RNs facing extinction
Professor Rhonda Nay argues that instead of simply calling for more registered nurses in aged care, we should dramatically re-structure their scope of practice so they effectively become nurse practitioners, and in the process give personal care workers and enrolled nurses a much greater role in the system.
Serially controversial, Professor Rhonda Nay argues that instead of simply calling for more registered nurses in aged care, we should dramatically re-structure their scope of practice so they effectively become nurse practitioners, and in the process give personal care workers and enrolled nurses a much greater role in the system.
Regularly there are calls for more registered nurses; whenever there is a ‘crisis’ in care it is blamed on insufficient staff and/or not enough nurses. I would like to suggest – again – that we think more creatively and base our thinking on resident/patient needs and a valid evidence base.
At the time of writing I could still find no sound evidence that simply increasing the number of RNs is a logical solution. In this piece I am concentrating on aged care, however the principles are applicable across settings.
The current RN is neither fish nor fowl. The education is insufficient to prepare a health professional significantly distinguishable from a skilled and knowledgeable EN.
A new approach is required because of these factors, but also because of:
- predictable increasing demands from an ageing society;
- decreasing workforce as the baby boomers retire;
- decreasing availability of family carers;
- unattractiveness of nursing as a career choice for the bright young things;
- reduction in educational preparation time with increasing crowding of the curriculum as more and more skills and specialities compete;
- graduates having had insufficient real-world experience;
- university entrants lacking maturity;
- graduates lacking the knowledge and skills required to work with older people and especially people with dementia; and
- I could add more!
Getting to the nub of the problem
I do not think I need to detail the first three points, I will assume readers know this already. So, let me focus on why I believe the RN is facing extinction, why that is not necessarily a bad thing and my vision of how it could look in 2025.
Entry scores for university are not good predictors of intelligence or success. They are however great predictors of who will apply for nursing. Parents, teachers and school leavers with high scores want entry to courses with high entry scores. They are seen to be more prestigious. While nursing has a low entry score, it will not attract the leaders of tomorrow that nursing and those being nurses need.
Increase the entry score for university nursing courses.
The majority of healthcare demands are related to chronic conditions and the care/support needed can be provided by people with minimal training (Cert 111), a person-centered approach and good learning environments and a police check. Some of the tasks with which older people want assistance, maybe simple dressings and injections, are well within the scope of EN practice. ENs are also capable of noting any changes from the baseline and reporting them. Indeed, I would nervously suggest that an EN’s scope of practice could include just about everything the current non-advanced RN does. We used to argue that the EN did not have the theoretical underpinnings and critical thinking advantage provided by a university education. I do not believe the current education provides this advantage to RNs anymore, if it ever did.
ENs in many situations can replace RNs and PCAs can replace ENs.
Am I saying back to the good old hospital days? Of course not. What I am saying is that we are not achieving the outcomes originally planned and we have the skills mix wrong. Neither am I saying we do not need nursing – rather what we need is a different approach to developing and targeting the skills of nurses.
The maturity factor
School leavers are in general far less ‘mature’ than say, 30 years ago. It is not uncommon for them to depend upon their parents throughout their teens AND twenties. They are protected and taught to be risk averse! And yet we expect them to be able to deal with major life and death situations.
Caring with older people – or anyone – requires a level of life experience that does not come from moving directly from school to a professional degree. Better that the first three years are spent learning about being a human, coping, communicating, thinking and reflecting. For those who plan to be professional nurses I suggest a common basic degree including one strand in nursing and such disciplines as philosophy, sociology, psychology, human bioscience, leadership and comprehension of research and evidence.
Alongside this, students would work in areas that have nothing to do with healthcare directly but where they would experience different cultures, religions, environments, families and occupations that gave them a broad development in life. Only then would they enter their professional discipline – in this case nursing.
A different model
The RN would, in fact, study to be a nurse practitioner. The numbers would be relatively fewer, and thus the entry score could be equivalent to those of other health professions; but the education would be deeper, more demanding and more rewarding. With fewer NPs it would be feasible to offer more attractive work conditions. NPs could work across boundaries and provide their advanced skills and knowledge to acute, community and aged care. Large organisations may be able to fully employ NPs and others may share. NPs could have private practice to further enhance their rewards.
NPs should replace RNs and thus address the current and future gap where nursing will be most relevant.
TAFEs would prepare multi-skilled health workers who could - with appropriate liaison and screening tools – deliver many of the services currently provided by RNs, ENs and allied health professionals. The educational preparation would commence at Cert III but progress through to Diploma, depending on career choices and capability. Those who had the desire and aptitude could gain credit toward the NP courses.
This approach would freeze some nurses in their tracks and I expect the outcry we had when university education was first announced. It is time for the next step which will be taken by those who can see where nursing may contribute to healthcare. Those who are only concerned with ‘what this means for me’ will undoubtedly resist.
NPs would fill the ever increasing gap between what nursing could add and what it is able to do with the minimalist approach to education which relates to the cost of preparing too many at university level. Quality IS better than quantity. An entry requirement and educational preparation equivalent to the long-term need for excellence in nursing will pass the cost-benefit test, attract and retain nurse leaders of the future and improve outcomes for older people. More nurses, ratios, more money have been ‘solutions’ for as long as I can remember. These are solutions that have not and will not work in the future.
More nurses, ratios, more money will not fix the problems
Older people need a team of staff with a range of skills, from when the support is directed by the older person through to the highest level when they cannot verbalise their wishes, have complex co-morbidities and need the very best end of life care. We will not have residential facilities in 2025 – no-one actually goes into nursing homes to reside! Only the people with high level care needs will be living and dying in facilities expert in triage, emergency support, rehabilitation and palliation with older people. I congratulate ACH Group for providing leadership on this front.
Rhonda Nay is Emeritus Professor at the School of Nursing and Midwifery at La Trobe University. She is a former Director of the Australian Centre for Evidence Based Aged Care.
This article first appeared in the November December 2013 issue of AAA.
Hi
I’m just at a stage in my work where I have struggled in the current climate on a family therapy MA after completing the third year I have Made a decision to withdraw. I am finding my confidence at 57 has been deeply knocked and although I already have an MA and lots of experience in the therapy area of work and a social work degree I am doubting my work and ability.
How can I pick myself up in my current role for eleven years I am thinking of a change but springing between doing something in an area that’s totally new and less pressured or staying with the same and re valuing the skills I have But each job I look at I feel incapable of applying for. I’m thinking this is a temporary feeling but it’s a hard place to be any ideas helpful.
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