the 46th patricia chomley memorial oration 2012 - Royal College of ...

23 May 2012Rcna National ConferenceClinical And Corporate Governance

OrationRCNAThe 46th Patricia Chomley Memorial OratorEmeritus Professor Robin Watts AM FRCNAPhD(Colorado) MHSc(McMaster) BA(WAIT) Dip NEd(CoN, Aust) RNProfessor Watts is an Emeritus Professor of Nursing, CurtinUniversity and a Director of the Western Australian Centre forEvidence Informed Healthcare Practice, a collaborating centreof the Joanna Briggs Institute. She has been involved in nursingeducation for 42 years and served on or chaired numerousnational and state nursing education committees, reviews andprojects.Professor Watts commenced her basic nursing training at PrincessMargaret Hospital for Children (PMH) in 1962. Following hergraduation in 1965, Robin undertook her midwifery training at theRoyal North Shore Hospital in Sydney before travelling overseaswhere she gained valuable nursing experience in both Canada and the then war torn Honduras.Upon her return to Australia in 1971, Professor Watts undertook her Diploma of Nursing Education atthe Royal College of Nursing in Melbourne and in 1973 accepted an appointment as the Senior NurseEducator in the School of Nursing at PMH for Children. Following the transition of nursing educationto the tertiary sector, she left the hospital in 1976 to take up a Lecturer’s position in paediatric nursingin the School of Nursing at the Western Australian Institute of Technology (now Curtin University).Although promoted to various administrative positions within the university since then, ProfessorWatts has always maintained a close interest in the quality of health care provided for children in allhealth care settings in Western Australia and beyond.Professor Watts’ contribution to the nursing profession has been and continues to be immense.Of particular note is her involvement with the Australian Health Ethics Committee, the AustralianCouncil of Deans of Nursing, the National Review of Nursing Education, management of the SharedHealth Interactive Practice initiative and her work as the Director of the WA Centre for Evidence BasedNursing and Midwifery. These are current examples of her leadership and ongoing desire to progressthe nursing profession.The 46th Patricia Chomley Memorial Oration 2012RCNA1

the Patricia Chomley Memorial OrationEstablished in 1966, the Patricia Chomley Memorial Oration has become part of tradition at RoyalCollege of Nursing, Australia (RCNA) and has been presented annually to honour Miss PatriciaChomley, the first Director of the College of Nursing, Australia (now known as RCNA).Appointed in 1949, Miss Chomley was director until her retirement from the position in 1964.During the 15 years of Miss Chomley’s leadership, some six hundred students undertook courses.Many of those nurses subsequently held responsible positions throughout Australia and wereinstrumental in important developments in the nursing profession and in upgrading the quality ofpatient care.Miss Chomley passed away on 24 October 2002 and the Patricia Chomley Memorial Oration is afitting tribute to her leadership and contribution to RCNA.Past Orators1966 Professor J A Ovenstone – Automation and its implications in Australia1967 Dr Phillip Law – The changing pattern of requirements in professional education1968 Professor R A Rodda – Pioneer nurses: Then and now1969 Miss Patricia Church – After twenty years – A pause for reflection1970 Reverend Mother Lois – The changing status of professional women1971 Mrs Joanna Wilkinson – Introduction to the concept of the group care unit into professionalnurse training1972 Mr M H Bone – Lifelong learning: The role of permanent education in the education system1973 Professor R M Mitchell – Nursing and modern medicine1974 Miss Beatrice Salmon – Pragmatic axles turn on emptiness1975 Sir Paul Hasluck – What is the use of history?1976 Miss Patience R Thomas – The role of women over three centuries1977 Professor David Madison – Coping with crisis: A challenge for the health profession1978 Dr John R Sabine – A jug of wine, a loaf of bread and thou1979 Mr James P Smith – Nursing needs a professional renaissance1980 Miss Rosalie Pratt FRCNA – A time for every purpose...1981 Dr Rosemary Crow – How nursing and the community can benefit from nursing research1982 Miss Patricia V Slater FRCNA FCN (NSW) – The role of nursing organisations in professionaleducation – Challenges for the future1983 Miss Bartz Schultz FRCNA – Founders of the College1984 Professor Baronees McFarlane of Llandaff – Nursing – Fit for the future?2 RCNA The 46th Patricia Chomley Memorial Oration 2012

Nursing’s legacyMadam President, distinguished guests and colleagues. It is a particular honour to have beeninvited to present what will be, given the amalgamation of the two nursing colleges, the finalPatricia Chomley Memorial Oration for the Royal College of Nursing, Australia. What an eminentlysensible legacy to hand on to the following generations of nurses – a single national professionalorganisation!As in any year, this year (2012) has some major anniversaries to celebrate. Some of these are ofparticular interest and/or importance. The Queen for example has reigned over us for 60 years, whileMawson and his men traversed Antarctica 100 years ago. Quite different achievements but both haveleft or will leave a significant legacy. Terms such as ‘dedication’ and ‘tenacity’, among others, spring tomind.In a recent program on Mawson and his team’s achievements, the commentator remarked: “The menhave gone but Mawson’s hut remains and so their legacy lives on”. 1 Does Australian nursing have asymbolic ‘hut’? If so, are we tending that legacy so it survives? Is it even a legacy that should survive?Is it rhetoric or reality, or a mix of both? There are some in the profession who argue any efforts wehave made, if we made an effort at all, in this regard have been a dismal failure. Kieseker’s recentblunt assessment was that “after being central to the wellbeing of Australians for 200 years, nurseshave failed to make a mark”. 2, p.11 Others are more positive but whether we, as a national group, couldvery confidently say that we are perceived as having made a significant contribution to this country isa moot point. I wish to explore these and other related issues tonight.What might we place in nursing’s symbolic ‘legacy hut’? I obviously have some suggestions whichI will present in no particular order; you may well have some other ideas. I should also at this pointindicate the context in which my more recent observations of what was and is happening in nursinghave been made as this inevitably influences my thoughts on this topic. Over the last 12 years Ihave been, in some ways, on the sidelines of nursing. In the eight and half years I spent in universitymanagement, only one day a week was assigned to being a nursing academic (and that was usuallySundays). I then spent another two years full time in the School of Nursing and Midwifery beforefinally retiring, only to pop up again in an adjunct position. The decision to share this aspect of mypersonal history with you was generated by a point made by a fellow orator one year ago. She was ofthe view that nurses who take up positions that lie outside nursing, such as university managementroles or participation “in medical research of uncertain relevance to nursing … should not beautomatically endorsed by us as representative of our profession”. 3, p.18 A quote from another source,with one addition, that is ‘men’, and one substitution, that is ‘senior university managers’ for ‘doctors’,also resonated. This is from Helmstadter discussing nursing leadership at the end of the 19th century:4 RCNA The 46th Patricia Chomley Memorial Oration 2012

OrationRCNA“... the compromise on nursing education these women made with the doctors in order togain rank and a higher social station placed them in an impossible position in terms of their4, p.189professional aspirations, leading them into all kinds of inner contradictions.”These two statements led to some reflection on my part but my conclusion was that nursing hasalways been absolutely core to me and that my experience as a nurse, in a somewhat uniqueposition as executive director of university planning, may well have provided me with someuseful insights that I could contribute to the debate. I will leave it up to you to decide whether myobservations have any degree of credibility.What immediately comes to mind is the significant numbers of educated individuals nursing hasprovided Australia with. I am not confining this legacy just to the period from the advent of tertiaryeducation for nurses 38 years ago – as an aside you will note that we are edging ever closer to halfa century here. The foundations of this legacy were put in place by a small number of nurses whowent to the UK to study for qualifications in nursing education and administration, then built onby the College of Nursing era here in Australia – the oft quoted 600 graduates in Patricia Chomley’sera and many more after that. Add to that the recipients of the Kellogg Foundation scholarshipsfor study in North America in the 1980s. Then there are the nurses who gained higher degrees innursing overseas and/or university qualifications in other disciplines both before and after the adventof postgraduate nursing degrees. Finally there are those who educated themselves, in spite of theconstraints of their training. 5 Not bad for nice, kind girls (and boys) who didn’t need to be bright.The impact of tertiary nursing education in this respect is most evident in the number enrolling inuniversity at undergraduate level once the transfer was completed. The most recent figures available– 2009 – for domestic students enrolled in courses leading to initial registration as a nurse were 33489, an increase of 6.5% for females and 5.3% for males from the previous year. 6 Many of these wouldbe the first in their family to have gone to university. Nursing enrolments would also have made asignificant contribution to the situation whereby women now make up more than half of universityenrolments – 55.6% in 2010. 7But are these undergraduate students actually being educated? Judging by the content of a numberof articles in our national journals, 8, 9, 10, 11 this is a very pertinent question. I do not intend to enterinto a philosophical discussion here on what constitutes ‘education’. Suffice it to say that the goalof those whose vision it was to have all registered nurses graduate with a degree argued for thisrevolutionary change on the basis that, in order to provide effective and appropriate nursing care inthe future, nurses needed to have, among other abilities, a solid and current knowledge base across anumber of relevant discipline areas, critical analysis skills and the ability to apply knowledge and skillsmeaningfully to their practice. Are we achieving that? A number would say ‘no’.The 46th Patricia Chomley Memorial Oration 2012RCNA5

The underlying reasons identified for this dispiriting response are multiple. We all know what theyare: rapidly increasing numbers of students with widely varying scholastic abilities and Englishlanguage skills, ever tightening university budgets leaving less and less money at the teaching level,the privileging of research over teaching, concertinaed curriculum content, decreasing availability ofclinical placements, overstretched clinicians with little if any time to support student learning, rapidlydecreasing attractiveness of academic positions, etc., etc., etc. We are not alone among the disciplinesto be experiencing these negative impacts. One example is the fraught issue of entry standards. Arecent study by the Australian Council of Educational Research 12 published last month found thatnearly every applicant (96%) for university entry in NSW and the ACT was offered a place, no matterhow low their school leaving score. And before those in the audience from WA and Victoria startlooking smug, your states weren’t all that far behind – in the high to mid 80%. Only in South Australiaand the Northern Territory were the figures in the high 70%. However, very low entry scores impacton some disciplines and not others, and some but not all nursing courses.I would think all here tonight would agree with Professor Simon Marginson’s comment on the study’sfindings: “... with such an influx of students, unless more money is provided for teaching and learning,quality will suffer as surely as night follows day”. 12, p.6 In line with the national government’s push forenrolling more students from the lower socio-economic category, the social class equity initiativeas it is termed, 13 some additional funding has been provided to universities, but how much of thatwill trickle down to the teaching coal-face through the multilayered levels of university budgetallocation? In all likelihood very little, if anything. At one university where nursing is part of a medicalfaculty the discipline has calculated that it receives a mere 18 cents in the dollar from the fundinggenerated by nursing enrolments. How can anyone be expected to do the job required on thatpittance?There have been a variety of responses, both actual and recommended, to these problems. Theserange from abandoning universities altogether and setting up degrees in the technical and furthereducation sector, to creative ways of learning and teaching, to much bemoaning and wringing ofhands, to ignoring the problem altogether and/or just getting on with earning research points. Myassessment from my reading and observation is that in general we have been very light on effectiveaction. And I am far from the first person to say that in recent times but I suspect my assessment willprobably have as little effect as theirs obviously have had.I have no intention of using up what time I have remaining in this oration to make suggestions as towhat might remedy the situation. I would need all that time and a lot more. I will however place onrecord that I am strongly opposed to forsaking the university system, for all sorts of reasons. We needto actively and quickly seek solutions to either fix the system or work around it to achieve the visionour leaders had five decades ago.6 RCNA The 46th Patricia Chomley Memorial Oration 2012

OrationRCNAWe could of course be too late and we will have a ‘solution’ forced upon us. As I was writing thisoration the prospect of an early election and a change of government was looking probable ratherthan possible. If the statements of the federal member for my electorate are anything to go by, thecurrent Opposition have their plans for nursing all ready and just waiting to be dusted off. Theseplans, as far as I can ascertain, reflect a view of the role of nurses that take us back in time.Before I leave this ‘legacy’ I would like to offer two positive examples of the impact of this educationalenvironment: one from NSW and the other from my home state. Once again, there will be similarexamples to be found in other states. The first example involves projects by nurses at the workfacedesigned to improve patient care or improve nurses’ work environment. 14 These projects wereinitiated by the nurses themselves with no funding. The aim of the umbrella project was to collectand analyse these local projects and then present the outcomes to both the state government,and the nurses’ peers and colleagues across the state. The then NSW Minister of Health’s commentat the launch of the project report to government was of particular interest: “What we see in thisreport is the result of 20 years of university education for nurses”. 14, p.1 What was probably of moreimmediate practical interest to those nurses in the audience was that his speech also included anannouncement of funding for further innovation projects of this nature.The second example involves personal observations of clinicians who have graduated from auniversity program in my home state. In undertaking our work of developing systematic reviewsin the WA Centre of Evidence Informed Healthcare Practice, we have a policy of involving cliniciansin as many aspects of the process as possible. This involvement includes identifying the clinicalquestion on which the review will be based, assisting with the quality assessment of studies forpossible inclusion (following a few refresher sessions on research), generating the implications forclinical practice based on the findings of the review and providing feedback on the final draft of thereport. Usually, but not necessarily, these clinicians are Level 2 or above so are not neophyte nurses,although in this day and age some at this level have graduated not all that long ago. These nurseshave ‘blown my socks off’ with the clinical knowledge and specialised skills they have demonstratedand their commitment to quality patient care. I realise this is a very small sample but I am sure theyare not alone and that you would also be able to provide similar examples from your experience. Isuggest that a combination of both their undergraduate education and the continuing developmentthey have experienced in the clinical area from their own personal efforts and the educationalsupport of their organisation have contributed to this outcome i.e. we all have to work together toachieve the outcome the nation needs.Let me move on to the image of nursing. What is it about the image of nursing? Why isn’t it obviousto everyone that in this day and age nurses need to be knowledgeable and skilled; we are no longerthe doctor’s handmaiden. We’ve done lots of lobbying at various times. Could it be that we haveThe 46th Patricia Chomley Memorial Oration 2012RCNA7

failed to convince the general public of the depth and breadth of our practice and what then mustunderpin that in the way of knowledge and skills if we are to provide safe, individualised, effectivecare? Gordon’s 15 view is that most members of the public haven’t got a clue what we do. If theyunderstood that then we wouldn’t have politicians deciding they can get votes by ‘sorting out’nursing.Granted it is difficult to get someone to appreciate the more subtle, less obvious aspects of skillednursing care in its entirety or to even realise that it has occurred. Patients who have been seriously illand their families are probably in the best position to gain this understanding, provided they haveskilled and knowledgeable nurses caring for them. But the general public’s image of us is primarilygenerated by the media. Despite some improvements in recent times, we are still seen primarilyas merely carrying out doctors’ orders with a few other plot lines thrown in to make it interesting –personal issues, sex, life threatening errors, etc.During the time I was writing this paper I watched several episodes of ABC Compass – HospitalChaplains. 16 There was one particular female chaplain serving the intensive care wards at Royal NorthShore Hospital who I thought conveyed the complexity of her role extremely well in an authentic,direct way. I sat there thinking I wish we could get something similar made to portray nursing thiswell. The series produced by SBS several years ago RAN: Remote Area Nurse 17 did a good job ofnot only portraying the professional side of their challenging role but also the personal aspect in abalanced way, avoiding stereotypical representations. Trouble is, how many of the general publicwatch the ABC or SBS – less than one in five.All this sounds ‘glass half empty’. Let’s look at the ‘glass half full’ version of nursing‘s image. There are Ibelieve some positive signs that the portrayal of nurses and nursing is becoming more professionaland reality-based. David Stanley, 18 a former colleague of mine, concluded, after conducting aqualitative analysis of 280 feature films produced between 1900 and 2007, that more recentfilms increasingly portray nurses as strong, capable, intelligent, independent and self-confidentprofessionals. This was in contrast to early films which pictured nurses as self-sacrificial heroines, sexobjects and/or romantics. However, I’m sure you all share my view that the portrayal of nurses intelevision ‘soapies’ still has some significant catching up to do.According to numerous polls, the public trust us; we’re seen as honest and ethical. In 2011 nursingagain topped the Morgan poll 19 seeking public perceptions of 28 professions – that made it 17 yearsin a row. Trust is essential to the work we do but is it sufficient? No, according to Gordon 15 – not ifthe public don’t really grasp what our practice entails. Gordon talks about the ‘trust trap’ – that it canlull us into thinking that because we are trusted then there is no need to inform people about ourwork, but trust does not equal knowledge and understanding. Her suggested corrective strategy isfor nurses “to talk, in detail, about what they do in their daily work”, 15, p.1 not just a once off but on acontinuing basis. Perhaps we all need to do that with our local parliamentarians as a starting point.8 RCNA The 46th Patricia Chomley Memorial Oration 2012

OrationRCNAHow do other health professionals perceive us? The results from a series of surveys20 the CurtinSchool of Nursing and Midwifery conducted in the last decade of graduates, one year and threeyears after commencing employment as a nurse, provide some insights in how clinical nurses mightanswer this question. Between the first and third survey – a period of seven years – the respondentswere significantly more likely to report respect and appreciation from other health professionals –an increase from 34% to 50%, and 33% to 49% respectively. But this is barely a ‘glass-half’ – full orempty. Their perceptions of whether the nurses were well regarded and respected by the public inthe three surveys ranged from 49–66% and 52–70%. However, their rating of nursing as a prestigiousprofession ranged from 12% to 28% agreement.I’m not sure whether to include, from the image perspective, the advent of nurse practitioners in this‘glass half full’ section. By all reports the public who attend accident and emergency departments inWA hospitals where they are employed have taken to them in a very positive way, even if the AMAhasn’t. A number of studies 21, 22, 23 have found that client satisfaction with nurse practitioners in anumber of different clinical settings is consistently high. But the question is: Do the public perceivethem as delivering nursing care or, despite the title, perceive them as a mini-doctor?In the academic world my personal experience has been that nursing’s image, or perhaps moreaccurately the image of nurse academics has changed quite significantly but this assessment is basedon an ‘n of 1’. It had to change – we were coming off a base of less than zero in the mid-1970s. Letme illustrate this claim. On arriving at work one day in my first week at what was then the WesternAustralian Institute of Technology, we were greeted by large sheets of brown paper plastered overthe walls of the Architecture building, in which our basement offices were located, inscribed withcomments such as: “Go back to your hospitals and bedpans”. Needless to say this had the oppositeeffect – we were staying put no matter what. I look back now from a point where we have nursesacross the nation in very senior university positions, including a Vice-Chancellor, as chief investigatorson large research grants, undertaking research assessed as world class or above, and winningnational teaching awards for innovative teaching and learning strategies, and I marvel at the changes.But that change was the result of courage, persistence, lots of hard work and learning from ourmistakes in this totally different culture.A third area I would like to touch on is the relationship between research and clinical practice.Until relatively recently the general consensus was that there was an almighty void between thetwo that appeared to many to be unbridgeable despite their efforts. My observation is that in thelast decade we have managed to bridge that gap, albeit the bridge might be lightly constructedand a bit wobbly but with more support will carry more and more two way traffic. The destinationis evidence informed nursing care. I base the claim that I’m about to make on observation but Ithink it is still a reasonable claim: the two health care professions in Australia that have adopted theconcept of evidence-based practice and then applied it most widely are nursing and midwifery. I alsoThe 46th Patricia Chomley Memorial Oration 2012RCNA9

suggest that both these professions have made a very significant contribution to broadening theconcept from that adopted by medicine with its focus on effectiveness of treatments assessed, quiterightly, by randomised controlled trials (RCTs). Given the scope of nursing and midwifery practice,we had other clinical questions that required answers in terms of available evidence and these canbe best answered by research designs other than RCTs. Australia, through organisations such as theJoanna Briggs Institute and its international network of collaborating centres now numbering wellover 60 across all continents, has provided international leadership and practical support in thisdevelopment. This isn’t because other health care professions haven’t taken up the concept, but itseems to be taking longer to embed across the board or they have been later adopters than us.The most measurable evidence of the extent of the uptake of evidence-based practice by nursingin this country lies in its widespread incorporation into nursing policies and the modification ofprotocols to align with current evidence. These policies and protocols have translated the evidenceto facilitate its application. But the key question is: Is this evidence being applied to meet individualsituations and needs? Evidence-informed practice has a triangular base: the best evidence currentlyavailable, professional judgement and expertise, and, at the peak of the triangle, the individualreceiving the care. To my knowledge we don’t yet have a solid base of evidence that indicates theextent to which individualised application is happening, although I’m sure we could all provideanecdotal evidence either in support or otherwise.What follows is an example of individualised application in practice. But first, some contextualinformation. Despite laboratory evidence that fever aids the body’s response to fighting infection,24the medical research literature is replete with references to the objective of ‘fever clearance’ inchildren. 25, 26 Therefore fever must be ‘treated’ as if it was the disease i.e. all efforts must be made toget the child’s temperature down to normal. That is not to say that all medical practitioners hold thisview, but judging by the advice and prescriptions given by GPs, many do. A number of course mayfeel pressured by parents influenced by very cleverly targeted advertising, to prescribe antipyretics,as with antibiotics. Epidemiological evidence is also now appearing that exposure to acetaminophen(paracetamol) in the intrauterine environment, infancy, childhood and adolescence is associated withan increased risk of asthma. 27, 28 So the currently available evidence is telling us to minimise as muchas possible the administration of antipyretics. This advice is, however, complicated by the fact thatthese febrile children may well be in pain or in real discomfort associated with their illness and soneed analgesia – managed by the same drug – along with other non-pharmacological care.A two year old boy is admitted to hospital following a diagnosis of pneumonia. He is miserable, noteating, doesn’t want to be cuddled, etc. He is ordered, among other medications, analgesia. Thegraduate nurse administers the medication and then takes time to explain to the mother that thishas been given to relieve her child’s pain/discomfort, not to bring his temperature down. She furtherexplains, in non-technical terms, the role of fever in fighting his infection and why the hospital had10 RCNA The 46th Patricia Chomley Memorial Oration 2012

OrationRCNAa policy of encouraging parents to minimise the giving of antipyretics to children. This child was mygoddaughter’s son. She, a social worker, and I had had several conversations about this topic in thecontext of how can we get the message through to parents. So it was with great glee she relatedthis story to reassure me that the message had got through to at least one nurse, not only aboutminimising antipyretic use but also individualising the application of evidence.Turning now to our legacy of political activity. There is no doubt that nurses have been politicallyactive – we wouldn’t be where we are today if a number of our predecessors hadn’t been politicallysavvy and strategic. However that activity hasn’t always been obvious to all and sundry.To my knowledge no nurse has resorted to the suffragettes’ tactics – hunger strikes, etc., althoughSister Paulina Pilkington did indicate in her oration in 2002 that a suggestion along these lines hadbeen made to her. And I quote:“When the debate regarding the future of nursing education was taking place in theseventies, the late Dr Sidney Sax was of tremendous support to those of us who were tryingto bring about change. On one occasion, when I was deploring the inactions of governmentregarding our recommendations, Sid asked me why we didn’t chain ourselves to the gates of29, p.8parliament house in protest?”But many nurses across Australia did find their voice and their marching boots in order to win thatbattle in the face of very strong opposition, some from within nursing itself. The latest example ofovert political activity is the Victorian nurses’ uncompromising stand on patient ratios which finally,after nine long months, was successfully negotiated on March 16 this year. 30However, examples such as these are not the norm in nursing. Our long history of being patronisedhas seen to that. In 2008, more than two decades after the completion of the transfer of nursing totertiary education, Walker and Holmes’ summary of the situation was that:“… nursing still struggles for an equi-authoritative voice at the decision-making tables of thoseconcerned with the future of healthcare and that much, if not most, of what nurses do is simplytaken for granted and what nurses have to say is politely acknowledged but, all too often,4, p.108largely ignored.”Shield’s 31 analysis of a recent publication Health of the Nation by a national newspaper suggeststhat the situation hasn’t changed. This report covered topics such as the country’s health system, itseffectiveness, costs, economics, and accessibility. In the 22 page supplement the word ‘nurse’ onlyappeared three times. If, despite all the efforts that have gone into making submissions to endlessinquiries into health care, we haven’t been able to make a significant impact on the system, we needto figure out how we can change that. We do after all, comprise 55% of the health care workforce 31and we have a lot to contribute given our experience.The 46th Patricia Chomley Memorial Oration 2012RCNA11

I was again reminded of this analysis very recently by two newspaper articles, one in a nationalpaper 32 and one in our daily state paper. 33 These articles were reporting on the projected shortfall inthe number of nursing and medical practitioners by 2025 based on modelling undertaken by HealthWorkforce Australia:34 109 000 nurses and 2700 doctors. Despite the significantly larger problemlooming with nurse supply, both articles allocated a number of column inches to the AMA’s responseto the report with no comments included from any nursing organisation, although the WA AMA didrefer to the impact the nursing shortage would have on health services. Did the newspapers notconsider seeking a response from a nursing organisation or make use of media releases, or did adecision have to be made to not use the response given space available? Whatever the reason, themessage to the reader is that what we have to be really concerned about is the supply of doctors;nurse supply fades into the background. As an aside, I did find the report’s focus on nurse retentionmeasures as the primary strategy for reducing this gap somewhat comforting; for once the solutiondoesn’t appear to be focused on significantly increasing intakes, although no doubt there willbe some pressure there. That is not to say retention will be an easy issue to address to the extentrequired – it too comes with its own unique challenges and need for some radical changes in thework environment.However we need to remember that there a number of ways of acting politically which don’t involvewearing a red vest, waving placards and marching down the main street. Although we know thatpart of the role of our professional organisations is to lobby, we probably don’t appreciate just howmuch time and effort goes into that activity. A recent success was the amount of additional fundingproposed for increased salaries for nurses in the aged care sector in the Australian Government’sresponse Living Longer, Living Better 35 to the Productivity Commission’s report Caring for OlderAustralians. 36 We did of course have very vocal support from the aged and their families on that score.Another area where significant political activity goes on, although those involved could never admitto this, is in the chief nurses’ offices in health departments. From what I have observed, without thisbackroom work, bringing the nurse practitioner concept to fruition might not have been achieved.Yet another activity that could be classed as political activity is individual nurses talking purposelyabout what their practice entails, in order to raise the public’s and politicians’ understanding of ourrole and responsibilities.So, back to our symbolic ‘hut’, “what contributions have we made that we can place in there for thefuture of nursing in this country?” I suggest the following; you can add to these:• Education as opposed to training• Adaptation, adoption and application of evidence to inform our practice.12 RCNA The 46th Patricia Chomley Memorial Oration 2012

OrationRCNAThere are several others that I have explored tonight that have potential but need more work andstrengthening:• Improving the public’s understanding of the complexity of nursing practice• Ensuring involvement of nurses across the board in ongoing political activity, in its various forms,to ensure the profession survives and prospers.• Further strengthening of productive partnerships between the clinical areas and academe;partnerships that are active, respectful and mutually beneficial.These are all in a sense fragile and need tending, that is without care and attention they could allwither and die, or easily disintegrate. Some need more immediate action than others to avoid thisfate. As Sara Henderson, she of outback fame advised (and this is a slightly modified quote given theoccasion): “Don’t wait for a light to appear at the end of the tunnel; stride down there … and light the37, p.10@#$! thing yourself.”The 46th Patricia Chomley Memorial Oration 2012RCNA13

References1. Barlow K. Mawson’s hut reveals history frozen in time. ABC 730. 2012 30 January.2. Kieseker P. Status and symbols of power. Nursing Review. 2012:11.3. McDonald T. Nursing - Our Multigenerational Work in Progress: Royal College of Nursing Australia 2011.4. Walker K, Holmes C. The ‘order of things’: Tracing a history of the present through a re-reading of the past innursing education. Contemporary Nurse. 2008;30(2):106-18.5. Lawler J. Nursing in Interesting Times: A reflection, an analysis and a reading. Sydney: Royal College of NursingAustralia 2007.6. DEEWR. 2009 Higher Education Student Statistics - Nursing Students Canberra: Australian Government. 2010.7. DEEWR. Summary of the 2010 Higher Education Student Statistics. Canberra: Australian Government; 2011.8. Walker K. Curriculum in crisis, pedagogy in disrepair: A provocation. Contemporary Nurse. 2009;32(1/2):19-29.9. Madsen W, McAllister M, Godden J, Greenhill J, Reed R. Nursing’s orphans: How the system of nursing educationin Australia is undermining professional identity. Contemporary Nurse. 2009;32(1/2):9-18.10. Shields L, Purcell C, Watson R. It’s not cricket: The ashes of nursing education. Nurse Education Today.2011;31:314-6.11. McAllister M, Madsen W, Godden J, Greenhill J, Reed R. Teaching Nursing’s history: A national survey ofAustralian schools. Nurse Education Today. 2010;30:370-5.12. Hare J. Warning standard slipping at unis. The Australian. 2012 24 April:1&6.13. Department of Education Employment and Workplace Relations. Higher Education Participation andPartnership program - Social class equity initiativeCanberra: Australian Government; 2011 [cited 2012 3 April]; Available from: http://www.deewr.gov.au/HigherEducation/Programs/Equity/Pages/HEPPPrograms.aspx#2.14. Chiarella M, Parker V, Patterson K. Foreward. Contemporary Nurse. 2010;35(2):131-2.15. Gordon S. Nurses Again Win Public Trust 2010: Available from: http://www.suzannegordon.com/?p=472.16. Doogue G. Hospital Chaplains: It’s a tough job. ABC Compass. 2012 15 April.17. Caesar D, McKenzie C. RAN: Remote Area Nurse. Australia: Special Broadcasting Services (SBS); 2006.18. Stanley DJ. Celluloid angels: a research study of nurses in feature films 1900-2007. Journal of AdvancedNursing. 2008;64(1):84-95.19. Morgan R. Image of Professions Survey 2011. Roy Morgan Research; 2011 [cited 2012 27 April ]; Available from:http://www.roymorgan.com.14 RCNA The 46th Patricia Chomley Memorial Oration 2012

OrationRCNA20. Nowak M, Thomas G. Employment Directions of Curtin School of Nursing and Midwifery Graduates 2005 and2007. Perth: Curtin University of Technology 2009.21. Carter A, Chochinov A. A systematic review of the impact of nurse practitioners on cost, quality of care,satisfaction and wait times in the emergency department. Canadian Journal of Emergency Medicine.2007;9(4):286-95.22. Wortans J, Happell B, Johnstone H. The role of the nurse practitioner in psychiatric/mental healthnursing:exploring consumer satisfaction. Journal of Psychiatric and Mental Health Nursing. 2006;13(1):78-84.23. Wilson A, Shifaza F. An evaluation of the effectiveness and acceptability of nurse practitioners in an adultemergency department. International Journal of Nursing Practice. 2008;14:149-56.24. Kluger M. Fever revisited. Pediatrics. 1992;90:846-50.25. Hay A, Costelloe C, Redmond N, Montgomery A, Fletcher M, Hollinghurst S, et al. Paracetamol plus ibuprofenfor the treatment of fever in children (PITCH): randomised controlled trial. BMJ. 2008;337(a1302):1-9.26. Meremikwu M, Oyo-Ita A. Physical methods versus drug placebo or no treatment for managing fever inchildren (Review). Cochrane Database of Systematic Reviews. 2009(2):1-16.27. Beasley R, Clayton T, Crane J, von Mutius E, Lai C, Montefort S, et al. Association between paracetamol usein infancy and childhood, and risk of asthma, rhinoconjunctivitis, and eczema in children aged 6-7 years:ananalysis from Phase Three of the ISAAC programme. The Lancet. 2008;372:1039-48.28. Beasley R, Clayton T, Crane J, Lai C, Montefort S, von Mutius E, et al. Acetaminophen use and risk of asthma,rhinoconjunctivitis, and eczema in adolescents: International study of asthma and allergies in childhood phasethree. American Journal of Respiratory and Critical Care Medicine. 2011;183:171-8.29. Pilkington P. Looking Back into the Future: Royal College of Nursing Australia 2002.30. Bennett J. Victorian nurses settle dispute. ABC News. 2012 16 March.31. Shields L. ‘Invisible’ nurses have to find their voice. Nursing Review. 2011 December:10-1.32. Cresswell A. Nurse shortfall to hit 100,000. The Australian. 2012 28-29 April:10.33. O’Leary C. Predictions for 2025: Alarm over nurse shortages. The Weekend West. 2012 28-29 April: 11.34. Health Workforce Australia. Health Workforce 2025 - Doctors, Nurses and Midwives- Volume 1. Adelaide: HealthWorkforce Australia2012 March 2012.35. Department of Health and Ageing. Living longer. Living better. Canberra: Australian Government; 2012.36. Productivity Commission. Older Australians: Overview Report No.53 - Final Inquiry Report. Canberra:Productivity Commission 2011.37. Gemmell N. Rules of the game. The Weekend Australian Magazine. 2012 24-25 March:10.The 46th Patricia Chomley Memorial Oration 2012RCNA15

RCNA Australianmember of ICNQualityISO 9001Views and opinions expressed in this paper are those of the author