Volume 43, Issue 2, February 2013 - ResearchOnline@JCU

Copyright © eContent Management Pty Ltd. Contemporary Nurse (2013) 43(2): 213–218.

A personal essay on the role of the nurse LINDA SHIELDS Tropical Health Research Unit, James Cook University and Townsville Health District, Townsville, QLD, Australia; School of Medicine, The University of Queensland, Brisbane, QLD, Australia

Abstract: Nursing has suffered a lack of understanding by the general public, who often can see no further than stereotypes of heroine, harlot, harridan or handmaiden. These have colored nursing’s development as a profession, in Australia as in the rest of the world. Australia, as the ‘lucky country’ has one of the best health systems in the world, and Australian nurses are amongst those at the forefront of the profession. However, it appears that Australian nurses, as with many sections of Australian society, do not recognize that they hold high professional standards. With the influence of the international nursing shortage and the ever-growing technological advances within health care, alternatives to nurses, and to the registered nurse, are emerging. It is vitally important that nursing controls and regulates these developments. Only by protecting the legitimate role of the nurse, ensuring that education standards are maintained at the highest appropriate level, and generating and using new nursing knowledge will outcomes for all those who come to us for care be of the highest order. This essay proposes that Australian nurses need to overcome the ‘cultural cringe’ and recognize that they are in charge of a profession which meets the highest international standards.

Keywords: leadership, professional development, workforce issues

PERCEPTIONS OF THE ROLE OF NURSES recent study by Field and Pearson (2010) in the International Journal of Nursing Practice discussed the portrayal of nurses who murder their patients. The discussion centred on why these murders create such shock and horror in the general public. To quote from the paper ‘… The thought that nurses can coldly premeditate, calculate and execute the murder of patients is more shocking and more disturbing for families, investigators, prosecutors and the public at large’ (Field & Pearson, 2010, p. 305). Such sentiments are redolent of the reasons that most of the nurses who killed their patients in the Nazi ‘euthanasia’ programs were never punished – it was thought that nurses would never do those things (Benedict, O’Donnell, & Shields, 2009). It makes one wonder what it is about the role of nurses that makes them seem to be, as Darbyshire (2010) suggests, either ‘heroines, hookers or harridans’. Darbyshire discusses the stereotypes surrounding nursing, of ‘angels’, ‘doctors’ handmaidens’, ‘battleaxes’, ‘naughty nurses’ and ‘nymphomaniacs’, and he posits that such stereotypes have a long history, with their genesis in Victorian times, and continued use in current media shows like ER, House, etcetera.

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The written history of nursing is replete with descriptions of the development and causes of these stereotypes. The role of nurses as we know them today, [as opposed to the medieval male-dominated world of monasteries and monks] was first recognized in the 16th Century, at least in the English-speaking world. Boulton (2007) reports a widow, Ellen Wright, of St. Botolph Aldgate (London) who, from 1588–1599 took sick people and pregnant women into her house and cared for them. He describes parish nurses working in London in the early 1700s, who, for a living, took in sick paupers, and nursed them. These women sometimes had over 20 people in their care, and usually there was one nurse for every 10–15 patients in their establishments. Today, we are so influenced by the ubiquity of Florence Nightingale that we forget that nursing has been around for much longer than the 19th Century. Indeed, I would lay some blame for the misconceptions surrounding the role of the nurses today at the feet of Florence Nightingale, or at least the large public relations machine which operated around her, often to the detriment of her real achievements in the fields of epidemiology and statistics. Vera Brittain, a young woman who went to World War I as a voluntary

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aid detachment (VAD) nurse, condemned all that Nightingale had come to stand for. To quote: … I thought then that the ‘holiness’ of the nursing profession is easily its worst handicap; a profession, it seems, has only to be called a ‘vocation’ for irresponsible authority to be left free to indulge in a type of exploitation which is not excused by its habitual camouflage as a ‘discipline’. What is true – it has to be true – that most of the women who choose this harsh, exacting life are urged by semi-conscious idealism, but idealists, being eager and sensitive, are often more liable to nervous strain than the less altruistic who take care of themselves before they think of others. (Brittain, 1933, p. 454)

This was written in 1933, surely things have changed now? NURSING IN AUSTRALIA History aids in contemplation of modern perplexities, and at present, there is much in the role of the nurse to perplex, even here in Australia. Australia has an advanced health care system. Its dichotomy of public and private services means that choice exists, with a concomitant ability to access the highest technology and expertise with ease and equity in both public and private systems (and with a sound safety net for the disadvantaged). Australian nursing, also, is advanced in practice, research and education. Australia is one of the few countries in the world where a degree is the basic qualification for registration, with postgraduate study required for specialization. There are some detractors from this principle; however, the work of Duffield et al. (2007) and Aiken, Clarke, Cheung, Sloane, and Silber (2003) ably and rigorously demonstrates that patient outcomes are optimized with a welleducated nursing workforce. The perplexity here is that some reprovers think that nursing has lost its way, and should return to hospital training. Personally, I strongly oppose such notions, having lived through years of hospital training, when, in a large metropolitan hospital, night staffing comprised two trainee nurses for 60 patients, and one registered nurse for two floors. Indeed, I well remember a night duty shift when, on a ward built for 36 patients, but which, on this particular night, held over 60, eight old

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ladies died, all on their own, and from probably preventable causes, because there were only two teenagers to care for all of them. And these are now called the ‘good old days’! The role of the nurse then was to complete as many of the tasks as possible before end of shift (punishment such as a severe dressing down ensued if one did not complete the task list) and it was forbidden to sit and talk with the patients. NURSING AND THE ‘CULTURAL CRINGE’ Australia is known as the ‘lucky country’. Horne (2008), in coining that phrase in the 1960s, used it as an irony, to warn that unless we as a nation moved away from the isolationist and colonial complacency that characterized much of Australian thinking, Australians would lose the qualities which made up their psyche, such as ‘a fair go’ and ‘mateship’. Illustrative of the fact that we may have saved ourselves from such a fate is the disgust (tainted, perhaps, by smugness) which Australians expressed when told about the difficulty with which Barack Obama was forced to tackle the provision of equitable health care provision in the United States of America (USA) (Rae, 2010). However, we should and could look at home to see that the risk of losing our strong sense of equity is transpiring, as demonstrated by the approach to asylum seekers taken by both major parties in the last election campaign (Dunkerley, 2010). When considering the role of the nurse, the ‘lucky country’ in its ironical sense is illustrated in the way we look to other countries for leadership. We have the means, ability, talent, capacity and expertise to maintain our world leadership, but we are slow to recognize this. In a speech to the John Curtin Parliamentary Library at Curtin University on July 6, the then Minister for Foreign Affairs, The Honorable Steven Smith (2010), explained that Australia was internationally recognized as being a ‘considerable and significant nation’, as demonstrated by its place at the table in the G20 meetings. Australia has the second-highest human development index, after Norway, in the world (United Nations Development Program, 2009). It has the fourth highest life expectancy (Australian Government, 2010), and amongst the lowest infant and maternal

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A personal essay on the role of the nurse mortality rates (World Health Organization, 2006). In other words, from a health perspective, Australia is indeed, the lucky country. However, we Australians are very slow to recognize and acknowledge that we are a ‘considerable and significant nation’ and I believe this is as true for nursing as it is for the rest of Australia. Why do so many Australian conferences have keynote speakers from the USA or the United Kingdom (UK)? Importing ideas and expertise from outside the country is a good thing, but why do we not look to other countries, such as Thailand, where nursing has been taught in universities for over 40 years, or the Nordic countries, with their amazing health care systems? What is it about the UK that takes us back there, especially given the current critique of concerns about British nursing (Shields & Watson, 2007, 2008; Watson & Shields, 2009; Watson & Thompson, 2004)? Could we be doing what Donald Horne warned about, and are we still stuck in a colonial rut, unable to break away from the ‘mother country’? When I see state governments, such as those in Victoria and Tasmania, bring people from the National Health Service to tell them how to run health services, and in that, nursing, as they did in 2004–2005 (Victorian Government, Department of Human Services, 2005) and 2008 (Elcoat, 2008), I suggest that the Australian cultural cringe is alive and well, that we do not recognize our real capacity and standing in the world, and do not acknowledge (or perhaps appreciate) that Australian nursing is a world leader. ERRONEOUS IMAGES OF NURSING I frequently wonder what it is about nursing that leads others to think they know what it is nurses do. Very often, public perceptions of nurses are flawed. Nightingale’s publicity machine started it off lady with the lamp, and nursing’s development was for so long linked with religious orders and promotion of nursing as vocational (Summers, 1989) that the resulting stereotypes are proving intractable. Even today, nurses in the UK commonly see themselves as ‘sister’ and ‘matron’ (Watson & Thompson, 2003) (one wonders about the men who happily take on these


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titles, as they do, especially under the ‘modern matron’ initiative). Darbyshire’s (2010) analysis of the public’s perceptions of nurses’ roles as heroine, hooker or harridan sums up the misconceptions that surround nursing today. But what is it about nursing that: (a) makes these fallacies so tenacious; and (b) makes nursing such a fertile field for widely held misconstructions of nursing roles? The general public would never hold strong opinions about the education of, say, engineers, or lawyers. Why does everyone think they know what is best for nursing? No where is this better illustrated than in the furore in the British media when the Nursing and Midwifery Council announced that from 2013, a degree would be the minimum qualification for registration (BBC News, 2009) (at present, only about 10% of nurses have a degree (Sastry, 2005)). A commentator in the Daily Telegraph stated: Of course, medicine is a university course with a very large element of apprenticeship about it. But medicine is both a learned profession and a severely practical art, which nursing is not and is never likely to be … The quest for power and status, then, is more important than the quest for higher nursing standards. That is why the nurses’ leaders are so keen on the idea: kudos is their goal. (Dalrymple, 2009)

While a journalist in The Sunday Times wrote ‘All sorts of people who might make excellent nurses will be put off, and lost to nursing: anyone who is not particularly academic; anyone who – frankly – is not particularly bright’ (Marrin, 2009). It is hard to imagine commentators having the effrontery to write similarly about other professions. Why do they feel they know enough about the role of the nurse to declare how they think the profession should be educated? NURSING WITHIN AUSTRALIA’S CULTURE One of the reasons Australia is so successful is its ability to critically analyze itself, or perhaps, those who take themselves too seriously. This may be cultural, a part of the ‘fair go’ ethos that means we do not suffer fools gladly. One hears papers at international conferences which present innovations and initiatives in research, and in health services, which give a glowing report of the subject


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to hand. Australians, on the other hand, are likely to present something ‘boots and all’. We use a criticality that allows us to see problems, address them, and then evaluate the changes. This degree of criticality and the concomitant ability not to worry about face is something that we should fight to maintain as part of our culture. For our purposes, when discussing the role of the nurse, we should embrace that criticality, that ability to examine what it is we do and what we need. Because we are the lucky country, the role of the nurse has been able to expand and improve patient care, generate new knowledge through a rich research culture, and provide some of the highest standards of education of nurses in the world. It is vitally important that we fight to retain these high standards. We cannot allow the role of the nurse to be jeopardized by dumbing down entry levels to our universities (which is happening is some states (Hiatt, 2010)); nor should we allow education of registered nurses to take place anywhere outside a university (Royal College of Nursing, Australia, 2007). NURSING LEVELS AND ROLES, AND UNREGULATED WORKERS

This brings me to the role of different levels of nurses. The international nursing shortage is putting immense pressure on health workforces everywhere. It would be disingenuous of me to demand that all nurses are educated to degree level. The second-level nurse, the enrolled nurse, is a vital part of any health workforce. The role of the enrolled nurse is expanding and developing. For these vitally important members of the nursing profession, we must maintain high standards in education. In some countries around the world, nursing education is done in senior-level high school (Shields & Hartati, 2003). The recent events in Australia that have seen a nursing degree being offered in a technical and further education (TAFE) college, might logically lead to enrolled nurse education being sent downwards to senior high school. We cannot afford to dumb down the role of the enrolled nurse, nor their education. The international nursing shortage is bringing about other changes which need careful monitoring if the role of the nurse is to be protected.

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Many countries and possibly some places here in Australia are employing minimally educated health care workers (McKenna, Thompson, & Watson, 2008). To protect the role of the nurse, we must be proactive here. Unless nursing as a profession controls the role of the health care assistant, then we will lose much of our role. A third level nurse, an assistant in nursing, must be brought under the aegis of a registered nurse. After all, it is part of the role of the registered nurse to be legally responsible for those delivering nursing care. We cannot afford to allow health care assistants, who undertake some nursing roles, to be under the control of any other profession, especially when registered nurses are legally responsible for what they do. There is another facet of development in the health professions workforce that must give us cause for concern if we are to protect the role of the nurse. Technicians of all kinds are beginning to be seen in health services. These are being allowed to take on the role of nurses [and in some instances doctors, for example, endoscopists], and strangely, it is often nurses who are educating them. The most obvious example of this is operating department practitioners, people who are educated to do circulating and scrub roles in operating theaters, but who do not and cannot undertake the role of the perioperative nurse. Their role is limited, and they do not have an education which includes critical thinking ability and problem solving, an inherent part of role of the perioperative nurse. Technicians have little of the knowledge of well educated, specialist perioperative nurses, who provide complete care for patients throughout the total operating theatre process (Shields & Watson, 2007). Consequently, operating department practitioners are unable to give holistic perioperative care. NURSE PRACTITIONERS At the moment in Australia we are seeing exciting initiatives in the development of the role of the nurse practitioner. While this is appealing, a word of caution should be sounded. These highly specialized nurses have a very real role to play in a huge range of health care settings. Specialist areas such as wound care, diabetes, and critical care; primary


A personal essay on the role of the nurse health care areas such as school nurses and community child health; and remote area health practice are fertile fields for nurse practitioners. However, it is vitally important for the sustainability of the role of the nurse practitioner that it is defined by nursing terms, rather than being defined around the skills and tasks that doctors no longer want to do. In one of the most egregious confidence tricks around the role of the nurse that I have seen is the implementation of schemes in the UK whereby nurses undertake hernia, varicose veins, and other surgery (BBC News, 2004). These roles are not and never will be anything but medical roles. They are not nursing. If one wants to do that work, then one must study medicine. I would strongly caution against the erosion of the role of the nurse in Australia to that degree. With the international shortage of nurses, we have enough trouble staffing our health services with experienced practitioners. Undertaking roles that are outside the role of the nurse, and our scope of practice, is irresponsible, damaging to the profession, and will ultimately lead to adverse patient outcomes. CONCLUSION Nursing has suffered a lack of understanding by the general public, who often can see no further than stereotypes of heroine, harlot, harridan or handmaiden. These have coloured nursing’s development as a profession, in Australia as in the rest of the world. Australia, as the ‘lucky country’ has one of the best health systems in the world, and Australian nurses are world leaders. However, Australian nurses, as with many sections of Australian society, do not recognize that they hold high professional standards that put them at the forefront of nursing internationally. With the influence of the international nursing shortage and the ever-growing technological advances within health care, alternatives to nurses, and to the registered nurse, are emerging. It is vitally important that nursing controls and regulates these developments. Only by protecting the legitimate role of the nurse, ensuring that education standards are maintained at the highest appropriate level, and generating and using new nursing knowledge will outcomes for all those who come to us for care be of the highest order.


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REFERENCES Aiken, L., Clarke, S. P., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2003). Educational levels of hospital nurses and surgical patient mobility. Journal of the American Medical Association, 290, 1617–1623. Australian Government. (2010). Australian institute of health and welfare: How Australia compares – Life expectancy estimates (years) for selected countries, by sex, 2005-2010. Retrieved from Australian Institute of Health and Welfare website: http://www.aihw.gov.au/ mortality/life_expectancy/compares.cfm BBC News. (2004, April 5). Training nurses to do surgery. BBC News. Retrieved from http://news.bbc. co.uk/2/hi/health/3580453.stm BBC News. (2009, November 12). Nursing to become graduate entry. BBC News. Retrieved from http:// news.bbc.co.uk/2/hi/health/8355388.stm Benedict, S., O’Donnell, A., & Shields, L. (2009). Children’s ‘Euthanasia’ in Nazi Germany. Journal of Pediatric Nursing, 24, 506–516. doi:10.1016/j. pedn.2008.07.012 Boulton, J. (2007). Welfare systems and the parish nurse in early modern London, 1650-1725. Family & Community History, 10, 127–151. doi:10.1179/175138107x234413 Brittain, V. (1933). Testament of youth. London, England: Penguin. Dalrymple, T. (2009, November 1). Sorry, Florence. No degree, no job. The Daily Telegraph. Retrieved from http://www.telegraph.co.uk/education/universityeducation/6558948/Sorry-Florence.-No-degree-no-job.html Darbyshire, P. (2010). Heroines, hookers and harridans: Exploring popular images and representations of nurses and nursing. In J. Daly, S. Speedy, & D. Jackson (Eds.), Contexts of nursing. Sydney, NSW: Elsevier. Duffield, C., Roche, M., O’Brien-Pallas, L., Diers, D., Aisbett, C., King, M., … Hall, J. (2007). Glueing it together: Nurses, their work environment and patient safety. Sydney, NSW: University of Technology, Sydney. Retrieved from University of Technology, Sydney website: http://www.health.nsw.gov.au/ pubs/2007/pdf/nwr_report.pdf Dunkerley, S. (2010, July 24). Asylum seekers back on election agenda. The Sydney Morning Herald. Retrieved from http://news.smh.com.au/breakingnews-national/asylum-seekers-back-on-electionagenda-20100724-10peg.html Elcoat, C. (2008). Report following initial visit to Tasmania, 2008. Unpublished report. Field, J., & Pearson, A. (2010). Caring to death: The murder of patients by nurses. International Journal of Nursing Practice, 16, 301–309.


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Hiatt, B. (2010, January 20). Uni sets nursing entry at 45 per cent. The West Australian. Retrieved from http:// au.news.yahoo.com/thewest/a/-/breaking/6698849/ uni-sets-nursing-entry-at-45-per-cent/ Horne, D. (2008). The lucky country. Camberwell, England: Penguin. Marrin, M. (2009, November 15). Oh nurse, your degree is a symptom of equality disease. The Sunday Times. Retrieved from http://www.timesonline. co.uk/tol/comment/columnists/minette_marrin/ article6917254.ece McKenna, H., Thompson, D., & Watson, R (2008). Health care assistants: An oxymoron. International Journal of Nursing Studies, 44, 1283–1284. Rae, M. (2010, March 15). Rudd feels Obama healthcare pain as he loses majority support. Bloomberg Business Week. Retrieved from http://www.businessweek.com/news/2010-03-15/rudd-feels-obamahealth-care-pain-as-he-loses-majority-support.html Royal College of Nursing, Australia. (2007). Lobbying fact sheet, July - September 2007. Development of bachelor of nursing in TAFE/vocational sector. Retrieved from Royal College of Nursing, Australia website: www.rcna.org.au/_literature_29340/ LFS_-_Issue_3_2007 Sastry, T. (2005). The education and training of medical and health professionals in higher education institutions. London, England: Higher Education Policy Institute. Shields, L., & Hartati, L. E. (2003). Nursing and health care in Indonesia. Journal of Advanced Nursing, 44, 209–216. Shields, L., & Watson, R. (2007). The demise of nursing in the United Kingdom: a warning for medicine. Journal of the Royal Society of Medicine, 100, 70–74.

Shields, L., & Watson R. (2008). Where have all the nurses gone? Australian Journal of Advanced Nursing, 26(1), 95–101. Smith, S. (2010). Australian foreign policy under Labor governments from John Curtin’s prime ministership to the present. John Curtin Prime Ministerial Library Anniversary Lecture, Curtin University, 6 July 2010, Perth. Retrieved from Curtin University website: http://john.curtin.edu. au/events/speeches/smith.html Summers, A. (1989). The mysterious demise of Sarah Gamp: the domiciliary nurse and her detractors, c. 1830–1860. Victorian Studies, 32, 365–386. United Nations Development Program. (2009). Human development report 2009: Statistics of the human development report. Retrieved from United Nations Development Program website: http://hdr.undp.org/ en/statistics/ Victorian Government, Department of Human Services. (2005). Better skills, best care: DHS workforce design strategy. Melbourne, VIC: Author. Watson, R., & Shields, L. (2009). Cruel Britannia: A personal critique of nursing in the United Kingdom. Contemporary Nurse, 32(1–2), 42–54. Watson, R., & Thompson, D. R. (2003). Will Modern Matrons carry on regardless? Journal of Nursing Management, 1, 144–146. Watson, R., & Thompson, D. R. (2004). The trojan horse of nurse education. Nurse Education Today, 24, 73–75. World Health Organization. (2006). Mortality country fact sheet: Australia. Retrieved from World Health Organization website: http://www.who.int/whosis/ mort/profiles/mort_wpro_aus_australia.pdf Received 25 October 2011

Accepted 06 September 2012

FORTHCOMING Supporting a Strong and Resilient Contemporary Nursing Workforce A special issue of Contemporary Nurse – Volume 44 Issue 2 – 160 pages – ISBN 978-1-921980-15-2 – June 2013 Editors: Debra Jackson (University of Technology, Sydney, NSW, Australia), Michelle Cleary (National University of Singapore, Singapore) and Sharon Andrew (Anglia Ruskin University, Chelmsford and Cambridge, United Kingdom) workforce in the context of clinical and academic practice

• Research papers and reviews on supporting the development of the nursing workforce • Debate papers that address key issues associated with nursing workforce

• Papers about educational strategies and issues aimed at enhancing the nursing workforce

• Relevant practice papers highlighting current issues in support and development of the nursing

• Papers highlighting threats or challenges to the strength and resilience of the nursing workforce

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