Specialization in Nursing - Report Example

RUNNING HEAD: SPECIALIZATION IN NURSING Specialization in Nursing [The Writer’s name] [The name of the Institution] Specialization in Nursing Introduction Australia, the transfer of specialised nurse education to the higher education sector was announced by Commonwealth ministers in 1984. Specialised nurse training was to move into Colleges of Advanced Education (CAEs) and the move was to be completed by 1993. The State Grant Act of 1985 announced that the qualification on completion of basic specialised nurse courses would be an `undergraduate diploma' (Martins, 2000). In the UK the decision was made to transfer nurse education from hospital-based training to college-based education (mainly polytechnics), comprising `Project 2000' [ 1] diploma courses, in 1989; the same year in Australia a `unified national system' was introduced in higher education, ending the old binary system of universities and lower-status CAEs (Gamage, 2003). And in the UK the polytechnics were awarded university status in 1992, after which the remaining colleges of nursing were quickly incorporated into the expanding universities. Hence, the path of specialised nurse education has followed a very similar course in the UK and Australia over the last decade, and in both the UK and Australia the initial training of specialised nurses is now located in universities. However, regarding the funding of specialised nurse education, the paths of the UK and Australia were rather different. In the UK the money to provide nurse education was retained by the Department of Health, while in Australia the money followed specialised nurse education into the higher education system, funding being transferred to the Department of Employment, Education, and Training. This paper examines the policy movements surrounding specialised nurse education in the period leading up to and during the transfer, in an attempt to explain why this significant difference over funding for specialised nurse education in the UK and Australia has arisen, when more generally the policies have been similar. A most recent examination of the use of deception in nursing included student and specialised nurses working in medical, surgical, community and psychiatric settings.( Teasdale K, Kent, 2005) The authors of this study proposed that nondisclosure (as the 'titration' of the amount of information) is widespread and justifiable. This so-called titration refers to disclosure to a patient up to but not beyond a certain point. Somewhat in contrast with other studies, Teasdale and Kent (Teasdale K, Kent, 2005) concluded that deception is rare in nursing. They stated that any deception that occurred was practised because nurses attempted to avoid the harmful effects of distress on their clients. Deception was also employed in situations that risked disrupting the ward. Furthermore, nurses differed in their willingness to use deception. Thus, some nurses practised the dictum: 'Truth, the whole truth' when questioned by their clients while others respected the request of family members when they asked that information should not be disclosed. Alternatively, studies on nurse and patient perceptions about care have reported differences. Nurses and patients, when asked to rank the importance of caring behaviours, revealed significant differences in the importance of honesty. In three studies, (Von Essen, Sjoden 2001, 2003) nurses ranked the item: 'Is honest with the patient about his medical condition', significantly lower than did patients. Further afield, writers agree that lawyers, (Temby, 2002) business people, (Carr, 2000; Wokutch, 2001) journalists (Sulch, 2002) and advertisers (Nelson, 2000) lie, bluff, mislead and use advertisement to create the illusion of fact from fiction. It does seem that nursing stands amidst this world of deception as a practice that is prone to speaking half-truths, omitting details, misleading through evasion, failing to disclose by 'fobbing' off a client, and simply not telling and/or giving partial insights by the controlled release of information. The practice of nursing The following re-examines the nature of nursing as a practice of caring. This objective is served by reflecting on the question: 'What ought nurses to do?' The answers will advance the discussion to question further: 'What type of virtue characterizes the practice of nursing?' An obvious response to the introductory question: 'What ought nurses to do?’ is that they ought to practise nursing. The concept of professionalism in nursing is arguably problematic. It is not the purpose of this article to examine what it means to be a professional. Nevertheless, because there is debate about nursing's claim to this label, (Fullinwider, 2005) introducing this tension that exists about 'the nursing profession' makes stronger the argument of nursing as a practice. A seminal work that examines and identifies virtues that are essential to any social endeavour or practice argues that a core set of virtues characterize a practice if it is to operate successfully. The assumption is that readers are familiar with virtue theory, the nature of which is examined elsewhere. Arguably, nurses function reasonably coherently within a well-defined, easily recognizable institution; that is, nursing is here accepted as a practice, based on MacIntyre's view of a rational and complex form of generally recognized mutual human action through which supplies internal to that form of motion are recognized in the route of trying to attain those values of quality which are suitable to ... that type of activity. (MacIntyre, 2004) If this is so, what are the internal goods that are characteristic of the practice of nursing? A major internal good in nursing is identifiable with compassion. Compassion, an intensive form of benevolence, is a good that is intrinsic to the virtue of caring in nursing practice. Compassionate nursing benefits the client, the nurse and the health care community. McAllister and Ryan (McAllister, Ryan, 2006) note that compassion 'requires mutual exchange and flow of power'. The nurse responding compassionately tends to the client's needs and, in the act of serving, improves the client's welfare. In doing so, the nurse 'is a beneficiary since good acts have a positive effect on [the nurse's] character and therefore benefit [the nurse] personally'. (McAllister, Ryan, 2006) MacIntyre's view on external goods furthers this appraisal of the practice of nursing. Accordingly, and in comparison with internal goods, external goods are 'contingently attached to an activity'. (MacIntyre, 2004) Hospitals and community health authorities concern themselves with external goods. A hospital concerns itself with money, power and status at departmental and ward levels. These are the components of accreditation in a competitive health care market. Thus, practices need institutions. However, nurses risk being vulnerable within an institution. Power and status are evident when senior staff instructs nurses to adhere to ward policy. Such a situation may result in responses that fail to care; that is, it may be fitting that a client should be told about 'X' (a perforated uterus), yet senior (medical) staff may insist that a nurse should not disclose this fact because that would be contrary to that ward's social order. This conflict between external and internal goods within the practice of nursing illustrates the atmosphere of paradoxical or complicated demands in which that practice operate. Nursing as caring: how ought I to be? How ought nurses to be? The most obvious answer is that they ought to be 'caring'. Kyle (Kyle, 2005) observed that nurses could be expected to describe themselves as caring. Caring has been extensively analysed and broadly described within the nursing literature. Some recognize caring as the central core for all that is nursing (Kyle, 2005) or the focus construct of contemporary nursing. (Rawnsley, 2000) Others have concluded that caring is elusive, defying a consensus definition. (Morse Solberg Neander, Bottorf, Johnson, 2000) Furthermore, describing the nature of caring, if it is dependent upon the context in which it takes place, becomes problematic because no two caring contexts are similar. First, a nurse going beyond the boundaries of rules has been previously described as defining excellence in nursing care. Excellence in nursing care is more than uncritically following rigid rules and principles. The second point is that this 'being in the world', which is indicative of caring, has been described as a human trait and part of human nature which is essential to humanity's existence. A commonly cited construct of care, exemplified by this response, is the virtue of compassion. Nurse Education Policy In Australia, as in Great Britain, concerns had been raised regarding the status of nursing and its appeal as a professional career. Parkes (2006) explains how many nursing organisations had been pressing for the move of specialised nurse training to higher education for nearly two decades. Goals in Nursing Education has been produced as a collective policy statement by various professional nursing bodies of Australia, arguing that hospital-based training was inflexible and `totally inappropriate' in contemporary society, and unable to meet the nursing needs of the changing Australian community. The statement argued for basic nurse education courses to be transferred to CAEs. Although there was some initial resistance to the idea of a transfer from government bodies (see below), the reports of the government-appointed commission on nurse education became gradually supportive of the idea. In the Advanced Education Council of the Commonwealth Tertiary Education Commission's Report for the 1985-87 Martins (2000), it was argued that the transfer of basic nurse education to CAEs was justified due to the changing health care environment. The report pointed out that in apprentice-style training service needs overshadow those of education, meaning that theory is neglected. It was argued that contemporary specialised nurse education should prepare nurse students to meet the `total health care needs' of the future; and multi-disciplinary, tertiary settings would be more conducive to such education. It also observed the concerns of nursing bodies that specialised nurses require college-based training to secure equal professional status with other non-medical professions. In Australia different policies on nurse education were adopted by different states at different times. For example, in New South Wales the state government awarded specialised nurse education degree status before this had been approved as national policy by the federal government (Martins, 2000). Moreover, besides policy variations within different states, there is a further important difference from the UK system; in that health care is the financial responsibility of the state governments, whereas higher education is the financial responsibility of the federal Commonwealth government. Therefore, the UK and Australia are not without significant differences. Notwithstanding this point, within the scope of this paper Australia provides a comparison of sufficient similarity to elucidate the peculiarities of the current UK dispensation. Transfer of Funds to Specialised Nursing Education In Australia, the transfer of funds to the Department of Employment, Education, Training and Youth Affairs means that nursing courses are funded like any other university course. This does mean that some discretion can be exercised by the university institutions in the level of provision of funds for nurse education courses, which may not always favour nursing courses (for instance, other departments might be prioritised at the expense of nursing). However, in terms of specialisation of nursing, the transfer of funds has been beneficial. It means that specialised nurse education is dealt with in the same way as other non-medical health professions, increasing the comparative status of nursing--often viewed as a `semi profession' (Moloney, 2002)--as a consequence. Moreover, it puts qualitative control of nursing in the hands of educationalists, rather than health care employers: health care employers cannot use funding to influence the type of education provided. Hence, the decisions over the type of training provided to a student nurse, and, thus, the type of nurse produced, is controlled by nursing academics and professionally dominated statutory bodies. The numbers of nurse students, and the issue of nurse shortages, remain a concern in Australia (Moloney, 2002), particularly as health departments no longer retain a formal influence. Close working groups and committees have been put in place to ensure co-operation between the health and education departments, with penalties if the committees' requirements are not met by higher education institutions. Yet employers retain no formal control over the length of the course or the course content. Without a market mechanism employers lack the influence which educational purchasing provides to UK health care employers. Once the transfer of funds had been made in Australia it was relatively straight-forward to move the pre-registration qualification from diploma to degree level. While the transfer of nursing to tertiary courses located in higher education institutions had always been the priority for the Australian nursing profession, many had also campaigned for specialised nursing to be a degree level qualification, Royal Australian Nursing Federation explicitly encouraged the growth and support of degree courses in nursing. In 1990 the years of campaigning bore fruit when the Australian Education Council accepted the recommendation of the final Working Party on Nurse Education report that the nursing award be changed from diploma to degree status, to commence from 1992. As promised, in 1992 specialised nurse education became a degree course: specialisation in Australian nursing was complete, with nurses enjoying the same educational status as the other non-medical health professions. (Ranade, 2004) Because health care is a state responsibility in Australia, the federal government had little formal control over health care policy: any new policy directions including reorganisation or specialisation of services were implemented at the discretion of state, rather than Commonwealth, government. This suggests an important difference between the Australian Commonwealth and British governments in their approach to the transfer of registered nurse education from hospitals to the higher education sector. The risks posed by the transfer included the possibility that the cost of nurses in the workforce would increase as a result of their higher education training (Ranade, 2004) and a possible loss of control on the part of health care providers over the direction and content of nurse training and (consequently) the nursing profession. In the UK these risks constituted a problem for the central government, who was both responsible for health services and paid for them. However, because the Australian Commonwealth government neither funds nor has responsibility for health care, it would have been less concerned about this. Conclusion In Australia the phase of nurse specialisation in which specialised nursing courses become conducted in the higher education sector at degree level was completed due to a combination of two factors. Firstly, the particular funding arrangements for health and higher education in Australia: because the federal government was not responsible for the cost of health care provision, other policy concerns (i.e. improving opportunities for women) outweighed concerns regarding potentially increasing costs implied by professional control of nursing; and secondly, the early start of the professional campaign, which became accepted before radical monetarist policies had been fully developed, especially with reference to health care. A lesser degree of enthusiasm for monetarist policies existed in the Hawke Labor administration, in comparison with the Thatcher Conservative government presiding in the UK at the time of the decision to transfer specialised nurse training into the higher education sector. Because the nursing profession began campaigning for a transfer of nurse training into higher education institutions in the 1970s, by the early 1980s this campaign had gained credence in the eyes of Australian Labor politicians, and had been given recognition and support as part of their policy to improve opportunities for women. The transfer to higher education was thus implemented by a Labor government, before monetarist discourses and policies had gained momentum. Moreover, the state Departments of Health and Family Services were ready to allow the responsibility for funding specialised nurse education to transfer from themselves to the federal government. We argue that as a consequence of the different funding arrangements, the rate of success of the Australian and UK professional projects in nursing has diverged. The Australian higher education project was completed, with nurse educationalists and statutory bodies controlling the constitution of specialised nurse training courses, and pre-registration courses leading to degrees. In Australia, nursing now shares a comparable educational path and status with other professions allied to medicine. Thus, specialised nursing has dramatically increased in status, and nurse educators and statutory bodies control the entry level and type of education provided--and consequently the type of nurse produced. Conversely in the UK the professional project of nursing has been moderated by employer power and the type of nurse produced can be influenced by the needs of employers. While the higher education diploma in specialised nursing has increased the prestige of nurse education (and consequently the status of nursing), the specialisation project has by no means been completed. Because of the quasi-market arrangement where the Department of Health retains the funds for education, and consortia of health care employers increasingly purchase nurse education directly from education providers, employers are well positioned to hinder or restrain the specialisation project, and we argue that this has happened. We have shown it to be the case that UK employer control over the nursing profession has been tightened, whereas in Australia the profession has more autonomy, and less fettered control of nursing. It remains to be seen whether or not employers begin to use their still new contracting power to manipulate further UK nurse education. References Carr A. (2000) Is business bluffing ethical? In: Beauchamp T, Bowie N eds. Ethical theory and business. 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