17 February, 2014 8:47AM AEST

The bedpan ceiling

Time to rethink public perceptions of nursing

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For many, the mental image of nursing is a young, probably sexy, female mopping brows and cleaning bedpans.

Professor of Nursing Linda Shields says the public perception needs to change.

There needs to be a deeper appreciation of the nursing role and to ensure its valuable contribition is maintained by ensuring any additional level of assistance is linked to nursing rather than administration.

"The general public don't understand that when a nurse, be it RN or enrolled nurse or an assistant in nursing, does something like put a patient on a pan, they're not just putting a patient on a pan.

"They're using all their clinical skills to assess that person while that person's getting on that pan and getting off: they're looking at their skin, they're looking at how they move, they're talking with them to find out how things are going with their family.

"There's a whole range of assessment going on while that activity is being done, being put on a pan, being bathed and showered, helping to move around the room."

She says this is much more complex than people realise and they need to understand this important part of what some call 'basic nursing care'.

"It's not really basic. It is really just as complicated and just as complex as giving the most complicated drugs."

In the UK there's been a call to return to the 'good old days' when nurses trained in hospital rather than in university, but Professor Shields hopes that idea won't reach Australia.

"I would argue very, very strongly that they were not the good old days.

"I trained in one of the big hospitals in Brisbane back in the 1960s. We had wards full of people with double the capacity of the ward because people had to be admitted to hospital and the health service in those days allowed people in in very overcrowded situations.

"We would pull curtains around beds that weren't normally in the ward and clip them with paperclips to try and keep them together to give the patient some privacy when they were using a pan.

"We would work like crazy and we were not allowed to speak to the patients.

"We were told if we were seen talking to patients then there wasn't enough work for us to do, so we had to go clean the bedpans."

A harrowing night

Professor Shields recalls working in a ward as a student nurse in 1969 on nightshift.

"It was a 36 bed ward, but there were 70 old ladies in that ward!

"There were two of us on duty, both of us student nurses, I was second year and the one above me was third year, so two teenagers to look after those 70 ladies all night.

"One night in particular I remember eight old ladies dying on us.

"Those poor women died on their own, probably of preventable causes and all we could do was wrap them up and send them down the mortuary.

"It was just harrowing."

That trying time of training and loss easily demonstrated to Professor Shields the importance of current education systems.

"These days health services are much, much more complicated than they were 30 or 40 years ago.

"We now have very complicated management systems in hospitals. They run with a huge bureaucracy; we employ people with MBAs to run hospitals these days.

"The complexity of drugs and treatments is mind-blowing and it's really only going to get a lot more complex with things like genetics and targeted treatments for specific diseases.

"People are coming into a hospital much, much sicker than they used to be, because in the old days they'd come into hospital, they'd be kept in hospital for a week and then they'd be discharged home.

"These days; most people stay for a day.

"That means the ones that do come in for a longer period of time are much, much sicker than they used to be because we only keep in for a long period of time now those who really need intensive type of care.

"The knowledge that nurses need to look after patients who have all these things going on around them, is much more than it ever was back when I did my training."

Training vs education

With the recent movements in the UK, Professor Shields worries that Australia may fall into thinking whatever happens overseas is better than what happens here, but she stresses the difference between training and education.

"I would argue so strongly that Australia has one of the best healthcare systems in the world.

"We have some of the best nurses; we have some of the most highly educated nurses and we need them because of the complexities of the healthcare today."

She says many people question why nurses need a university degree.

"In the university education now they will learn anatomy, physiology, biochemistry, pathology.

"They will learn a whole raft of science based subjects; they'll also learn the whole theory of nursing and how nursing models work and how best to care for patients in different situations.

"They also learn law and ethics, because that's a huge component of nursing today, the whole ethical framework of how nurses and all health professionals work needs to be embedded in every curriculum for every health professional.

"Of course the public don't actually see all that happening, but it's vital that we continue the terrific nursing education we've got in Australia and maintain those standards so that Australians continue to get the best healthcare that they can."

Working 24 hours a day, nurses are usually the first face of the healthcare system when a patient needs help, but few patients recognise the complexity of the work of the nurse.

"They see nurses who come in and hold hands, give them a bath or help them to the shower, take bed pans, make sure they're comfortable, do something with their pain control and possibly talk to their relatives.

"And the general public are sometimes very perplexed about why nursing needs such a high level of education."

The cost of care

Professor Shields says both registered nurses and enrolled nurses are expensive to employ and because they make up the largest proportion of the workforce they cost a great deal.

"Health ministers across the country look at the amount of money these nurses cost and try to work out a way to reduce those costs.

"Today in Australia to be a nurse a registered nurse you have to have a Bachelor of Nursing degree.

"Enrolled nurses do a diploma at TAFE and… they cannot do many of the decision making activities that a registered nurse would do... but they're an invaluable part of the healthcare system.

"What's happening now is that some governments are bringing in, or trying to bring in, healthcare assistants which is something that's happening in the UK.

"These are unqualified health care workers who come in with no education and are being put into the wards, and this is a very big factor in the aged-care sector, but it's happening right across all health care systems as well.

"Healthcare assistants are coming in to work in the wards to help give out things like bed pans and help with baths and cleaning mouths and all that sort of thing."

But it concerns Professor Shields that there's a lack of understanding about how that care is given.

"Healthcare assistants are not answerable to the registered nurse, but all other nursing people in a facility, ward or a unit are answerable to the registered nurse.

"Because they're not labelled nurses, they're answerable to corporate services or operational services, even though everything that happens in that ward the registered nurse is responsible for."

Professor Shields hopes assistants in nursing might be the answer, with some training in basic nursing skills and answerable to the RN in charge.

"The reality is that we are going to have to have some sort of ancillary nurse of some kind, to help give care; that's just the economics and the reality of it these days.

"It's really important that the public know that we're trying to bring in assistants in nursing who will answer to the registered nurse and not healthcare assistants who answer to someone corporate and don't understand the clinical aspects of care."

The male nurse

Professor Shields suspects nursing has long been a misunderstood career.

"It's always been mopping brows and holding hands and putting on bed pans.

"What happens in many television shows and films about nurses is that they're portrayed as the doctor's handmaiden, or they're portrayed as some sexy nurse, and of course that's absolute anathema to the profession."

One very persistent stereotype is that of nursing as a feminine profession.

"We need lots, lots more men coming into nursing," says Professor Shields.

"Language is often really powerful, and often when people talk about men who work as nurses, they're described as 'the male nurse', you never hear anyone say 'the female nurse', so they're instantly labelled as something different.

"Only 10 per cent of nurses in Australia are men, but interestingly in countries like Indonesia 25 per cent of nurses are men.

"In some countries it doesn't have the stigma that it seems to have in Australia and countries like the US and UK.

"But it's vitally important that we get men into nursing.

"They bring a different perspective, they're fabulous to work with children, fabulous to work with women giving birth, there's a growing number of men who are midwives.

"It's really good to see that this is going to happen, but it's so slow!

"And it's all to do with the gender stereotyping."

Linda Shields, MD, PhD, FACN Professor of Nursing at the Tropical Health Tropical Health Research Unit for Nursing and Midwifery Practice, James Cook University and Townsville Health Service District.