Patricia Violet Slater : a remarkable leader in the nursing profession in changing times

Patricia Slater opposed the entrenched traditional system of educating nurses in hospital programs and, in the years 1960-1983, she was an advocate and activist for tertiary level ducation for nurses in the general education system. Ms Slater’s educational expertise and unique position in nursing affairs, positioned her to progress nursing education at both undergraduate (basic) and graduate (post basic) levels and to take a leading role in the reform of nursing education. In this biographical account of Ms Slater’s professional life, her contribution as a pioneer and key player in the late twentieth century radical reform of nursing education, is distinguished from the collective activity of the nursing profession. The 1950s-1970s, highlighted many shortcomings in nursing practice drawing attention to the inadequacy of the contemporary preparation of nursing students. The traditional nursing education system, couched as it was in the cultural ethos of nineteenth century and rule driven, is identified as a major contributing factor to the apparent stasis in educational growth and development in Nursing. Social, cultural and political ideologies, to which the nursing profession was subject, worked to constrain and contain the profession, contributing to the apparent powerlessness of the profession to readily adjust and rectify its position. Chief among these influences was firstly, the domination and control of the medical profession over the health system and all health matters. Secondly, paternalism, that kept women in society and in the workforce subordinate to men. Thus nurses, being mostly female, were also professionally subordinated in the workplace being subject to medical control and direction. Thirdly, the Nightingale legacy of discipline and obedience in combination with the apprenticeship model of nurse education and the hierarchical organisation of nursing work, combined to encourage passive and conservative traits in nursing students that persisted over time. Ms Slater returned from nursing studies in America in 1960 with a vision as to how the nursing profession in Australia could advance and prepare nurses able to carry the profession forward, to determine the role and function of the nurse and the education required to develop nursing students at all levels. It would not be until the 1970s that sufficient numbers of nurses were ready to support the radical solution that Slater advocated, the transfer of nursing education into the general education system. Achieving this aim drew support from leading nursing organisations and the profession’s collective effort, sustained for over a decade, ultimately proved successful. Ms Slater’s thinking on nursing education, her vision for the nursing profession’s future, her philosophy and values in respect of Nursing, are drawn from her published work and some unpublished papers. Finding little to give insight into her personal reactions to events in her professional life, I approached individuals who had worked with Ms Slater ranging in time from approximately 2-12 years. Sixteen individuals were interviewed to gain their perspectives on events and their views and perceptions of Ms Slater: all but four were former employees. Interviews were taped verbatim, transcribed and reviewed by participants, all of whom agreed to be identified in the study. The official records of the College of Nursing, Australia and the then Royal Australian Nursing Federation, provided further primary source material together with the many reports of inquiries into nursing education. A diverse range of material was used to place Ms Slater’s life and the Nursing profession as a whole, in the social, cultural and political context of the times. Nursing in Australia was compared with like countries in the same time period. It was established that all were facing similar problems for much the same reasons. Patricia Slater’s leadership and expertise, were essential components in the successful achievement of tertiary level education for nurses. As a result, in the years 1984-1994, the nursing profession moved from a skilled craft towards becoming a knowledge based discipline, the equal of other health professions. The change in nurse education at that time, was as radical as that introduced to Australia by the Nightingale nurses in 1860s, in that the position and status of nurses and Nursing was radically changed on both occasions. The story of one of the most important Australian nurse leaders of the twentieth century is related for the first time in this work.Doctor of Philosoph

Rationed or missed nursing care: Report to the ANMF (Victorian Branch)

In May to July 2015, 1683 nurses, midwives and personal care workers (PCW) and Assistants in Nursing (AiN) employed in public and private health facilities in Victoria completed the MISSCARE survey. This represents around 3 percent of the total number of nurses and midwives employed in the state of Victoria. The survey was administered via Survey Monkey by a research team from Flinders University in collaboration with the Victorian branch of the Australian Nursing and Midwifery Federation (ANMF Vic Branch). The Victorian MISSCARE survey is a modification on the original design developed by Beatrice Kalisch (2006). It contains eleven demographic questions, 23 questions dealing with working conditions including questions on staffing tools, 21 questions concerning missed care (care that is omitted, postponed, or incomplete) and 20 questions addressing reasons why care is omitted in the settings in which the nurse/midwives practice. Victoria is the only state in Australia to have mandated nurse-patient ratios. The state of Victoria is experiencing rapid growth in population. Missed nursing care is a global phenomena linked to the rationing of health care. Nurse researchers around the world are recording the levels of missed, delayed or rationed care. Nurses have always rationed care tasks, or prioritised them when work intensifies. Nursing assistants known as health assistants in nursing, have been employed in some public hospitals in Victoria since 2009. Patient satisfaction surveys conducted by the public hospitals in Victoria show high rates of satisfaction with nursing care, and the courtesy of nurses, and low scores for organisational issues such as food, restfulness of hospitals and waiting times. There is some overlap between the patient satisfaction surveys conducted in the public hospital system and the MISSCARE survey such as length of time taken for nurses to respond to call bells, patient education, hand hygiene and medication requests. Sixty-seven percent of nurses in Victoria are employed on a permanent part-time basis. This is higher than NSW where 48.3 percent of nurses are employed part-time permanent. Fifty-six percent of nurses work 30 hours or more in Victoria. Sixty-five percent of nurses and midwives prefer to maintain their current schedule. Over 22 percent of nurses said they worked overtime greater than 20 times in the last 3 months. Thirty-four percent of nurses and midwives worked 2 to 3 shifts over the last 3 months even though they were sick or injured, with 32 percent stating they felt an obligation to their colleagues to go to work. Fifty-three percent of nurses and midwives felt that there were adequate staff between 100 and 75 percent of the time. The remaining 47 percent felt staffing was inadequate between 50 and all of the time. Seventy-three percent of nurses and midwives had less than 9 patients per shift, with eighty-six percent reporting that they had fewer than 5 admissions per shift Rounding appears to be used in 53 percent of situations, although many nurses had not heard of the term. Nursing care tasks most often missed include skin and wound care, and glucose monitoring. The care missed is consistent across all three shifts, although some tasks are more likely to be missed on a particular shift; eg afternoon shift has higher scores for missing the promotion of PRN medications, while night shift staff report the omission of managing parenteral devices. Nursing care tasks such as turning patients, oral hygiene, prompt medication administration and patient education are least missed. Missed nursing care can be categorised into low, intermediate and high treatment. Lower priority care includes emotional support, patient education and discharge planning, and high priority care includes handwashing, IV/CVC lines, call bells, BSL, vital signs. Treatment (intermediate) related care is the most likely form of care to be missed. These include nursing specific tasks such as feeding, turning/positioning, wound care, administering medication on time, ambulation, mouth hygiene, and toileting. This finding is consistent with survey results from NSW. Variables with a direct impact on missed care include the hospital location (rural hospitals report higher rates of missed care), the use of rounding impacts on missed care, and staff adequacy. Reasons for missed care include urgent patient situations and unexpected rises in patient volumes which impact upon staffing issues. While just over 50 percent of nurses thought their ward was adequately staffed 75 to 100 percent of the time, unpredictable work increases such as increased admissions and discharges contribute to missed care. Other important reasons for missed care include: ‘Inadequate skill mix for your area’, ‘an unbalanced patient assignment’ together with an ‘inadequate number of assistive and/or clerical personnel’ and ‘supplies/equipment not available when needed’. Two hundred and eighty four nurses and midwives provided qualitative comments within the survey. Responses illustrated a stronger focus on nursing the budget, with participants indicating they were more aware of financial constraints or the need for profits than previous generations of nurses. Midwives reported that early discharge of mothers curtailed adequate patient education. Nurses and midwives targeted cost constraints, lack of adequate numbers of clerical and ancillary staff, particularly on night duty, the lack of mandated nurse-patient ratios in private hospitals, poor access to medical staff, patient acuity, and competing demands placed on nurses who are at the centre of the ward or unit. Consistent with survey results from other states, lack of access to equipment including medications also impacts on missed care. Nurses in Victoria also indicated that poor communication was a factor in missed care. When nurses were asked about personal issues that impacted on missed care they reported that their capacity to deliver uninterrupted care and an inability to attend case conferences as causing missed care. This was followed by the absence of hospital policies and inability to delegate work to others. The frequencies and types of missed care are significantly influenced by both hospital/clinical unit effects including hospital location and by individual nurse/midwife factors. Missed care shows greater variation within Victorian rural hospitals. The average frequency of missed care on Victorian afternoon and night shifts is significantly less than reported in NSW however, the average frequency of missed care on the Victorian day shift is equivalent to that reported in NSW. Employer type (private or public agency) was not associated with missed care by Victorian respondents The use of rounding practices in the clinical arenas presents as contributing to and preventing missed care dependent upon context. The rate and frequency missed care is defined by the type of care missed. Intermediate treatment related care is more likely to be missed than higher priority and lower priority nursing tasks. In Victoria, the morning shift is associated with the greatest volume of missed care, followed by the then afternoon shift and then the night shift. Country of origin of nursing/midwifery qualifications is associated with significant variation in the frequencies and types of care missed in Victoria. Age of the staff providing care shows a mixed but statistically significant influence on missed care in Victoria. The gender and the level of qualifications held by the Victorian nurse/midwife is associated with significant variations in treatment-related missed care. Staff employment status (both full and part-time employment) demonstrates variance in frequencies of Victorian missed care. The complexity of staffs’ ability to manage daily work tasks shows significance variation in missed care in Victoria.. Dissatisfaction with work teams has a statistically significant influence on Victorian missed care. Current job dissatisfaction has a statistically significant influence on Victorian missed care. Staffs’ self-rated level of their current health and the number of hours they are employed for per week are not associated with Victorian missed care. In order of magnitude, the reasons why Victorian care is missed care are issues associated with the provision of resources for care, communication tensions between care providers, workload (un)predictability, (dis)satisfaction levels with members of the team and workload intensity

Key milestones in the operationalisation of professional nursing ethics in Australia: a brief historical overview

Objective To provide a brief historical overview of the achievement of key milestones in the development of mechanisms for operationalising professional nursing ethics in Australia; examples of such milestones include: the publication of the first Australian text on nursing ethics (1989), the provision of the first Australian national distance education course on nursing ethics for registered nurses (1990), the adoption of the first code of ethics for Australian nurses (1993), and the commissioning of the first regular column on nursing ethics by the Australian Nurses Journal (2008). Setting Australian nursing ethics. Primary argument An historical perspective on the achievement of key milestones in the development of mechanisms for operationalising professional nursing ethics in Australia has been poorly documented. As a consequence an authentic ‘Australian voice’ is missing in global discourses on the history and development of nursing ethics as a field of inquiry. Compared with other countries, the achievement of key milestones pertinent to the operationalisation of nursing ethics in Australia has been relatively slow. Even so, over the past three decades an Australian perspective on nursing ethics has gained a notable voice in the international arena with Australian nursing scholars now making a significant contribution to the field. Conclusion Nursing ethics in Australia remains a ‘work in progress’. Although significant achievements have been made in the last three decades, the ongoing development of mechanisms for advancing nursing ethics in Australia would benefit from the development and implementation of a strategic agenda of collaborative, internationally comparative, cross disciplinary scholarship, research and critique

Gendered relations to working time: enterprise bargaining outcomes in acute care and community nursing settings in Australia

In this paper we examine the outcomes of the 2001, 2004, 2007 Enterprise Bargaining Agreements between the Australian Nursing Federation (SA) and the South Australian Government with particular focus on union-based strategies for de-intensifying nurses’ labour in the acute and community sectors. Consistent with the theoretical and empirical research on time, the strategies employed in the acute sector reflect rational, linear, bureaucratic, logical and masculinist relations to time through the use of computerised time and task measures. Community sector solutions are characterised by cyclical, messy and highly relational feminised approaches to reducing work intensification. We argue that the outcomes of these two approaches are contradictory. The community-based solution of case management is less successful in reducing workload, but maintains worker control over the labour process, while in the acute sector, the highly Taylorist approach is successful in de-intensifying workload but at the cost of reduced control over the labour processes

Workplace aggression experiences and responses of Victorian nurses, midwives and care personnel

Background: Workplace aggression is a major work health and safety, and public health concern. To date, there has been limited investigation of population level exposure and responses to workplace aggression from all sources, and little evidence on the experiences, reporting and support-seeking behaviour of nurses, midwives and care personnel in Australian settings. Aim: To determine the 12-month prevalence of aggression experienced by nurses, midwives and care personnel from sources external and internal to the organisation, and the reporting behaviours and support sought from employers, health services, Trade Unions, work health and safety agencies, police and legal services. Methods: An online survey of the membership of the Australian Nursing and Midwifery Federation – Victorian Branch was conducted between 1 st May and 30th June 2017. Findings: In the previous 12 months, 96.5% of respondents experienced workplace aggression, with 90.9% experiencing aggression from external sources and 72.3% from internal sources. A majority indicated they just accepted incidents of aggression, and most rarely or never took time off work, sought medical or psychological treatment, or sought organisational or other institutional support, advice or action. Levels of satisfaction with institutional services were mostly neutral to poor. Discussion: Victorian nurses, midwives and care personnel work in aggressive and violent workplaces. The incivility endemic in health care likely sets the climate for the generation of and exposure to so much explicit aggression and violence. It appears that any systems or processes instituted to protect health care personnel from harm are failing. Conclusion: More targeted and effectively operationalised legislation, incentives and penalties are likely required. Further research may elaborate the extent of the impact of exposure to workplace aggression over time

Nursing home subsidies

On 13 July 1998 the Treasurer referred the current and alternative funding methodologies for nursing home subsidy rates to the Productivity Commission for inquiry and report within six months. The Aged Care Structural Reform Package, announced in the August 1996 Budget, included a process of ‘coalescence’, under which the different nursing home subsidy rates in States and Territories would gradually move to national rates over a period of seven years, commencing from 1 July 1998. The Government decided to delay the implementation of the coalescence process pending a review by the Productivity Commission into differential subsidy rates.nursing home subsidies - nursing homes - residential aged care - bed numbers - quality of care - resident fees - coalescence - subsidy - funding - workers compensation - tax - wage trends - productivity

A case study of pressure group activity in Western Australia: Medical care of the dying bill (1995)

When the Australian Labor Party member for Kalgoorlie, Ian Taylor, presented his Private Member\u27s Bill - the Medical Care of the Dying Bill (1995), he laid the foundation for this thesis. Mr Taylor introduced his Bill to the Western Australian Legislative Assembly on 28 March 1995. The Bill codified the terminally ill patient\u27s right to refuse medical treatment, which clarified common law. This thesis attempts to overcome the dearth of literature in Western Australian lobbying concerning conscience-vote issues. It also identifies the key issues in understanding political lobbying, the form of pressure group activity that takes place and why certain groups respond in different ways. The pressure groups selected for this case study are examined, classified and evaluated resulting in a prescription for lobby group activity for similar conscience-vote issues. According to the Bill\u27s sponsor, Ian Taylor, the legislation was needed to deal with the inconsistencies in common law of the medical treatment of terminally ill people. The Law Reform Commission in its 1991 Report on Medical Treatment for the dying, stated that there was a need to deal with the issue in Western Australia. Due to the advances in medical treatment practices in the past 50 years, doctors can prolong the life of patients for whom there is no cure. The major problem, however, is the Criminal Code: doctors and care providers can be at risk of prosecution and conviction if the patient\u27s wishes are respected and medical treatment is withdrawn, leading to the patient\u27s death. At present there is a general common law right to refuse medical treatment. According to Mr Taylor, the difficulty lies in the fact that in Western Australia, the common law is overridden by the Criminal Code. The Bill also highlighted the role of palliative care and the treatment of the dying. The opinion of most pressure groups was that the rights of terminally ill patients should be protected and enhanced. Of the groups selected for this case study, only the Coalition for the Defence of Human Life objected to the Bill. Other groups supported the principles of the Bill, while some hoped for voluntary euthanasia legislation and others gave tacit approval. Of all the groups the L. J. Goody Bioethics Centre distinguished itself as a key organisation which tended to monopolise political influence. Media exposure of the issue was high, particularly in The West Australian. The right to die issue was canvassed and often was reported with references to euthanasia. At the same time the Northern Territory legislation, the Rights of the Terminally Ill Bill (1995), was receiving much media attention. The issue of euthanasia was necessarily discussed in the context of national and international arenas. The political masters of thought on citizen participation and group theory were introduced early in the thesis. John Locke, Jean -Jacques Rousseau, James Madison, Alexis de Tocqueville, Thomas Paine and John Stuart Mill provided valuable insight into the nature of modern political thought on this interesting aspect of political activity. Contemporary political writers such as Trevor Matthews. Dean Jaensch and Graham Maddox were also consulted. The eight pressure groups selected for the study were the: • West Australian Voluntary Euthanasia Society Inc. • Coalition for the Defence of Human life • Australian Medical Association (WA Branch) • Australian Nursing Federation (WA Branch) • L. J. Goody Bioethics Centre • Silver Chain Nursing Association Inc. • Uniting Church of Australia • Anglican Church of Australia Information from the groups formed a significant part of this thesis. An attempt was made in the conclusion to ascertain the effectiveness of the various strategies utilised by the pressure groups and provide an insight into lobbying practices. Ultimately, though, the contentious Bill was not given a third reading. Nor was it debated in the Legislative Council. At one stage it was considered likely that the Bill would be recommitted to parliament. The monitoring of the Medical Care of the Dying Bill (1995) undertaken in this thesis, indicates that this would have been a lengthy and divisive process

Missed nursing care: Report to the Australian Nursing and Midwifery Federation: Tasmanian Branch

Executive Summary • From June through to the end of July 2015, the missed care survey was run through the Australian Nursing and Midwifery Federation Tasmanian Branch. Six hundred and forty eight nurses, midwives and four personal care workers completed the survey. These figures mirror state numbers in terms of gender, and number of RNs to ENs and midwives. • The survey was made up of ten demographic questions, 22 questions that explored working conditions including questions to do with how workload is measured and staff assigned to the ward or unit, 21 questions concerning missed care (care that is omitted, postponed, or not completed) and 19 questions that asked the participants why they believed care was missed. • The survey also included questions on staffing tools, rounding and whether or not nurses considered they worked within their scope of practice. Kalisch defines missed care as “required patient care that is omitted (either in part or in whole) or delayed” and acknowledges that it is a response to “multiple demands and inadequate resources” (Kalisch & Williams 2009, p. 1510). • The proliferation of research on missed care, including the work on rationed care is ensuring that researchers are exploring underlying causation in more depth. To date analysis by the Australian team have focused on the relationship between missed care and work intensification linked to new public management. • Recent research published by Kalisch (2006; 2009; 2012) makes a distinction between missed care as an error of omission (care not given) and missed care as an error of commission (incorrect care). In tracking omitted care, Debney and Kalisch (2015a) have developed a missed care survey for patients which demonstrated considerable consistency with nurses’ perception of missed care. • A significant finding of the patient surveys is the impact of skill mix on missed care. Registered nurses are less likely to miss care than lower grades of care workers. This is attributed to their knowledge and deeper understanding of the importance of timeliness in providing care. • Recently published research by Kalisch et al. (2012), showed that skill mix, leadership and team work are also factors strongly associated with missed care. • Castner et al. (2014) explored missed care during times of hospital merger. Their research demonstrates that unit level factors and individual nurse factors are both contributors to missed care and there is ample evidence of related factors during hospital merger such as re-admissions following early discharge and reduced staffing levels that point to missed care. • Both the Castner et al. (2014) and the Blackman et al. (2015a) studies confirm Kalisch et al. (2015) observation that nurse skill mix and nurse communication are key to reducing missed care. • Studies suggest that highly experienced nurses report more missed care than younger nurses with less years of expereince and these same nurses report major issues with supply and communication problems. It is not clear whether this is because these nurses are more reflective than younger less experienced nurses; intuitively this would seem a reasonable assumption. • One of the managerial responses to missed care is to introduce mandatory rounding. Rounding involves nurses carrying out regular and standardised checks on all patients at set intervals to assess and manage their fundamental care needs. This is usually done on an hourly basis and is promoted as an opportunity for the nurses to involve the patient in their own care, and for them to ensure all is well (Tea, Ellison & Feghali, 2008). • Tasmania is a small state with low population and a resource base limited by low revenue. • Tasmanian health care like the rest of Australia it is a mixed system. There are 27 public and 14 private hospitals in the State. Four of the public hospitals are major providers, the other 23 are rural or community based. These smaller hospitals offer varying services from residential aged care, emergency, primary care and sub-acute and same day surgery. • Health outcomes for Tasmanians are below Australian national averages. This is reflected in lower life expectancy rates for both males and females, and the percentages of the population who smoke, are obese or overweight, as well as prevalence of chronic conditions - all of which are higher than national average. • Health system performance in Tasmania is also below peer hospitals in other states, with outcomes for patients influenced by where they live. • The major reform direction for 2015 and beyond is to organise the sector into one system, rather than three health organisations with specific hospitals operating as centres of excellence. • The concept of universal health care equity and access, the corner stone of the 1983 Medicare agreements has given way to quality and risk reduction, and a stronger focus on medical expertise. • Similar to mainland Australia, people living in Tasmania have access to private health care services. There are 14 private hospitals in Tasmania. However, the number of people with private health insurance in below the national average. • According to the Australian Health Practitioner Regulation Authority Nursing and Midwifery (AHPRA) statistics (March 2015) there are 7989 registered [6429 - 792 male] and enrolled nurses [1426- 127 male] plus 47 with dual qualifications in Tasmania with around 87 of these not practicing. There are 647 nurse/midwives with 7 not practicing and 17 midwives with a single qualification. • One of the confounding issues for Tasmania is remoteness. New South Wales has the highest average available beds per 1,000 population in Remote areas (5.0 beds per 1,000 population) and Tasmania had the lowest (1.5 beds per 1,000 population). • The NEAT target for Tasmania for 2015 is 90 per cent of patients to be attended to in Accident & Emergency (A&E) within the four hour time allocation. Current performance is between 65 and 70 per cent (AIHW 2015; DHHS 2015b). Meeting this target will impact on missed care. Tasmania also has long waits for elective surgery. • Participants reported a broad range of beliefs about the frequency of missed care with the bulk of staff indicating that missed care is occasionally to frequently missed. Staff did not indicate whether that care is always missed or never missed at all. • Missed nursing care can be categorised into treatment related, lower priority (emotional support, patient education and discharge planning) and high priority care (handwashing, IV/CV lines, call bells, BSL, vital signs). Treatment (intermediate) related care is the most likely form of care to be missed. These are nursing specific tasks such as feeding, turning, wound care, medications given on time, ambulation, mouth hygiene, and toileting. This finding is consistent with survey results from NSW and Victoria. • The frequency of missed care across the three shifts does not deviate significantly from each other, in terms of not only missed care frequency but also the different aspects of missed care. • Focused reassessment according to patient condition is missed the most frequently across all shifts, whereas staff hand-washing is missed the least frequently for the same corresponding time periods. • Staffs’ perception of how effective they are in managing their daily work tasks are strong predictors underlying the frequency of and types of missed care • Hospital or unit characteristics including the location of the health care service (regional or city based) and whether the health unit is publicly or privately owned has no effect on missed care during any shift. • Increased day shift missed care is associated with two factors: staff effectiveness in self-managing their work, and the staffs’ level of (dis)satisfaction with being a member of a team in their own workplace. • Nurses/Midwives who experience difficulty managing their daily work, who are not satisfied with their current job, nor their current work rosters, or who are working less than thirty hours per week and believe their clinical areas are not adequately staffed for long periods of time, indicate greater incidences of day treatment-related missed care. • Current job (dis)satisfaction remains a significant influence on missed care during the afternoon shift, particularly with staff employed on a part-time basis. • Staff age, particularly younger staff, are more likely to miss lower priority tasks during afternoon shifts than older staff. • Afternoon and night shift staff link missed treatment-related care to consequence of work rosters and would prefer to change these. • Staff holding a Bachelor’s degree (or above) indicate a greater likelihood for missing higher-priority care tasks during the night shift than staff with hospital qualifications or at diploma level. Length of clinical experience is a factor in missed care; staff with less experience are more likely to miss higher-priority care at night. • Reasons for missed care identified by nurses in order of magnitude are; the provision of resources for care (+0.51), communication tensions between the care providers (+ 0.34), workload predictability (+0.19), issues related to workload intensity (+0.14), and finally satisfaction levels of staff in their role as a team member (-0.15). • Hospital location is a significant factor behind why care is missed. Tasmanian regional sector venues are more likely to be identified as contributing to missed care compared to city based health care venues. • The average frequency of missed care is approximately the same for both morning and afternoon shifts, and is significantly less overall in all shifts compared to NSW and Victorian. • Employer type (private of public agency) was not a factor associated with missed care in Tasmania. • The use of rounding practices in the clinical arenas has produced (a small) negative result in both the frequencies and types of missed care