A shared post by Victorian Nia Sims, whose father died in distress despite palliative care involvement, and who writes from the perspective of both witnessing this and having scleroderma, a rare autoimmune disease that may result in her applying for voluntary assisted dying herself.
In my previous post I wrote about why we (including the media) should pay less attention to the pronouncements of the AMA on voluntary assisted dying, and instead look at organisations that better represent the population/s for which they speak. While there’s a general belief that the AMA represents most, or at least many, doctors, that’s far from true. Even taking that into account, however, the AMA’s stated position on behalf of its members isn’t as representative as it appears.
In 2015, the AMA (Federal) announced that it would review its policy on ‘euthanasia and doctor-assisted suicide’ , which had previously been unremittingly negative – a position that had, in turn, affected the willingness of politicians and the public alike to support various incarnations of assisted dying legislation. The review process, which concluded in 2016, included an online survey in which 3700 members participated. The conclusion? The AMA continues to oppose any legislation around assisted dying, but wants its members involved should such legislation come to pass.
A logical assumption from this is that the majority of AMA members, if not Australian doctors in toto, oppose voluntary assisted dying. But Neil Francis of Dying for Choice analysed the review process, in a fascinating report titled AMA Uncovered, in which he examines design flaws that encouraged desired responses, on the analysis of results, and on the way the survey was selectively publicized to justify the policy. The full report runs to 50 pages, but I’ve summarised what I see as the key aspects to take into account when assessing the AMA’s ‘revised’ position.
Doctors often underestimate the severity of patient symptoms but want significantly less medical end-of-life care for themselves. Nearly nine out of ten USA doctors would not want intensive end-of-life treatment they provide to others. Yet patient death, despite its inevitability, is often regarded by doctors as a ‘failure’ of medicine, with many still uneasy even about withholding and withdrawing life-preserving interventions. – p.15
There are three main areas to appreciate about the original report, as unpacked by Francis.
First, the data comes from an opt-in survey that captured just over 3,700 AMA-affiliated doctors; as the AMA represents just under 30% of Australian medical practitioners, respondents to the survey represent 12% of AMA membership, and only 3.6% of Australian doctors.
What the methodology variations suggest is deeply-entrenched hostility towards assisted dying that has flowed through to substantial biases is the survey design. These in turn will result in significantly more negative responses toward assisted dying in later questions than if the AMA’s policy had been revealed later in the questionnaire, after doctors had been asked their attitudes about various facets of assisted dying. – p. 21
Second, the survey is multiply flawed, a fact that was brought to the AMA Executive’s attention and dismissed. The most important of these flaws are briefly listed below:
- the way questions are worded means responses are less likely to be genuine reflections of respondents’ beliefs and more likely to be weighted toward an anti-assisted dying response (see p. 16 of the critique for specific analysis)
- the survey omits suffering or intolerable pain from its definition of euthanasia/assisted dying
- the survey definition of euthanasia/assisted dying includes neither voluntariness or competence, both of which are key requirements
- some established life-limiting practices (withholding/withdrawing treatment, the doctrine of double effect) are defined as separate to euthanasia/assisted dying
- the introductory statements prime participants to lean towards then-current, anti-euthanasia/assisted dying policy
- multiple questions presuppose a response in the framing of the question (e.g. “Do you agree…” or “To what extent do you agree…”
- the first two questions separate ‘good medical practice’ and ‘clinically appropriate’ treatment when they’re dependent components of appropriate professional practice
- similar, often successive, questions are differently constructed for no apparent reason
- at least one question rolls two aspects of euthanasia/assisted dying together: being compelled to participate in the practice and (if unwilling) being compelled to refer a patient to another practitioner
- 68% of respondents agreed suffering can’t always be relieved with even optimal palliative care
- 60% want doctors to perform lawful assisted dying (i.e. be involved if it’s legislated)
- just over half of those (32% of respondents) were prepared to be involved
- 52% said this is a legitimate intervention
- 50% disagreed with the AMA policy against E/AD “under any circumstances”
- over half of 20-29 year old respondents agree with euthanasia/assisted dying, compared with a third of those 70+
- when a question was reframed to ask about legalized euthanasia/assisted dying, approval rates jumped, indicating some resistance is because of illegality, not the act itself
- 35% of respondents thought euthanasia/assisted dying should be lawful
- Swiss, Dutch, and Belgian populations rank in the top 3 when it comes to trust in doctors (Aus is tenth); they have AD laws
- the AMA has published and not corrected information about E/AD that they know is false, including that palliative care deteriorated in Belgium; the opposite is true
- despite claims by many opponents, including AMA President Dr. Gannon, there has been no slippery slope targeting minors, incompetent people, or the vulnerable, in any jurisdiction (see pp. 31-32)
- an overwhelming majority of Australian doctors (SA: 89%, Vic 93%, NSW: 96%) believe patient suicide can be rational
Third, despite these significant methodological flaws, Francis notes these outcomes, which don’t correlate with the AMA’s ‘revised’ position:
A couple of additional notes:
Many Australian doctors don’t believe that the law is as important as medical and family consensus when making such decisions, and are inclined to ignore the law anyhow. – p. 19
Finally, and worryingly, it seems as though much of the opposition to or concern about this legislation is that a sizeable proportion of doctors don’t want this practice legalized. From the report, Francis notes that:
In a 2006 study “25% doctors were not opposed to euthanasia itself yet were opposed to its legalisation. In other words, a quarter of doctors thought ‘private’ euthanasia practice acceptable, but didn’t want the practice legalised.” The researchers said this was “in significant part due to ‘the resistance of doctors to further intrusion by the law and bureaucracy on their clinical and professional autonomy.’” – p. 25
I leave you with this observation by Francis, which should be particularly alarming for all of us (including opponents to voluntary assisted dying) who champion voluntariness, competence, and consent:
Francis, p. 39
Nia has a highly informed perspective – an experienced nurse, she watched the protracted death of her father with cerebral cancer (recreated by Go Gentle in Stop The Horror), and is living with and dying from the autoimmune connective tissue disease scleroderma. For her, voluntary assisted dying is not hypothetical or professional but as personal as it gets.
Image: View from a red velvet couch, Parliament House library, 6am, Friday 20.10.17
First published – Crikey.com, 23.10.17
By the wee hours of Friday morning, the mood in the house was slightly delirious. My friend, colleague and registered nurse Jane Morris and many others cried when the vote on voluntary assisted dying, 47-37, was finally declared to a packed house at 11am after a record 22 hour sitting in Victorian Parliament. It was met with a weary but fulsome round of applause from most in attendance.
My vantage point from the “accessible” section of the public gallery was one of the few perks of being, as far as I know, the only visibly seriously physically sick or disabled person to attend the sitting. I could see the entire public gallery, press gallery, and members to the right of the speaker. If I craned my neck forward, I could watch the…
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I take pride in the calibre of nursing I provide – I’m good at what I do, thanks to a combination of aptitude, experience, education, compassion, intellect, and reflective practice.
So I understand why many palliative care nurses are upset, offended, angered, and otherwise unhappy about the voluntary assisted dying movement in general, and Go Gentle’s Stop The Horror film in particular – it seems to say that palliative care isn’t good enough, that too many people suffer at the end of life, that patients and families can’t trust their expertise, and that their expert, skilled, informed care isn’t valued or valuable.
I’m sorry that this is how the push for VAD is perceived. It’s not the belief held by anyone I’ve communicated with; without exception, their position is the same as mine – quality palliative care is the best, more effective, most appropriate intervention for the overwhelming majority of dying patients; we need to improve access to and funding for palliative care; and there are a small number of cases (industry estimates vary from 2-4% of patients) where symptom management is ineffective or inadequate, despite the best interventions available. These are the patients for whom another option is appropriate.
Acknowledging that there is still room for improvement is part of reflective professionalism and best practice. Responding to first-hand experiences of colleagues and family members with, “That wasn’t good palliative care!” is defensive and unhelpful – it means their experience is dismissed, along with a learning opportunity. Often that’s right – there were gaps in care, or in knowledge, or prescribing, or in anticipating how rapidly the patient’s dying trajectory would escalate.
And sometimes the person received the very best care possible, but their intractable nausea, terminal dyspnoea, restlessness and agitation, seizures, neurological pain, or distress couldn’t be resolved. That happens. It really does. Not often, but not never.
Transplanted organs reject. Antibiotics don’t succeed. Wounds don’t heal. Surgery is unsuccessful. Hypertension doesn’t resolve. Asthma doesn’t respond. Intubation isn’t enough. Labile BGL’s don’t stabilise. DIC runs rampant. HBO is ineffective. Chemotherapy fails. Autoimmune diseases rampage. HIV progresses. The flu kills.
Mostly we win the battle, if not the war; we never win the war – eventually, all our patients die. But whatever our specialty, we’re never effective all of the time. We’re just not. And that’s as true for those who midwife death as it is for those who work to defeat it.
Acknowledging that doesn’t invalidate our work, our value, our effectiveness, our professionalism, or the difference we make. It just means that we still have room for better.
I hope we’ll one day have no need for voluntary assisted dying – that nobody will suffer, and that all anticipated deaths are gentle. We’re not there yet, and it’s cruel to deny peace to those we can’t help enough.
One year and two days after ANF (Vic. branch) released our log of claims, the public sector EBA has gone into effect – look for pay rate increases, back pay (to March 31) and CPD funds (where applicable) from your next pay.
Our officials are at FWA today, in Conciliation proceedings with RDNS; an acceptable final offer from VHIA for Mental Health nurses is looking promising; and Forensicare negotiations continue.
Even if all our EBAs were resolved tomorrow, I know none of us will quickly forget what it took to get even modest outcomes in the face of a government determined to erode conditions, remove ratios, deskill the workforce, weaken the profession, increase burnout and turnover, and compromise care – all for a dollar, and not even cost-effective in the medium term.
Victorians go to the polls in 876 days, which is just under 29 months away, Australians will vote some time in the next 511 days, around 17 months from now. In both cases we need to look not only at the leader we’re voting for, but the principles of their party. I know I don’t want to do this again in 2016, and I’m sure I’m not alone.
I’ve just read a post on the FB page of the same name as this post – It’s okay, not to be okay post stories and support for and about Astralian men battling (and too often the ultimate victims of) depression.
The story I read was exceptionally well written by the partner of a man whose depression overwhelmed him. Nicole’s pain was heightened by the fact that the notification of his death, by police accompanied by her mum, occurred hours after the birth of their baby.
For me, the biggest takeaway message was a regret expressed to Nicole by one of Pat’s friends:
None of Pat’s friends were aware he’s suffered from depression…
One of his mates told me how much he wish[ed] he knew Pat had suffered, as [he] was a sufferer too and wished they could have talked about it.
This is the silence that makes so many people with depression, particularly men, think they’re alone – not Pat’s mate, but society’s silence. And I understand it – for 29 years I told nobody of my episodic, far less malignant, depression, which is a long overdue story for another post.
Though saddened and troubled by this account, what stirred me to write this post were the comments from people who, despite Nicole’s clear descriptions of Pat’s pain, still saw his death as “weak,” “selfish,” “a coward’s act,” and not something anyone would do if they really loved those they leave behind.
MRI and PET scan imaging shows that major depression alters the way our brains work – it’s not something you can overcome through strength of will, fortitude, determination, or the live and support of those around you, and more than these would stop asthma or diabetes.
This outcome may have been different if Pat had help (antidepressants, therapy, inpatient care in crisis, even much maligned but sometimes invaluable ECT), but mental ill health is so strongly stigmatised, and this ‘snap out of it’ mentality so prevalent, that he fought alone.
For many people with major depression, the utter bleakness and pain of living is overwhelming. They may think their existence is a burden on those they love, that everyone would be better off without them. They’re wrong, but that feels so true they believe it. Surviving every day takes more work and courage for some people than many of these commenters will ever need to draw on.
(by Matthew Johnstone, for SANE)
For people who still can’t or don’t get that, know this – first, you are luckier than you realise. Second, if you don’t understand, shut up. Your uninformed opinions about depression are not just unhelpful, they’re actively damaging to those surviving with depression, and those left behind when the disease was too much.
If anything here has distressed you, or prompted you to seek help:
(Vic) SuicideLine 1300 651 251
(Aus) LifeLine 13 11 14
(Aus) SANE Australia 1800 18 72 63 (business hours, AEST)
(Aus) Suicide Call Back Service 1300 659 467
(Aus) Kids Helpline 1800 55 1800
Nurses are not alone in having positions where our work includes the potential for misuse of power over vulnerable people. As Australians have been appalled to learn in the last week, as footage of barbaric treatment of detained children was broadcast on Four Corners, there are professional cultures where egregious mistreatment (and that is an unquestionably mild categorisation) appears to not only be accepted but almost expected.
Nursing is not immune to that – several years ago I wrote about the horrifying treatment of patients at Mid Staffordshire in the UK, the contributing institutional factors, and the injustice of focusing on clinicians alone instead of the managers whose policies not only facilitated but almost demanded it.
It’s reasonable to expect that, at a bare minimum, those in our care are treated humanely and with respect. As I’ve commented several times on social media since the ABC broadcast, excusing corrections officers’ actions because of juvenile detainees’ behaviour misses the mark. I have been spat at, sworn at, threatened, slapped, pinched, bruised, groped, scratched, punched, and had projectiles from faeces to metal bed pans thrown at me; my colleagues have been sexually assaulted, knocked unconscious, partially scalped, contracted infectious diseases after being spat on, had bones fractured, and needed breast reconstruction after biting. Not only do we not retaliate by dropping patients naked and leaving them, restrained and alone, to do so would justifiably be condemned, by our profession and the public.
We are, however, human. We carry with us to work the same stressors everyone else does – relationship woes, family worries, financial concerns, inadequate sleep, colds that are enough to cause misery but not enough to warrant time off work… When work frustrations are added to that, sometimes something has to give.
I love what I do. I get to make positive differences to people’s lives every day: my colleague said, through education and support; family members, with explanation and reassurance; most of all my patients, through skilled, compassionate, experienced nursing care. After returning to the bedside after over a year of illness, my commitment to providing that care is even stronger.
I am proud of few things – I am privileged that most of my positive attributes come without work, so taking pride in something I have by good fortune would be ridiculous. I am, however, proud of managing my temper (which was once significant), and my still-evolving capacity to step back rather than engage and escalate conflict. These are not qualities that came effortlessly, for all their necessity in my position.
Despite one’s very best efforts at calm, professional, therapeutic distance, sometimes someone manage to find your last nerve and play it like a virtuoso. And I recently had a shift that was dominated by a patient for whom I could do no good, as I was repeatedly told, but who nonetheless called for me multiple times each hour, only to react with anger and disparagement despite my genuine best efforts to help.
It is fortunate that my other patients were stable, needing few interventions; I was certainly unable to assist and support my colleagues as much as I’d have liked.
I know my patient was scared, distressed, anxious, panicked on occasion, enormously fatigued, sleep deprived, and angry. I also know that we are often safe targets – our patients know we won’t abandon them, or retaliate. I certainly hope they know that.
And, despite my experience, my empathy, my knowledge, and decades of honing professional distance, I became frustrated – by not being able to meet my patient’s needs, by their expectation that I should know what they wanted without asking, by my every suggestion being shot down, by going over the same ground with repeated futility, by hours of belittlement.
I didn’t express any of my frustration to my patient – though I took a slow, deep breath before responding to each call, every interaction was polite, warmly professional, as long as my patient needed, and I responded in under a minute on every singly occasion.
The reason I was able to maintain this for my whole shift was because I vented my frustration to my colleagues. A little hyperbole, some fantasy, and I was able to optimistically smile the next time I walked through the patient’s doorway.
All of this has been preamble to the point of this post. I also wrote a Facebook entry where I described my venting. There, as here, as always, I omitted identifying details. I made it clear that the issue was not so much my patient as my frustration. And I wrote about how this informal debriefing allowed me to work effectively, to provide professional care, to put my patient’s needs first.
And I was reminded today that none of those aspects matter, because my post could have been enough to jeopardise my registration. The days of acknowledging the emotion labour of dealing with ‘difficult’ patients have gone – when text, absent tone, can make jest indistinguishable from the corrosive, toxic culture revealed last week, staying silent is the safest option.
Every week nurses and midwives attend disciplinaries, recieve warnings, and face employment and registration consequences of social media activity. Oftentimes this is completely warranted, because of confidentiality breeches, employment conditions (don’t take sick leave then tweet about being at a music festival!), and the like. Sometimes it may seem like an overreach. Either way, determination isn’t made by those who know us and our intent – it’s made by people whose job is to safeguard the public, and who understandably err on the side of caution.
I am no social media neophyte. As a union rep I have a better idea than most how inappropriate social media posts comprise a significant, and growing, number of disciplinary procedures. And even as I wrote my post I wondered how wise it was, even adorned with caveats and clarifying notes.
So, for myself and for any health professional who’s made it this far, a reminder: before posting anything remotely work- or profession-related, think twice. And if even the smallest part of you has any doubt, hold back – you can always write it later, you may not be able to retract it.
Like all nurses of any length of practice, my clinical experience includes the most intimate moments of people’s lives. I suspect most laypeople think first of physical intimacies – bedpans and nakedness, though those are the least intrusive; for me and most of my colleagues, though, the real intimacies are less tangible – people who need to be strong for their families allowing themselves to be vulnerable with us; confiding long-held secrets and fears; making their dying days comfortable and calm; continuing care after their lives end.
While nursing care and death work have been the foundation of my academic career, I realised today, after starting a response to ‘Nurses Grieve Too,’ an excellent guest post by Emily Rankin on Ian Miller’s blog The Nurse Path, that I haven’t written about it here.
Like one of my favourite medical authors, American surgeon Atul Gawande, Emily introduces and closes her writing with the dying of a specific patient, while the body of her piece explores the emotion labour of grieving for and with our dying patients, wondering if we could have done more, and of needing to contain our emotions as we continue to care for our other patients.
Approaching her second year of registration, Emily is near the beginning of her career; I commemorated the 27th anniversary of my hospital-based education 45 days ago, and I long ago lost track of how many of my patients have died on my shift. I certainly don’t remember all of them, though there are some I will never forget.
Like many nurses, I prioritise the care of the dying – as well as pain relief, sedation, and secretion management (do they stiffen or grimace when turned? Are their eye movements rapid? Is their breathing shallow, rapid, laboured, moist?), fundamental nursing practices like smoothing sheets to prevent uncomfortable wrinkles, flipping pillows to the cool side, frequent mouth care to avoid caked secretions and dry lips, position changes, and back rubs make a huge difference. Helping someone die well is a mitzvah, for them, their loved ones, and it also helps us.
The deaths most of my friends and I remember most vividly are where the dying was not peaceful. Where the medical team, the family, sometimes (but rarely) the patient themselves pursued treatment long after the benefits outweighed the toll; where someone bleeds to death as we stand by, helpless to stop it; where end-stage organ failure means the only doses of pain relief high enough to treat condition A would kill them thanks to underlying disease B, so we have to see them suffering on their inevitable trajectory to death.
We remember the young people, whose time was cut cruelly short; the confused and demented people, terrified by things only they can see; and the unexpected deaths of those who seemed to be doing well.
I have shed tears for my patients, and for the grieving loved ones they’ve left behind; I hope that those who’ve seen the glisten of tears, the pinkening of my nose, also see compassion, without loss of professionalism. But I have not wept – whatever distress we feel, whatever we’ve seen and felt, the expectation is always that we keep going, absorb the experience, because it’s part of the job.
I have once been offered formal debriefing, after a patient I didn’t know committed suicide on site. It was disruptive, distressing, and chaotic on several levels, but not close to the most traumatic experience I’ve had. Without in any way blaming my management (for this attitude pervades the profession at all levels), it is only these spectacular deaths that we’re ‘supposed’ to be troubled by – not the elderly man drowning in secretions we can’t stop, the young mum with congenital vasculopathy, the younger man with breathtakingly rapid progression to advanced HIV, the woman who’s been cared for by us over the eight year decline from neurodegenerative diagnosis to death, or the man whose decision to end dialysis was received with a diagnosis of depression and course of electroconvulsive therapy.
I believe this lack of acknowledgement, along with intimacy, little direct control, the honour and responsibility of caring for people at their most vulnerable, and only rare opportunities to direct the residue of that labour and emotion, plays a part in why some of us speak to our patients while performing post-mortem care: we get to say goodbye, give uninterrupted care, and complete a journey that we have uniquely travelled.
I woke this morning to heated discussion among my social media peers about One Nation’s policy on nursing education in Australia
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)
To all Victorians, Please take care on the roads this long weekend. Long weekends are notorious for an increase in the number of people coming into our emergency department as a result of road trau…