My eye was caught today by an article in on the ABC news website.

Public hospitals could save $430m by getting nurses to do some doctor tasks: report – ABC News (Australian Broadcasting Corporation)

The gist of the piece is that “routine” procedures can be easily carried out by nurses at less cost. The author suggests endoscopies, colonoscopies, and sedating patients for low risk procedures.

The author appears to be an economist and public policy academic. This perspective is the only one in current Australian culture that the report makes sense. The Grattan Institute (http://grattan.edu.au/about-us) states that “it is an independent policy think tank providingindependent, rigorous and practical solutions to some of the country’s most pressing problems.”

I don’t have issue with the article per se (although at no point has anyone thought to ask any nurses what they think…) but I am riled by some of the more obvious comments attached below.

None of the Users commenting actually seem to understand the point of the original report or what the people in the modern health system actually do.

Comments all seem to follow a small number of themes:

1. Just plain bitchy (“… our definition of a colonoscopy was “six feet of fibre optics with an ar*ehole at each end” … Modern nurses are well qualified to replace the current proceduralists” – User discus49, retired anaesthetist) Let he who casts the first stone, sir. You’d know, maybe having been one of the ar*eholes at some point. And I hope I never worked with you.
2. The “I nearly died from an anaesthetic and I’m not going to let a nurse near me” response. I’m not even going to address this User’s concerns directly, they obviously had a bad experience which has hopefully resolved. They do suggest that nurses “are not trained specialtists” and several other claims not bearing scrutiny. Although I guarantee that what ever happened it was not fixed by doctors alone.
3. The “perhaps vocational training at a hospital level (as it was 25 years ago) would be a good way to save resources instead of insisting on degree level training” – User cynical wasp, no occupation listed) line of thought. This comment unfortunately represents a large proportion of the general population who don’t understand what we actually do.

Further comments reflect the original article’s assertation that the RN duties of bathing and feeding could be passed on to vocationally trained nursing assistants.

So I suppose what this post is really about is a rebuttal to the “let’s train nurses as we always have” mixed with some thoughts about why nurse sedationists are a bad idea in modern Australia. If neither of these topics interest you, please read something else (really, my opinions aren’t going to change yours…come back though, there’ll be something else later more your style…)

The obvious response is why do we let the public have a say regarding nurse education anyway? Other professions don’t do this. We tend to invite “consumers” onto our Nursing Boards of Registration (the now defunct QNC used to have two such representatives) and as nurses we engage the community with position statements from Nursing Colleges and policy organisations.

In doing so we may educate a percentage of the population regarding the reality of modern healthcare and nurses place within it, but I believe that is the absolute minority. I feel that the vast majority of society only meet nurses when they find themselves in the unfortunate position of needing nursing care.

So should we go back to the old days of signing our (mostly female) young adults over to a regime of residential curfews, administration spies and vocation (read task focused) based training? Should we remove the rights of junior nurses to go “out” for social events (on own time) without the employers permission? Should we leave them without the ability to advocate for their patients, subservient to the requirements of the medical profession, with all the job satisfaction of knowing that if they keep going and achieve another poor pleb will come and relieve them of the burden of the bedpan?

Rather than answer in the manner in which I normally would (No! with references)…

Would we ever expect that surgeons give responsibility for their education back to barbers?

Would we ever expect that in order to save money, the health system sack all the anaesthetists in favour of good, strong sticks for patients to bite?

Would we ever expect that modern dentistry return to the “everything can be fixed with a good extraction” days of the past?

I could go on…(architects? airline pilots? rocket scientists?)

Society has changed. Nursing has changed. There is no real correlation between “what a doctor used to need to know and what a nurse needs to know now” but the body of knowledge involved in both professions does intersect and cover the same ground. One complements the other, not replaces it.

Nurses do and will likely always look after the patient as a person in an attempt to return that person to the best functional state they can achieve. That does involve feeding, and toileting, and bathing. These aren’t things that can always be passed off to another with vocational training. They are further opportunities to assess, to look closely, and they may be the only time available to do so. The fact that these things are not done is not always an indictment on the nurse but a comment on the current conditions in which we work: doing more with less.

The public perception that the nurse is more interested in completing the paperwork (computerised or not) couldn’t be further from the truth to the average nurse. Most could easily have gone for an administration job (without night shift) if that is what they wanted to do. The paperwork is devoted to justifying the hours costed for staffing the ward, and ultimately the costs spent by government in looking after the patient.

Part of my thinking in working in my chosen specialities was the potential for the nurse practitioner role in anaesthetics: the nurse anaesthetist. As alluded to by the Grattan Institute’s report and the ABC article, the role does exist in several countries. One of the prime impediments to adopting such a role in Australia is one of culture.

In the US, nurses have administered anaesthetics (or anesthetics, in American) since the earliest surgeries. Medicine only took responsibility for sedation relatively recently, in the 1960’s or thereabouts (with few exceptions, the people administering drugs to patients during surgery in M*A*S*H* were nurses).

In Australia we followed the English model. Thus doctors have always had responsibility of anaesthesia, and even the anaesthetic nurse role is defined by hospital policy rather than codified by any particular legislation (ANZCA, the College of Anaesthetists recommend that a staff person be provided by the hospital to assist the anaesthetist as required, they shall not be answerable to the surgeon, and shall have 18months ‘suitable’ educational preparation).

In practice, this means that the anaesthetic assistant is a former wardsperson, or some one off the street, or any other background deemed to have satisfied the 18 month rule (no specification is made of what the 18 months should include). Or if you are lucky, the hospital has a preference for Registered Nurses, with their Bachelor of Nursing (3 years) and a Graduate Certificate in Anaesthetic Nursing (1 year). This still isn’t an “I’m better than you are” argument: I can train an anaesthetic nurse in a shift and a half (that was all I recieved at the time) but it’ll take about two years before you really know what you’re doing.

After all that, I could keep someone asleep during surgery whilst the Anaesthetist went to the toilet, I could anticipate, I could intubate and assess, I was handy in an emergency, understood and could administerl all the medications, all the things you would want in an assistant. Once I came to ICU I learned a lot more, all relevant. I have all the experience I need to apply to a US-style program (they call them Certified Registered Nurse Anaesthetists, or CRNA’s).

The US model requires the equivalent of a Masters degree preparation, AFTER the background and preparation and education I currently have. I could do that. But I won’t. Even if we followed the Grattan Institute’s ideas and adopted the system here.

The CRNA model requires supervision. It has been a part of the system since the beginning and the nurses undertake ALL anaesthetics during ALL the procedures a hospital offers. All of them. Patients aren’t always given the choice, and the literature shows there is not a difference in the care from a nurse as from a doctor.

We simply do not have that culture in Australia. Nursing has an image problem (as demonstrated by the comments above indicating a lack of understanding with the staus quo) and the public likely won’t accept nurses in the role (imagine the outcry!!!)

As a child of cost cutting measures, the CRNA model in Australia would be a hard pill to swallow. There are not enough training positions for the doctors, never mind the CRNA’s requiring supervision. It is easy to foresee a potential future where should the adoption of CRNA’s be successful (against all odds) the newly minted CRNA’s are required to fill the backlog of vacancies in rural centres…

Aargh

As a nurse, my interest is in the patient as a person. Not in cost cutting for Government. That’s what the Grattan Institute is for.