I woke this morning to heated discussion among my social media peers about One Nation’s policy on nursing education in Australia
[source, via Ian Miller at The Nurse Path]
I was part of one of Victoria’s last hospital-based nurse training groups, so I had opportunities to compare our experience and knowledge with my then-college educated peers, and with university-educated nurses in the two-plus decades that RN qualifications have been solely via university.
There were undoubtedly advantages to the way I learned how to be a nurse. To start, we were paid from day one, whether we were in class, on the floor, on specialty placements, or on leave – 40 hours a week, 52 weeks a year, until we qualified. That meant that, unlike the majority of today’s students, we didn’t have to balance the needs of study and placement with survival.
We knew early on whether or not actual nursing was really what we wanted to do – shift work, short changeovers, abusive doctors, terrifying charge nurses, rude relatives, violent patients, every single disgusting fluid our bodies produce, bursting wounds, maggots, caring for people sicker than we knew it was possible to be and still breathe, the helplessness of not being able to make a difference to someone’s anguish, watching people treated past usefulness and into cruelty, caring for the bodies of the dead, making mistakes that could have (and sometimes did) make patients worse or even die, the heavy cloak of being literally responsible for strangers’ lives every single day, were all known to us within months.
Our educators taught us in the classroom and on the floor – they knew all of us by name, because each intake (three per year) was capped at 60-65 students; when I graduated I confided in one of my teachers that, had there been cardiac questions on our state exam paper, I’d have failed. Though she’d taught our cardiology block more than 18 months earlier, June drily replied, “Yes, Tara, I know.”
Our progress was monitored consistently, every step of the way, with ward reports for every rotation longer than two weeks. Those charge nurses cut no slack, and we lived in fear of bad reports – we could lose our career, job, and home in one fell swoop.
We lived together on site, at least for the first six months, which meant both strong team building and ready access to peers and students ahead of us when we had questions or needed debriefing.
And there’s no question we had strong clinical skills: well over 4,000 hours (100 weeks+ of 40 hours of patient care) of general and specialty medical, surgical, theatre, emergency, paeds, radiology, midwifery and neonates, psychiatry, RDNS, community health – I knew where I wanted to work as an RN, and what I had no interest in at all.
All of which sounds like a really good grounding for our nursing workforce. Here’s the other side.
We were employees first, students a poor second – our rotations were based on where they needed hands. I remember a two month period of fortnightly rotations: two days off, a PM shift, nine AMs, two days off, and a new ward – no time to become part of a team, to learn the specialty, to even know where all the equipment was.
We were frequently frighteningly out of our depth. I vividly remember being told six hours into one shift that I was needed on another ward to special (nurse 1:1) a patient. I had almost no time to hand over my patients to colleagues whose workloads just jumped without warning, and my sole introduction to the patient was, in essence, “they’ve got an axilla DVT [clot in a deep vein running under the armpit]. This infusion’s [a medication that breaks down clots]; don’t leave their side; don’t take down the dressing; buzz if they’re symptomatic [have signs the clot’s moved or the medication’s caused abnormal bleeding].” Then she left.
I was so terrified I didn’t speak to the patient. At all.
I wasn’t familiar with the kind of pump used. I’d only ever heard of streptokinase, and didn’t even know it could be used as a continuous infusion.
I didn’t know what I was looking for, or what the management plan was. I had no access to the patient’s history, and my only way to contact other nurses or a doctor was to press my patient’s button, then wait.
Nobody checked in on me until the night special came.
I was so relieved to see her that I almost cried – and I can count on my digits how often I’ve cried at work. My overwhelming feeling as I left was relief that my patient was alive.
When I arrived on my ward at 7AM the next morning as was told I was going back to the special, I thought I’d vomit.
The plan was to transfer my patient from this ward to another ward I didn’t know, via radiology. We went down to imaging, then waited in a corridor for an hour until an orderly took us up to the new ward – I had no way to get help, should I have needed it, except to yell.
On the new ward I was reminded by the charge nurse not to leave the patient, who I was still afraid to talk to. Whenever I buzzed to get a pan for my patient, a responding nurse would tell me the pan room was just outside. Whenever I went to the pan room the charge nurse would see me and tell me not to leave the patient.
I found blood in the infusion line. I had no idea how to get it out, how long the IV could be stopped for, and I was afraid to ask. Fortunately I knew not to bolus [give a larger dose over a short time] streptokinase, and went out to the desk. The charge nurse was irate that I’d once again left my patient. When I told her about the blood, she directed me to get a new infusion set. As I didn’t know where anything was on this ward, I ran down two flights of stairs the old ward, got a set, ran up the stairs, and found the nurses had fixed it already.
Nothing bad happened – I don’t know what happened in the long term, but when I finished my shift the patient was fine. But 25 years later than remains one of my ten worst shifts – and the others include a Coroner’s case, a patient fall with fractures, a patient so severely vomiting blood that the room looked like a murder scene, a patient bleeding to death in front of me, accidentally increasing an IV medication that could have been fatal, and the death of a young mum.
We were thrown in the deep end with one floaty, and expected to swim.
And here’s the thing. Our patients are so much sicker now, they have more comorbidities, and their stays are shorter. Almost without exception our patients are too vulnerable to entrust to early-level students with almost no supervision. If you take nothing else away, know this: patients would die, and it would be the individual students, not the system, held to account.
Nursing and midwifery have transitioned from vocations to professions, and education has been a vital part of that change. Health care today demands a far more technical, detailed, complete knowledge base than hospitals can provide. The old method of half a dozen interchangeable students, overseen by one or two RNs, is long gone, and that means better patient outcomes.
Which is not to say that change isn’t needed.
Our students should be able to survive without working on top of study and placements – increasing Austudy to a reasonable amount would allow student nurses and midwives to focus on learning.
Students’ placement assessments are currently done by clinicians, who have no training in it, often have no guide to expectations of proficiency at this placement, no easy access to processes for unsatisfactory performance, and who are supervising students and completing their assessments in addition to their workload, without compensation. Returning educators to the floor, one per ward, would help catch struggling students before they’re registered.
The idea of nursing and midwifery as apprenticeships is right, though my analogy would be with medicos rather than tradies.
Doctors must complete an accredited program post-graduation, that includes an intern year, residency, registrar experience, exams, and then specialist training.
Nurses and midwives can apply for a graduate year position, somewhat like an intern year – they include a supernumary period, a preceptor, study days, supervision of clinical educators, and individualised goal setting. The cost of this is met by state government funding.
Unfortunately, graduate funding is grossly inadequate – in Victoria alone we have 800 or so graduates, every year, who are unable to find a position. While the programs are theoretically optional, in practice it’s next to impossible to work without one. This is fiscally short-sighted: tax payers have subsidised the education of needed professionals, who now also have a hefty HECS debt they can’t repay, for a career they can’t pursue.
Instead hospitals hire overseas-educated nurse said, who cost less in the short term because they don’t need as much support. Some of the best nurses I’ve worked with have come here after qualifying, and easily half of my locally-educated nurse friends have worked overseas. This reciprocity is a good thing all around, for individuals and the system. But it shouldn’t come at the cost of our early career nurses and midwives.
Our nursing and midwifery work forces are aging – the average Australian nurse is mid-forties, and global shortages are projected within a decade. It makes sense to encourage the next generation to join us, but we need the funding to ensure the best candidates are attracted to degrees that will lead to jobs. Not debt.
TL;DR? There was a time when hospitals were the best place to educate nurses. That time has passed, and it’s in all our interests not to go back.
Addit: as The Conversation recently noted, patients are more likely to survive when cared for by a nurse with a degree (with thanks to Meta4RN)