Throughout the world, nurses make a difference. In fact, over the years, nurses have been integral to the process of providing quality health care by putting the patient or client “front and centre”.
In 2021, the world will not forget how essential nurses have been and will be in the future.
The Healthovation team presents an exclusive interview with
Dr Leone Hinton, Past Professor and Dean of the School of Nursing, Midwifery and Social Sciences at CQ University, Australia. Having devoted the best years of her nursing life to the health care needs of those in regional, rural and remote Australia, Dr Hinton speaks her heart out on the future of nursing, especially against the milieu of the COVID pandemic when nurses stepped up to the challenges and put themselves on the front-line.
Imagine a farmer having a serious tractor accident. He is trapped lying underneath the tractor and now needs surgery. He lives in a rural area of Queensland growing fruit in a sub-tropical area. A nurse may help transport the injured farmer.
A nurse will assess and triage his condition on arrival to the Accident and Emergency department at the hospital. And a nurse will assist to prepare him for surgery. This farmer is to have his leg amputated. He will wake up in intensive care and will be lying next to a young man who has also had an amputated leg from a motor bike accident. It will be nurses who comfort these two men and provide the minute-to-minute, 24-hours intensive care. And, of course, it will be nurses who provide personal care, administer medication and manage the life support systems that will stabilise the condition of both patients.
Looking into the future, it should be nurses who first see the patient, even in their homes, just like nurses who triage in accident and emergency departments. This does happen in rural and remote areas in Australia and we know that rural clinics are set up in many countries by nurses.
This mostly happens because doctors are unavailable, but ideally this should be the norm where we all benefit from a new community position of nurses triaging health care, referring to the doctor, rather than assisting the doctor.
Dr Hinton has seen this in action and she feels that if nurses have risen to the occasion, demonstrating the ability to act as frontline health professionals, why not make this the future? Dr Leone Hinton is among those nurses who continue to quietly contribute to nursing as well as the health and well-being of others. During her career,
Dr Hinton has seen many changes in the education of nurses and in clinical nursing practice. As a Board member of not just one, but two hospital boards currently, she remains focused on the nursing workforce as her contribution to the community.
Her passion is regional and rural health services. Having lived in regional Queensland her whole life, Dr Hinton understands the challenges that health services and nurses have had to face in their attempts to provide quality and safe health care.
Dr Hinton often advocates for regional Australia to politicians who, like many city dwellers, may not appreciate the geographical, economic and social challenges people living in rural areas face.
Tell us about one of the biggest challenges in nursing that made a significant contribution to the health and well-being of people.
Dr Hinton: “During my career span, there have been many contributions to nursing. When I, myself, was a junior nurse, one such contribution that impacted health care the most was evidence-based practice, particularly research into the practice of nursing. Nurses themselves have done this and set up standards/guidelines of practice. In turn, the knowledge built by nurses have informed other kinds of practices of health professionals, which in turn, further improved the health of the patient or client.
Evidence-based practice is a big one. Nurses have been clever to do this for themselves. Nurses have also developed ways to partner with the patient or client to improve their health care. Nurses naturally put the patient in the “centre of attention”. In fact, it was nurses who first raised the importance of “Person-centred Care or Patient-centred Care” and that has been the real strength of nurses for a long time. They start with the patient at the centre and work back from there, always thinking ‘how can we make it better for this person’. This has improved care for individuals and led to policy changes, such as standards of care and guidelines. The changes you see in the Australian Quality and Safety Framework changing standards in all professional groups will help you understand that while patients are in our care, they do have a right to safe and quality health care.”
Dr Barr: “I know what you mean. I was once approached by an osteopath who was an academic at a university and wanted me to supervise her Ph.D. She wanted to study with me and learn about critical thinking and critical self-reflection to improve student learning about clinical practice. Nurses had been using those principles and teaching this for 20 years or more. Such a simple thing and yet nationally the profession of osteopathy was not using those principles at the time. It started with one curious academic and now it is a part of student learning and used in practice by graduate osteopaths across Australia. Nurses often do start such developments and yes, you are right, other health disciplines translate nursing evidence into their practice and education.”
What are the major issues that nurses are facing globally, considering the Covid-19 pandemic?
Dr Hinton: “Nurses looking after themselves, of course. It is a concern, as one in eight health professionals are infected by Covid-19. At this point of time, health professionals, particularly nurses, are at risk. In fact, nurses should remind themselves of the marvelous job they have been doing; but this should not come at a cost. They need to look after themselves before they can look after others.
2020 was the International Year of the Nurse and the pandemic has shown that nurses know how to step up to the challenges. Nurses have been pretty much front and centre on the frontline, fighting this pandemic. This has created a global profile of nurses and people seem to be more aware of the value of nurses. In our local region, we called for help when we had a Covid-19 cluster. Nurses volunteered and mobilised with 40 nurses coming to our region. It is amazing that they are willing to put themselves at risk to care for the people. Nurses just get on with it and do what needs to be done. In my view, nurses are the real warriors against this pandemic.”
Dr Barr: “Yes, if we look at Australia, nurses make up to 60% of the health workforce. I appreciate that in intensive care, doctors are available more frequently too, but I do see your point. Remembering what the Prime Minister of the UK said after he survived COVID – that he was surrounded by 4 nurses who never left his side for more than a few minutes.”
Dr Hinton: “Another major difficulty that nurses are facing globally in this pandemic crisis, is the ethical issue. How do you deal ethically with the outcome of what the pandemic can do when there are large groups of infected people?”
Do share your personal experiences with Covid-19 that puts a human face to what is happening with the pandemic.
Dr Hinton: “I have a chronic respiratory condition. The Chief Medical Officer in Queensland had indicated that anyone with a chronic health issue should be tested for Covid-19. I went down to the health service early during the pandemic and this is how it went: you don’t come into the surgery; you don’t get out of the car until you ring them; they put you on a chair in the car park; then when I am told to, I walk in and I start coughing. There was a heavily pregnant woman waiting in the same room that I was. And the moment I coughed, the staff rushed over and “double masked” me. The pathologist took me into another room and put on more PPE (Personal Protective Equipment) over her first mask. When I came out of the health service centre, I felt like I was walking “the walk of shame” down the corridor, all because I had coughed.
I have a friend of mine in Hawaii. She has caught the Covid-19 and is on the tail end of her experience, journaling the experience all the way through. She wrote “I feel like I am breathing glass”, highlighting what she felt and how she was made to feel, especially when she was isolated from her family.
The Covid-19 is an unwilling sociological event. It has forced us as a human species to think differently about how we populate, gather and communicate with each other. On reflection, it begs questions like “how do countries use their experts; how do they use their resources and the government’s money; how do they mobilise or demobilise workforce; how do they instill fear and deal with basic human interactions such as grief, love of family, and of the community”. Look at what happened on social media with people reaching out to others and messaging “are you all right”, “stay safe”, “be well” and so on. It heralded the importance of others. Such conversations have not been held before on such a scale! The pandemic has “percolated” a sense of caring about others in the last eight months. The pandemic also begs bioethical questions such as: “what is the value of a human life? What is the price of lives? What about the right to health care and where that health care occurs” These are necessary conversations. People are speaking up and wanting quality of life as well as the right to health care, even for elderly persons. This is likely to improve the use of advanced care plans.”
How do you think the post-COVID health outcome is likely to increase due to the pandemic infection?
Dr Hinton: “Post-COVID, I do think it is worth saying that the centre of the earth is not the hospital! The centre of the earth is the person – the client, the patient. If health care is being provided for a person at home, that is great. If it is being provided in the community, that is great as well. I can see acuity getting more acute. From a nursing perspective we will be focusing on public health, “hospital in the home” and on the client, our patients.
There has been very little discussion about the post-COVID health outcome for people who have been infected. The significance of rehabilitation and the management of long-term chronic health conditions post-COVID will be an emerging area. This needs to be reflected in the nursing curriculum: Co-morbidities, post-COVID. I have read about precision medicine as well.
There are many things that make up “me”. So, when I am being dealt with as a patient, I would want everything to be managed. Not just my pathology. I personally want to be cared for as a “whole story, not just a partial story”, if you know what I mean.
In the future, if you do address one health issue with a patient it will affect another aspect of that individual. Mental health during Covid-19 is also massive. So, we also need to be mindful of what Covid-19 and the lock down means in terms of the isolation and the resulting mental health issues. I am hopeful that nurses will go back to the old-fashioned nursing care where they engaged with the patient in the latter’s safe environment: the patients’ homes where the family is also involved in care and recovery.”
Since you work on two hospital boards – one that is private and the other from government funding – one of which includes aged care as well, what differences do you observe that affect nurses under these different entities?
Dr Hinton: “During COVID, a good thing happened. The government signed an agreement with the private systems wherein private hospitals would receive the overflow for surgery as well as accident and emergency issues that would normally be managed at the public hospital. This is unheard of – the public and private systems working together. We had started to do this in our region but COVID has forced the government to do this in an official way across Queensland.
The public hospital is the COVID hospital while the private hospitals became the medical, surgical as well as accident and emergency hospitals for vehicle accidents and so on. People had to work together for the benefit of our community, resulting in a different hospital and health service model. All services have been forced by the pandemic situation to look at things differently and use a new version of working together. They have focused on the need for survival rather than turf wars of hospitals. This is a good thing.
From a personal perspective, I had a respiratory episode and had to go to the accident and emergency at the public hospital. I was surprised and disappointed at the nurses’ reduced scope of practice, which was “less” and minimized. It was not person-centred care and there was nothing more than the crisis health care. Yet, on another occasion when I went to the private hospital, I was surprised that it was nurse-led. The nurses created a patient-led care plan. I asked to be given my own usual medications and the nurses arranged it. I felt in control and the nurses worked with me to give me this personal control.”
You live in a regional area of Australia where the Boards govern the health services. What are the challenges that regional, rural and remote nurses face at these locations?
Dr Hinton: It’s a really good question. The main issues for nurses in these areas include not just access and equity of health care but also scope of practice for nurses.
In regional areas, nurses have an extended scope of practice so they are professionally developed to work with greater autonomy than those in metropolitan Australia. It is a double-edged sword though.
The autonomy is fabulous but when you live in the community, you may be the only professional there and you could be burnt out by trying to care for the entire community.
In Emerald (QLD) rural area, they have a super general practitioner (GP) clinic that is truly inter-disciplinary and transcends the usual professional boundaries. The clinic has a motivated group with different professional roles, who are respectful of each other. Their model of care puts the person in the centre and then brings in the health professionals to the person. Another similar model is the nurse navigators that use the same principles of putting the person first. It is an excellent holistic model that avoids the double, triple levels of referrals to services. The nurse navigator assesses the situation with the person and then starts to prepare care plans, creating referrals to the required type of health care and other services, including legal service. These registered nurses provide the consistent point of contact, case manage the person to satisfaction and monitor the whole process. So, it is not just about referring to different services to meet the person’s different needs. It is also about monitoring that person’s health and wellbeing. People using a nurse navigator have reported higher levels of satisfaction with this type of model, compared to the traditional health care model.”
Dr Barr: “This is a great idea. Would you like to see this expanded for the future of health needs?”
Dr Hinton: “Yes, nurses need to advocate to maintain such effective models in the future. Nurses need to take their leadership seriously and advocate for the persons in their care, seeing the consumer’s needs and putting him/her front and centre.”
What else makes nurses great providers of quality care?
Dr Hinton: “In my view, it all starts with the nursing curriculum. It starts with nurse educators in practice and at the university, where nurses realize what they need to know to provide appropriate care to their patients. We need to teach thinking principles so student nurses can realize the approach of moving forward and meeting contemporary needs when they are registered nurses. Sometimes you see educators fragmenting the curriculum and teaching topics, rather than how to practice for contemporary times. Practice is about specialisation these days and yet we need a generalist approach for the Bachelor of Nursing. The way of the future is how we plan to teach a generic course and yet prepare nurses for specialization.
I know a registered nurse who works in aged care and thinks about residential aged care as a way of life. She changed her title from Director of Nursing to Health and Wellness Manager. For her, aged care is not “doing it to” those residents but “with” the residents. She advocates that the quality of living instead of the quality of dying should be a natural way of life, and that these residents should not be cared for using a medical model but the new health and wellness model where we think about the resident and what they want every day out of life.”
Considering what you have just said, what do you think are the future roles and places nurses will be working in?
Dr Hinton: “I think in the future nurses will be managing community health care, where nurses will be the primary carer and doctors will be secondary. People would not be going to the doctor first. They will be reaching out to the nurse. I had this happen to me during the pandemic. A registered nurse came to my home when I was sick and assessed me first. It was not the doctor. The nurse suggested health strategies I could use and then recommended I go see the doctor. The initial health care was done right on the veranda of my home.
Nurses are well positioned to be leaders. There are many things nurses are more than capable of addressing and in these times when doctors are so busy, it begs the question: “why not let registered nurses be the first to assess (a version of ‘step downs’). However, the Australian government is not into ‘step downs’ but with the social distancing, the crowded hospitals, rising costs of hospital and busy doctors, it’s high time we do things differently.”
How do we educate our nursing students for the future?
Dr Hinton: “When we are planning new services or evaluating old services, I suggest we ask people themselves what they need in their health care, rather than assume what is needed. I feel we should move on from the medical model and care for people from the client or patient’s point of view. You know, like putting the person in the centre of attention, including in aged care. Why can’t someone living in aged care decide when they have a shower? Nurses do have the opportunity to lead the way. So, it is in this sector that nurses need to lead the way and change from a medical model.
The future is technology. And it should be all over health care. Of course, we need to use it with caution. I don’t wish to see technology replacing the decision-making power of the nurse. I am not sure technology can have that human ability to observe a patient, understand their mood or wellbeing and ask the right questions.
Technology may tell us the number of beats per minute, but nurses can feel a pulse and know its strength or weakness. Technology can do a lot in a quality care model but not create the quality of the care. Nurses do that. So, I would suggest we use technology to augment the essence of the consumer care model, person-centred care and retain the person at the centre. Use technology in an intelligent way because technology cannot replace the service provided by nurses. It is a tool and we should be conscious it is just that, and not the centre of the information – the patient.
Our history of growing person-centred care needs to be protected in this growing specialisation of nurses. Nursing in the future will become even more specialised but in that new terrain, we cannot lose the person-centred care. In the past nurses used touch. Who uses touch these days? High-tech, low touch seems to be growing and in the future nurses need to make sure that this humanness is not lost. Nurses need to listen to those living the experience. I still want to be touched as a patient, even if it is a hand in a glove. In the future, what we should teach nurses and how nurses should practice, needs to have a united approach where we are willing to change curriculum away from the traditional mode.
I think in the future we need to make sure that nurses do not forget the entire person. You can’t “cookie cut care”. So, nurses can work with, rather than work on patients.
Curriculum in the future needs to include the importance of nurses learning how to self-care as well. Many students take up nursing as they have had a life experience and would want to care for others.
But if they do not self-care then they cannot appropriately care for others. Nursing looking after nurses, including themselves. That is how you keep them on the frontline, right where they do best.