Ray Morgan Image of Professions Survey identifies the public’s level of trust in key professions.  The 2011 results found that 90% of Australians (aged 14 and over) rate nurses as the most ethical and honest profession.  This has been the same result for the 17th year in a row, since nurses were first included on the survey in 1994.

The 2011 results showed the following;

Nurses (90%)

Pharmacists (85%)

Doctors (81%)

School Teachers (78%)

Engineers (71%)

Dentists (69%)

State Supreme Court Judges (68%)

High Court Judges (67%)

University Lecturers (67%)

Police (65%)

Source:  www.roymorgan.com 2011

 The Australian results are similar to the results in the Unites States – where nurses have been found again to be the most trusted professions for the past 11 years in row (since including on survey in 1999). The one year that nurses were not surveyed as the most trustworthy in the US was in 2001 when terrorist attacks occurred (commonly referred to as 9/11).

More importantly I believe are that the results in the US found that more Americans are likely to turn to their doctors for health and medical information (and have confidence in that information) than other potential information sources.  This seems at odds with the survey results as it suggests that although nurses are more trusted and perceived as having a higher level of honesty and ethical standards, the public have more faith in the knowledge of doctors than nurses. What does this mean for nurses?  Although it is astounding that the public hold nurses in such high regard, it is concerning that they do not have equal belief in the nursing professions level of professional knowledge and expertise.

 Bernice Buresh and Suzanne Gordon, in their book From Silence to Voice: What nurses Know and Must Communicate to the Public summarise this concern.

“In spite of years of desire and demonstration to the contrary, the public's perception of nursing practice is still largely that of a handmaiden to the physician”.

“Although the public highly regards nurses, they do not highly value nurses in terms of believing that nursing care is equally as important as medical care in contributing to health.”

So why do the public trust nurses? More importantly if the public don’t know what we do, why do they trust us?

Perhaps it is because the profession is predominantly women - the perception of woman as mother, nurturer, self-sacrificing. Perhaps nurses as care providers are seen as sympathetic?  It is easy to like people who care about you - seen as a trusted friend and confidant?  Perhaps as nurses are advocates for their clients they are seen as empathetic – on their side – part of their support group or family? Perhaps because nurses have held the universal trust of the community for many years – during war times, caring for the poor and disenfranchised over centuries – nurses hold the captive faith of the people. 

The issue is however that the public trust nurses to care for them but do not trust that nurses have the necessary knowledge, to assist them to make the most appropriate decisions about their care. Not only do we want to continue to have the faith of the public behind us but we want the public to be well informed about the unique role and contribution nurses make to their health outcomes.

The only way that this is going to be achieved is if nurses are able to articulate what they do.  Over the course of my career, however I have talked to many hundreds, if not thousands of nurses who are unable to clearly define what nursing is and what it does and how it is different from other professions.  The plain truth is if nurses can’t articulate what they do, how can the public be expected to know?

When I ask any group of nurses to define nursing they frequently offer vague responses like “care”, high standards”, quality health care” and  “health outcomes”.  When I ask them to tie these into a sentence the process becomes even more arduous and we end up in small working groups trying to include ever key word….nurses provide the highest standard of nursing care to achieve quality health outcomes (and them to finish off with a flurry)…for all Australians!  I appreciate the difficulty, writing an overarching definition for something as broad and as complex as nursing practice is a difficult task, but if we don’t clarify our role and function who will? 

 The International Council of Nurses Definition of Nursing is;

“Nursing 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 in patient and health systems management, and education are also key nursing roles” (updated 2010)

The American Nursing Association Nursing's Social Policy Statement (2003) defines six essential features of professional nursing as;

·      Provision of a caring relationship that facilitates health and healing,

·      Attention to the range of human experiences and responses to health and illness within the physical and social environments,

·      Integration of objective data with knowledge gained from an appreciation of the patient or group's subjective experience,

·      Application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking,

·      Advancement of professional nursing knowledge through scholarly inquiry, and

·      Influence on social and public policy to promote social justice.

 What do the public see?

The public perception of nurses and nursing is shaped by the images people see – as clients, their family members, the community and as consumers of media (from the press to entertainment)

The public view of nursing focuses on the art of nursing – caring and nurturing, sweet, kind, honest, ethical, attentive and willing to talk (the emotive components of nursing that have been historically the role of nurses). The public are not commonly aware of the science of nursing. They do not view nurses as critical to their health care planning, interventions, treatment and health outcomes. They are unaware that nursing is evidence-based, technologically sound and based on critical thinking and professional judgment.

I was in a cab recently on the way to the airport.  Bruce, my cab driver was espousing his philosophies on life, one of which included his view of nurses! Bruce told me how he had recently been in hospital and he was ‘disappointed with the nurses of today. Nurses today want to be doctors not nurses…they want to be noctors.” Bruce told me how the nurses who cared for him were more concerned with the ‘technical things than just plain nursing”. When I asked what they were he said “ like taking his BP and checking his drip and doing his dressing - the doctors role. But they didn’t really spend time taking care of him.”

Bruce’s comments sunk home with me. He had no understanding at all of the role the nurses played in his care. Bruce saw any clinical task that took the nurse away from caring and nurturing him as the role of the medical practitioner.  Bruce was looking for an ‘angel of mercy’ and he got a ‘noctor’!

 If nurses do not educate their clients and the public about their role and contribution to health care they continue to be at risk of being marginalised from influencing decision making in relation to;

·      organisational policy and protocols

·      government standards and legislation

·      scope of practice and emerging roles

·      resource allocation and salaries and conditions of employment;

·      expanding autonomy and control over own practice, and

·      the ability to advocate for patients and deliver high quality nursing care.

Nurses need to focus on maximising their visibility, viability and voice to ensure the public understand the role of nursing and its contribution to health care. Without this understanding the public will continue view nurses and trustworthy and caring but lacking in knowledge and expertise and needing to be guided by the medical profession.

Do nurses really want to be viewed by the public as kind but dumb?

Recommended Readings and References

From Silence to Voice: What nurses Know and Must Communicate to the Public Bernice Buresh and Suzanne Gordon 2003 updated 2006

Darbyshire, Philip and Gordon, Suzanne (2005). Exploring Popular Images and Reputations of Nurses and Nursing. In Daly, John, et al., (ed.) Professional Nursing: Concepts, Issues, and Challenges. pp. 69–92. New York: Springer Publishing Company.

International Council of Nurses (ICN)  www.icn.ch

American Nurses Association www.nursingworld.org

Nursing Autonomy Part 2: How can Nurses Enhance their Autonomy?

Nurses can promote and expand their autonomy and the control over their own practice by publicly identifying their unique expertise in health and client care in easily understandable terms in a way that shows the value of their nursing expertise.  

Nurses need to communicate that their work involves an exclusive knowledge base and skill set that is different from and even unknown by physicians. Nurses must to be able to articulate nursing practice and fully understand their scope of practice to show nursing as a distinct and critical profession.

But how do we enhance our autonomy?

Encouraging continuous examination of practice allows nurses to reflect on the degree of autonomy in their decision making. By creating and fostering environments that support continuing educational opportunities and learning provides for autonomous clinical practice (through establishing and ensuring an evidence-based practice approach).

Supportive management, education, and experience are the three most important factors in enhancing autonomy over client care. Part of the dilemma is that most nurses practice as employees, the result being that nurses must structure their work within imposed rules, at the discretion of their employer rather than based on the critical judgement of the nurse. Unlike other health professions nurses do not usually have a discrete client base and it is therefore, more difficult to establish control over decision-making and determining client care. This of course has a profound effect on nursing practice.

Nurses need to foster understanding with other professions, with employers and the public, that nursing practice involves both direct clinical care and management of the context in which care is delivered. 

Nurses are not merely automatons, performing the tasks delegated to them by the physician in rote response. Nurses are autonomous yet interdependent practitioners who case manage complex care by; providing direct care, by collaborating with and seeking advice from other key health professionals and by negotiating components of that care that are the purview of other practitioners. 

Nurses are ground zero, from which all care occurs.

 Further, nurses are often under-represented on management and/or governance issues (issues that determine autonomy) and therefore their Influence on cultural change limited.Clinical nurses more likely to participate in clinical care decisions/policies but not organisational decisions/policy. Nurses must understand and engage with health service policy beyond clinical practice as decisions about autonomy and control over professional decision making are made at  level organisational governance and operational management levels. Nurses need to demand clarification of the rationale behind policy decisions affecting their practice and expose assumptions made in relation to their scope of practice.

Developing autonomy in nursing practice also requires a shift in communication styles and practice. Development of skills related to communication, interdisciplinary teamwork, and negotiation can assist nurses to master the skills necessary to advocate for their clients and demonstrate their autonomy. Our communication skills and the information and way we communicate can help articulate our autonomy to other professions. This may require a level of professional confidence to seek out feedback and critical review without being defensive.

Nurse Leaders

There is no one linear leader/ship. Leaders operate at all levels and evenly distributed throughout the whole organisation. They are characterised by being strong, visible and influential across the whole of the workforce, and may not hold management positions but lead through their this strength and their ability to engage with and address issues.  

Nurses should actively seek out and support nursing leaders who role model promoting autonomy and control over their own practice.This acts to create and shape culture and 

influence change in practice and policy.

Nurse Managers are well positioned to promote conditions to promote nurse autonomy and influence decision-making that supports control over nursing practice. There is evidence to support that Nurse Managers who are (1) informed about current nursing practice,  
(2) support staff to develop autonomy, and (3) communicate effectively with executive management about this practice, enhance professional autonomy. (Kramer & Schmalenberg, 2002;Upenicks, 2003).

Nursing Executive to need to promote and represent nursing staff/practice. A Nursing Executive who (1) advocates for a strong, influential nursing presence in the organisation, (2) is open and communicative and (3) supports participative management,is associated with a professional environment that includes autonomous clinical practice and nursing control over

practice (Hinshaw, 2002). Our Nursing Executive is our direct link to rest of executive team and nurses should expect and demand that nursing management and executive accurately and proactively represent current nursing best practice and advocate for professional autonomy.

Each and every nurse can:

• Clarify expectations about clinical autonomy – expected practice
• Enhance competence in practice – foster clinical case analysis and critiquing
• Establish participative decision making – within policy and governance structure
• Enhance competence in decision making – educate nurses about policy/decision making and how to contribute effectively
• Identify, foster and support nurse leaders – engage with nurse leaders at all levels
• Work upstream – seek to influence social, politician and economic factors in practice
• Articulate nursing practice – to other nurses, other health professionals clients and the public

My advice...

Tell everybody what you do and how you do it....without you there is no care.

See Nursing Autonomy Part 3

Reference:

Kramer, M., & Schmalenberg, C. (2004). Essentials of a magnetic work environment: Part 2. Nursing, 34(7), 44–47.

Upenieks, V. V. (2003). The interrelationship of organizational characteristics of magnet hospitals, nursing leadership, and nursing job satisfaction. Health Care Manager, 22(2), 83–98.

Hinshaw, A.S. (2002). Chapter 4. Building magnetism in health organizations. In M.L. McClure & A.S. Hinshaw (Eds.), Magnet hospitals revisited: Attraction and retention of professional nurses (pp. 83–102). Washington, DC: American Nurses Association.

Nursing/Midwifery Documentation…what is its real purpose?

You didn’t become a nurse or midwife to sit in front of a computer (or written health record) to write notes all day.  You don't have time either. The more time writing repetitive notes, the less time you have to actually provide the care! You were always told to be clear, concise and accurate but no one really ever showed you how to write it! Everyone seems to use a different system and/or different terminology!  You find that you are often writing something merely for the purpose or writing something….if it isn’t written it didn’t happen.

You don’t really want to do it and you certainly don’t enjoy it but….. 

                                               …. in reality, documentation is part of client care.

It may not feel that important today…but in 2 years time when you find yourself before a disciplinary or legal investigation….will your documentation set you in good stead to defend your actions and provide inconclusive evidence of the care you provided?

It is interesting (and concerning) that there are at present, no nursing or midwifery professional standards in Australia (correct me if I am in error) outlining something as imperative as professional documenting.  (Note: there are government and industry based standards (in each state and territory) for record keeping and client health files but these rarely outline or define nursing and midwifery documentation best practice).   

Yet documentation is a vital component of safe, ethical and effective nursing and midwifery practise regardless of the context of care or the form or purpose of the documentation. It provides an account (your professional account) of critical thinking and professional judgement you used in and across all aspects of the nursing process (ie assessment; diagnosis; planning; intervention and evaluation) and partnership between the midwife and the woman.

Documentation…

·      reflects the application of nursing knowledge, skills, and expertise

·      reflects your judgement and establishes your accountability and responsibility

·      is a legal record of events

·      is a source of evidence

·      is a permanent record

·      preserves facts and corroborates and clarifies your recollection/s

·      records the unique contribution of nursing and midwifery to health care 

A Definition

Nursing/Midwifery Documentation refers to any and all forms of documentation by a nurse or midwife recorded in a professional capacity in relation to the provision of nursing or midwifery care. It includes written and electronic health records, audio and video tapes, emails, facsimiles, images (photographs and diagrams), observation charts, check lists, communication books, shift/management reports, incident reports or any other type or form of documentation pertaining to that care.  It may be clinical data, management or educational information or research analysis.   It may also include anecdotal notes or personal reflections by the nurse or midwife.  Willis nbsa 2005 (rescinded)

Refers to written or electronically generated information about a client, describing the care of services provided to that client (eg charting, recording, nurses’ notes or progress notes). In other words, documentation is an accurate account of events that have occurred and when they occurred. Clinical documents are defined as legally authenticated (ie attested or signed) and persistent entries in a client’s health record. Nurses may document information pertaining to individual clients or groups of clients.  Registered Nurses Association of British Columbia 2003

So What is the Purpose of Professional Documentation?

1. Client Care

The permanence of health records makes them a primary client care tool.

Information increases likelihood client will receive consistent/informed care or service.

Particularly in relation to providing necessary information to ensure consistency/continuity of clients’ care.

Encourages health professionals to assess clients’ progress over time, determine effectiveness of interventions, and identify required changes to care plans.

2. Communication

Ensures all involved in a client’s care have access to reliable, pertinent, and current client information upon which to plan and evaluate interventions.

Provides clarity for other health practitioners and reduces duplication of intervention, facilitates multidisciplinary team processes/practices.

Source of information within and across professional groups and teams.

Communicate assessments about status of clients, interventions carried out and results of these interventions.

3. Accountability

Demonstrates the practitioner’s accountability and records their professional practice.

Meets requirement to comply with professional standards, organisational protocols, govt policy.

Demonstrates practitioner has applied knowledge, skills and judgement according to professional standards/best practice.

Reflects/honours ethical concepts of sound practice

Respects client’s privacy, confidentiality, information and circumstances.

May be used in relation to:

·      performance management

·      internal inquiries

·      regulatory proceedings

·      legal proceedings

·      Freedom Of Information (FOI) requests.

4. Legal Record of Evidence

Its importance cannot be overemphasised.

Thorough, accurate, timely documentation is one of the best defences against legal claims.

Can be used as evidence in court of law, coroner’s inquest, regulatory investigations, disciplinary proceedings.

Documentation can be used as evidence in legal proceedings as a measure of nursing care against

·      Standards/Guidelines…

·      Best practice/evidence based practice

·      A ‘reasonable and prudent’ nurse or midwife…..

5. Risk Management

Promotes highest quality of care through quality assurance/improvement.

Risk management processes are used to identify, assess and reduce risk to clients, visitors, staff and assets (eg financial, equipment, human).

Designed to promote safety by reducing incidence of preventable accident/incident/injury.

It may be used for audits, ethical and disciplinary reviews, accreditation surveys, legislated inspections, critical incident review and ongoing risk management analysis.

More readily able to evaluate client/groups progress, identify client care issues and recommend changes/improvements to practice.

A conceptual process to evaluate professional practice.

6. Research Evidence/Analysis

Serve as a valuable/major source of data for nursing and health related research (eg statistical trending helps to prevent or minimise specific developments such as an increase in infection rates).

Identify long term trends/issues for health services/models/resource needs

used in health research to assess nursing interventions, evaluate client outcomes, and determine the efficiency and effectiveness of care.

The type of research made possible through the information in health records can enable nurses to further improve nursing practice.

Precise, clear and complete documentation is essential to ensure accurate research data.

7. Resource/Workforce Management

Provides a valuable source of evidence and rationale for funding and resource management.

Used for workforce measurement data/projections.

Used to measure/determine client classification systems.

Used for skillmix/workload data and funding /resource allocation.

Source of evidence for funding/resource submissions/grants.

I recommend referring to a number of excellent Nursing Documentation Standards from Canada (the best I've seen). Note: They are equally relevant for Enrolled Nurses (Div 2).

Documenting Care: Standards for Registered Nurses Nurses Association of New Brunswick

Practice Standard: Documentation  Nurses Association of New Brunswick

Documentation Guidelines for Registered Nurses College of Registered Nurses of Nova Scotia

Nursing Documentation College of Registered Nurses of British Columbia