transitions in nursing...accessible, reality-based and practical. more importantly, it is a resource...

ESTHER CHANG & JOHN DALY

G ALY

Preparing for professional practice

FIFTH EDITION

Transitionsin Nursing

Activate your eBook + evolve resources atevolve.elsevier.com

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Transitions in Nursing

Preparing for professional practice

FIFTH EDITION

EDITED BY

Professor Esther Chang RN, CM, DNE, BAppSc(AdvNur), MEdAdmin, PhD, FACN

Professor of Nursing, Professor of Aged and Palliative Care School of Nursing and Midwifery

Western Sydney University, Sydney, NSW, Australia

Professor John Daly RN, PhD, FACN, FAAN Emeritus Professor, University of

Technology Sydney, Sydney, NSW, AustraliaEmeritus Professor, Western Sydney University, Sydney, NSW, Australia

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CONTENTS

Preface viiContributors ixReviewers xiii

SECTION 1: FROM STUDENT TO GRADUATE

1 Managing the transition from student to graduate nurse 3Esther Chang and John Daly

2 Becoming a competent, confi dent, professional registered nurse 17Jill White

3 Becoming part of a team 29Tracy Levett-Jones, Lorinda Palmer and Amanda Wilson

4 Understanding organisational culture in the community health setting 45Deborah Hatcher and Kathleen Dixon

5 Understanding organisational culture in the hospital setting 59Gary E. Day

6 Preparing for role transition 77Jan Sayers

7 Processes of change in bureaucratic environments 93Michel Edenborough and Esther Chang

SECTION 2: SKILLS FOR DEALING WITH THE WORLD OF WORK

8 Caring for self: the role of collaboration, healthy lifestyle and balance 113Judy Lumby

9 Managing approaches to nursing care delivery 129Bronwyn Everett and Patricia M. Davidson

10 Dealing with ethical issues in nursing practice 147Megan-Jane Johnstone and Elizabeth Crock

11 Communication for eff ective nursing 161Jane Stein-Parbury

12 Evidence-based practice/knowledge translation: a practical guide 177Rick Wiechula, Tiff any Conroy and Paul McLiesh

13 Perspectives on quality in nursing 195Cathy Jones

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14 Managing emotional reactions in patients, families and colleagues 213Christine Ashley and Paul Morrison

15 Clinical leadership 227Caleb Ferguson, Phillip J. Newton and Joanne Edwards

SECTION 3: ORGANISATIONAL ENVIRONMENTS

16 Excellence in practice: technology and the registered nurse 239Caleb Ferguson

17 Establishing and maintaining a professional identity: portfolios and career progression 259Susan Alexander and Lyn Stewart

18 Refl ective practice for the graduate 279Kim Usher, Carey Mather and Zac Byfi eld

19 Mentoring for new graduates 295Stephen Neville and Denise Wilson

20 Professional career development: development of the CAPABLE nursing professional 311Jane Conway and Margaret McMillan

21 Transition into practice: the regulatory framework for nursing 331Amanda Adrian and Mary Chiarella

22 Understanding primary healthcare 351Jane L. Phillips, Louise D. Hickman and Priyanka Bhattarai

Index 365

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PREFACE

Hooray – welcome to the fi fth edition of Transitions in Nursing: Preparing for professional practice . This book has been developed to assist undergraduate students, new registered nurses and other professionals interested in issues and challenges associated with the transition from higher education to practice in various health environments. For the majority of new graduates, this rite of passage is associated with a degree of stress, strain and culture shock. These are issues that have existed in nursing for decades. The literature shows that this transition is a multidimensional and complex process. Intensive socialisation brings to the surface many challenges and opportunities for new registered nurses as they assimilate into their professional work roles. Research through the years has shed much light on the issues associated with transition and has uncovered knowledge, including strategies that can be useful in negotiating the process.

The book has been designed and written to provide comprehensive information on key issues associated with transition. You will fi nd viewpoints that are challenging and sometimes disconcerting, but at the same time motivating and thought-provoking. The fi fth edition is divided into three sections. Section 1 examines issues from student to graduate nurse. Section 2 looks at skills for dealing with the world of work. Section 3 discusses the organisational environments that we work in. This edition also includes new contributors and a new chapter, ‘Understanding primary healthcare’, an important framework for our healthcare system.

Understanding the context in which we work is crucial to effective functioning in the workplace. Knowing how to provide care for patients and their families in the health system is not suffi cient: we need to learn how to care for ourselves in order to care for our patients effectively. Understanding the regulatory framework for nursing will help us to be safe registered nurses. Do not forget your professional career development – establishing and maintaining a professional identity in your portfolios and career progression. This book shows you how to be a successful graduate and at the same time how to care for yourself. The exercises and learning activities that appear throughout the book offer you a range of helpful suggestions in understanding the nursing context, managing stress and caring for yourselves. In addition, each chapter includes recommended readings, case studies and refl ective questions for further exploration. For this new edition, there is also access to additional case studies on Evolve.

Our intention was to involve clinicians and academics in producing a resource that is scholarly, accessible, reality-based and practical. More importantly, it is a resource for every student, practising nurse, educator and administrator in understanding the issues of transition for new registered nurses. By reading the book, refl ecting on the issues and posing possible answers, you should be able to gain a comprehensive view of the issues, challenges and opportunities that lie ahead for you. The journey during this period can be rewarding, with implications for a long-term career for you, particularly when educators, administrators and clinicians collaboratively anticipate and manage the socialisation process.

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We extend our most sincere appreciation to all the contributors to the book for their shared interest in and concern for the issues and challenges of transitioning from student to registered nurse. This book would not be possible without them. They have stood by us for almost 20 years. We would like to extend our special appreciation to Natalie Hunt, Rochelle Deighton, Elizabeth Ryan, Fariha Nadeem and the rest of the team at Elsevier for their encouragement and support. Elsevier Australia joins us in thanking the reviewers for their feedback on the manuscript. This book is dedicated to all our amazing and awesome students through the years. Most importantly, we would also like to dedicate this book to our partners, Ron and Neil, for their enduring support through the years.

Esther Chang and John Daly

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CONTRIBUTORS

Amanda Adrian RN, BA, LLB, FACN Non-Executive Director , Healthcare Australia Pty Ltd. , Sydney , NSW , Australia

Susan Alexander RN, BN(Hons), GradCertTertEd, GradDipCounsel, GradDipPallCare, PhD Lecturer , School of Nursing and Midwifery, Edith Cowan University , Joondalup , WA , Australia

Christine Ashley RN, RM, BHlthSc, GradCert Ethics and Legal Studies , DipPM, MN, PhD, FACN Independent Consultant , Christine Ashley Consulting , Canberra , ACT , Australia

Priyanka Bhattarai BN(Hons) Research Assistant , The University of Notre Dame , Fremantle , WA , Australia

Zac Byfi eld BN, BPhil, GradDipNurs(Paediatrics), MN(Clinical Education), MPhil(Health) Lecturer in Nursing , Faculty of Health and Medicine, University of New England , Armidale , NSW , Australia

Esther Chang RN, CM, DNE, BAppSc(AdvNur), MEdAdmin, PhD, FACN Professor of Nursing, Professor of Aged and Palliative Care , School of Nursing and Midwifery, Western Sydney University , Sydney , NSW , Australia

Mary Chiarella AM, RN, RM, LLB(Hons), PhD, FACN, FRSM Professor of Nursing , Susan Wakil School of Nursing and Midwifery, The University of Sydney , Sydney , NSW , Australia

Tiffany Conroy RN, BN, MNSc, GradCertUnivTeach&Learn, PhD, FACN Senior Research Fellow , College of Nursing and Health Sciences, Flinders University , Adelaide , SA , Australia Deputy Director , The Centre for Evidence-based Practice, South Australia (CEPSA): A Joanna Briggs Institute Centre of Excellence , Adelaide , SA , Australia

Jane Conway RN, BN(Hons), GradCert HRM, DEd Associate Dean , Teaching and Learning, Faculty of Medicine and Health; Discipline Lead, Nursing, School of Health, University of New England , Armidale , NSW , Australia

Elizabeth Crock RN, ACRN, BSc, GradDip Ed, MPH, PhD, HIV Nurse Practitioner Clinical Nurse Consultant HIV , Bolton Clarke HIV Program/Homeless Person ’ s Program , West Melbourne , Vic. , Australia

John Daly RN, PhD, FACN, FAAN Emeritus Professor , University of Technology Sydney , Sydney , NSW , Australia Emeritus Professor , Western Sydney University , Sydney , NSW , Australia

Patricia Mary Davidson RN, MEd, PhD, FAAN Dean , School of Nursing, Johns Hopkins School of Nursing , Baltimore , Maryland , USA Professor , Cardiovascular and Chronic Care, University of Technology Sydney , Sydney , NSW , Australia

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Gary E. Day RN, DipAppSc(Nursing Mgt), BN, MHM, DHSM, EM Director , Education, Training and Research, Sheikh Khalifa Medical City, Ajman , Abu Dhabi , UAE Adjunct Professor – Health Services Management , Griffi th University School of Medicine , Southport , QLD , Australia

Kathleen Dixon RN, BA, C&FH Cert, MHA, PhD Director Workforce , School of Nursing and Midwifery, Western Sydney University , Sydney , NSW , Australia

Michel Edenborough BSSc(Hons), BA, DipMgmt Frontline Mgmt, PhD Lecturer , Social Work and Community Welfare, School of Social Science and Psychology, Western Sydney University , Sydney , NSW , Australia

Joanne Edwards RN, MN, GAICD Adjunct Associate Professor , School of Nursing, Western Sydney University , Sydney , NSW , Australia Adjunct Associate Professor , Sydney Nursing School, University of Sydney , Sydney , NSW , Australia

Bronwyn Lee Everett RN, BAppSc, MSc(Hons), PhD, MACN Associate Professor , School of Nursing and Midwifery, Western Sydney University , Sydney , NSW , Australia

Caleb Ferguson RN, BSc(Nursing), MHlth(Leadership), PhD Senior Research Fellow , Western Sydney Nursing & Midwifery Research Centre , Western Sydney University and Western Sydney Local Health District , Penrith , NSW , Australia

Deborah Hatcher RN, MHPEd, BHlthSc(N), DipTeach(PhysEd), PhD Dean , School of Nursing and Midwifery, Western Sydney University , Sydney , NSW , Australia

Louise Hickman RN, MPH, PhD Director of Studies , Palliative Care Programs IMPACCT, Faculty of Health, University of Technology Sydney , Sydney , NSW , Australia

Megan-Jane Johnstone RN, BA, PhD Adjunct Member , Alfred Deakin Institute for Citizenship and Globalisation, Deakin University , Melbourne , Vic. , Australia Retired Professor of Nursing , Deakin University , Melbourne, Vic., Australia

Cathy Jones BAppSc(Hons), MBA National Manager , Healthscope Ltd , Melbourne , Vic. , Australia Lecturer , MBA Faculty , Business School of Finance and Management , Frankfurt , Germany

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Tracy Levett-Jones RN, MEd & Work, PhD Professor of Nursing Education , Faculty of Health, University of Technology Sydney , Sydney , NSW , Australia

Judy Lumby AM, RN, BA, MHPEd, PhD, FACN Emeritus Professor , University of Technology Sydney , Sydney , NSW , Australia Honorary Professor , University of Sydney , Sydney , NSW , Australia Honorary Professor , University of Adelaide , Adelaide , SA , Australia

Carey Mather RN, BSc, GCert ULT, GCert(Creative Media Technology), GCert(Research), PGrad Dip(Health Promotion), MPH, PhD, FHEA, MRCNA Senior Lecturer and Course Coordinator, Honours (Research) , School of Nursing, College of Health and Medicine, University of Tasmania , Launceston , Tas. , Australia

Paul McLiesh BN, GDip Orth, MNSc Lecturer , Adelaide Nursing School, University of Adelaide , Adelaide , SA , Australia

Margaret McMillan PhD OAM Conjoint Professor , School of Nursing and Midwifery, University of Newcastle , Callaghan , NSW , Australia

Paul Morrison RMN, RN, BA, PGCE, GradDip(Counselling), AFBPsS, CPsychol, MAPS, PhD Professor , College of Science, Health, Engineering and Education (SHEE), Murdoch University , Mandurah , WA , Australia

Stephen Neville RN, PhD, FCNA(NZ) Professor and Head of Nursing , Auckland University of Technology , Auckland , New Zealand

Phillip Newton RN, PhD, FESC, FAHA, FCSANZ Professor , School of Nursing and Midwifery, Western Sydney University , Sydney , NSW , Australia

Lorinda Palmer BSc, Dip Ed, GradDipAppSci(Nursing), MN Lecturer , School of Nursing and Midwifery, Faculty of Health and Medicine, University of Newcastle , Callaghan , NSW , Australia

Jane Phillips RN, PhD, FACN Professor Palliative Nursing, Director IMPACCT , IMPACCT – Improving Palliative, Aged and Chronic Care through Clinical Research and Translation , Faculty of Health, University of Technology Sydney , Sydney , NSW , Australia

Jan Sayers PhD Former Director of Learning & Teaching, Deputy Director of Research and Lecturer, School of Nursing and Midwifery , Western Sydney University , Sydney , NSW , Australia

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CONTRIBUTORS

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Jane Stein-Parbury RN, BSN, MEd, PhD Emeritus Professor , Faculty of Health, University of Technology Sydney , Sydney , NSW , Australia

Lyn Stewart RN, BHScN, MEd(Adult Ed), Cert IV TESOL Adjunct Fellow , School of Nursing and Midwifery, Western Sydney University , Sydney , NSW , Australia

Kim Usher AM, RN, PhD Professor of Nursing , School of Health, University of New England , Armidale , NSW , Australia

Jill White AM, RN, RM, MEd, PhD, MHPol Professor Emerita , Susan Wakil School of Nursing and Midwifery, University of Sydney , Sydney , NSW , Australia Professor Emerita , Faculty of Health, University of Technology Sydney , Sydney , NSW , Australia Western Pacifi c Member , Nursing Now Campaign Board

Richard Wiechula BA, BN, OrthCert, MNSc, DNurs Director , Centre for Evidence-based Practice South Australia: A Joanna Briggs Institute Centre of Excellence , Adelaide , SA , Australia Senior Lecturer , Adelaide Nursing School, Faculty of Health and Medical Sciences, University of Adelaide , Adelaide , SA , Australia

Amanda Wilson RN, BA(Hons), MCA, PhD Deputy Head of School , Education, School of Nursing and Midwifery, Faculty of Health and Medicine, University of Newcastle , Callaghan , NSW , Australia

Denise Wilson RN, BA(SocSc), MA(Hons), PhD, FCNA(NZ) Professor M a - ori Health , Taupua Waiora Centre for M a - ori Health Research, Auckland University of Technology , Auckland , New Zealand

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REVIEWERS

Melissa Arnold-Chamney RN, MN(Nephrology) Year 3 Lead Bachelor of Nursing Program; Education Specialist – Adelaide Education Academy University of Adelaide , Adelaide , SA , Australia Editor in Chief , Renal Society of Australasia Journal

Melanie Bather RN, BN, MN(Clinical Teaching), GradCert Advanced Nursing Cert IV Training & Assessment, Authorised Nurse Immuniser Nurse Educator , St Vincent ’ s Health Network , Sydney , NSW , Australia

Karen Clark-Burg RN, GBQ, EMBA, PhD, MACN Dean , School of Nursing and Midwifery, The University of Notre Dame , Fremantle , WA , Australia

Justine Connor RN, BN, MPhil Assistant Head of Course BN, Academic Lecturer , Central Queensland University , North Rockhampton , QLD , Australia

Aunty Kerrie Doyle RN, BA(Psychology) (Hons) , M. Healthcare Leadership , MSc, MIndigHlth, GradCertIndigMneHlth & SocEmotWellbeing, GradDipAppSci, GradCert(Indigenous Research & Leadership), PhD Professor of Indigenous Health , School of Medicine, Western Sydney University , Sydney , NSW , Australia

Jayne Hartwig RN, BN, GradDip Nurs Ed, GradCert Health(Paeds) Nurse Educator , Transition Support Nursing & Midwifery, Women ’ s and Children ’ s Hospital , North Adelaide , SA , Australia

Bernie Kushner RN, BScN, MPhil(Nursing) Lecturer , Clinical Liaison, School of Nursing, College of Health, Massey University , Auckland , New Zealand

Rebekkah Middleton RN, BN, MN(Res), GradCert Emergency Nursing, GradCert Clinical Management, PhD Senior Lecturer, BN Academic Program Director L&T Scholar , School of Nursing, University of Wollongong , Wollongong , NSW , Australia

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INTRODUCTION

Transitioning to the graduate role is both exciting and challenging. It ’ s exciting because you fi nally embark on your professional career, and it ’ s challenging because of your expectations of yourself within the high-paced demands of the healthcare environment. You may experience a mix of feelings and emotions – from exhilaration and satisfaction to self-doubt and inadequacy – as you endeavour to meet the requirements of your new role and the expectations of other nurses and members of the interdisciplinary team. 1 As described in Chapter 2 , the fi rst step in your career trajectory is that of a novice. 2 The gradual and continual development of self-confi dence and skill acquisition will enable you to move from the novice role through the various stages of advanced beginner, competent, profi cient, and ultimately, an expert nurse. 2 As you move through these stages, your role and responsibilities in delivering person-centred care will change together with your role within the healthcare team. Each team member, be they a nurse, doctor or physiotherapist, assumes a specifi c role providing person-centred care. An understanding of these roles is fundamental to ensuring eff ective communication between team

LEARNING OBJECTIVES

When you have completed this chapter, you will be able to:

▲ understand the infl uence of social processes on role acquisition and performance ▲ demonstrate an awareness of factors infl uencing role stress ▲ appreciate the importance of positive role models and a positive self-concept for successful

transition ▲ utilise resilience strategies to support role stress and successful role transition ▲ know the standards required for practice as a registered nurse.

CHAPTER 6 �

Preparing for role transition Jan Sayers

KEYWORDS: transition , role acquisition , work relationships , role stress , coping

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78 Transitions in Nursing: preparing for professional practice

members and may enable you to better understand why people behave the way they do in certain situations. Role theory is a useful theoretical perspective from which to consider the novice role. In this chapter, we will explore the following aspects of role theory in relation to transition:

■ roles and society ■ role acquisition ■ role stress – incongruity, confl ict, ambiguity ■ establishing and nurturing role relationships and a positive self-concept.

Transition from student to graduate is a challenging process that you will fi nd both exciting and rewarding. In your new graduate role, you will fi nd yourself in situations where both your personal and professional values may require some adjustment to meet workplace expectations and demands. 1–3 During this period, you will experience rapid growth as a person and as a professional, and as a result of this process you are likely to experience emotional highs and lows. It is likely that you will feel some anxiety and apprehension about how well you will function in your new role and whether or not you will meet the expectations of your patients, other nurses and members of the healthcare team, and your workplace. 4 No amount of prior learning or experience can completely prepare you for role transition, but thoughtful preparation can help to ease the stress and strain. 3,4 In this chapter, we focus on furthering your understanding of the graduate role and how you can prepare yourself to meet the expectations of that role during transition by utilising role theory as the underlying perspective.

ROLES IN SOCIETY

Roles are assigned to individuals and groups in society as they describe predictable and patterned behaviour. In other words, each recognisable role has certain behaviours associated with it. Roles and their assigned behaviours enable us to have a clearer understanding of what to expect from others. Each member of society may hold a myriad of roles at any one time; our immediate role may change from one situation to the next; and we can play numerous roles across the course of our life. 5 Our self-perceptions are highly dependent on the roles we assume and how the people we interact with value these. Learning to conform to role expectations starts when we are very young because most people seek the approval and acceptance of others; the approval of others is a strong motivation to conform throughout our lives. The feeling of not fi tting in can be uncomfortable and infl uence us to adapt our behaviour very quickly to be accepted by the group to which we wish to belong. 5 Resisting the pressure to conform can be diffi cult; however, in some situations, if the behaviour change required by the group is so great that we feel our behaviour is no longer acceptable to ourselves, or if it requires more effort to maintain our behaviour than we are willing or able to give, this can prove to be just as uncomfortable. 6 Such feelings may lead to role relinquishment and group abandonment. 6

One way of looking at your behaviour is to see yourself as an actor playing a part and following scripts that direct your performance. The fi rst notions that led to the development of role theory were generated in this way. 7 Our role scripts contain the rules about how others in society expect us to behave. Many of our roles come to us

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79CHAPTER 6 Preparing for role transition

because of our abilities and education, and these are more likely to be formal, as they have an identifying role name and are tightly controlled – that is, they are more tightly scripted by society. The registered nurse role is a good example, as the practice of registered nurses is regulated and subject to codes of conduct, ethics and standards. 8–11 All professional groups experience this type of role governance; however, there remain many aspects of a professional role, no matter how formal, that are not always clearly scripted or accessible. These aspects can depend on the situation or the context in which they occur. Expectations of the graduate role, for example, differ according to whether the graduate is working in a hospital ward or in the community. 4,7 Even experienced graduates will talk about the challenge of meeting set expectations when moving from one specialty area to another. Most graduates will never fully understand their professional role until they are experiencing or acting their part. Furthermore, script expectations may not become clear to an actor until the person transgresses the role boundaries or does not fully address what is expected by interdependent others. When expectations are not met, fellow actors exert pressure to control an actor ’ s behaviour to bring it into line with expectations. Resisting the pressure to conform takes a good deal of effort and resolve on the part of an actor/nurse. 12

A word of advice: even though acceptance by nursing colleagues will be crucial to your professional development and comfort in the clinical setting, it should not come at the cost of losing your personal values or those you developed at university. 3 Furthermore, the responsibility to make role expectations ‘right’ is not a task for the new graduate alone. The tertiary sector and industry are also responsible and need to work towards removing the incongruity between sector expectations that can make beginning practice for the new graduate more stressful than necessary. 6

Learning, the role of the registered nurse, like other formal roles in society, involves not only acquiring knowledge about the role and its dimensions, but also an awareness that there are aspects of the role that are only accessible through experience. Careful preparation is essential to a smooth transition, and of equal importance is the acceptance that your conception of the graduate role will be altered to some degree by exposure to the expectations of others in the workplace. 1–4

Primary and Secondary Role Acquisition

As mentioned above, role acquisition is a social process. Your decision to become a registered nurse has evolved over time and can be divided into primary, secondary and tertiary phases.

During the primary phase of socialisation you internalised values, beliefs and behaviours from signifi cant others that motivated you to become a student. 13 This motivation is in part related to an internalised set of expectations about your professional role, expectations that have probably been altered in many ways by your education. Exercise 6.1 will allow you to compare your earlier expectations of your professional role with the ones you hold now; it will be interesting to consider how your perceptions have changed over time.

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Secondary socialisation has to do with acquiring knowledge, skills and dispositions such as those you have learnt during your university program. 13 This process has shaped your present image of the graduate role, and this is probably evident from your refl ection in Exercise 6.1 . It is during this phase that your professional values and standards are formed and integrated with a developing understanding of your profession ’ s scope of practice and variety of service. Despite an almost completed undergraduate education, you may still feel somewhat unclear about what the graduate role fully encompasses. A good place to begin to increase your understanding is by reviewing the various codes and standards that apply to practice as a registered nurse. 8–11

An understanding of the codes and standards that apply to the professional behaviour of registered staff is essential for students who are preparing for transition. Australian undergraduate nursing programs aim to address the standards developed by the Australian Nursing and Midwifery Council (ANMC) within its curricula, and this then forms the basis for curriculum approval by the registering authority. The competency standards identify the requisite knowledge, skills and behaviours required for both the enrolled and graduate nurse. 11 Universities and health facilities use these standards for assessing the clinical competence of students, enrolled nurses and new graduates. 11 The ANMC has also developed codes of professional 8 and ethical 9 conduct for nurses in Australia. Similar codes and standards developed by the Nursing Council of New Zealand (NCNZ) 10 apply to nurses in New Zealand.

Importantly, enrolled nurses who upgrade their qualifi cations to become registered nurses need to understand that there are higher expectations of professional behaviour in the new role. As is often the case when you have been successfully working in an associated role, elements such as a sense of responsibility and accountability can be underestimated or discounted with regard to the new and more responsible role and may result in increased stress. 3 For graduating students who entered their Bachelor of Nursing with enrolled nurse qualifi cations, it may be benefi cial to discuss with registered nurses from similar educational backgrounds the challenging aspects of their transition to the workforce. This process allows graduates to ‘reframe their practice’ within the realities of the work setting. 14 Simulated learning experiences may also serve to provide a feeling of the responsibility and accountability associated with the new role that is not achievable through clinical practicum in the student role. 14

EXERCISE 6.1 � Changing Images of the Nursing Role

1. If you had been asked on your fi rst day of university to draw an image of a nurse, what would you have drawn? How would they have looked? What would they have been doing? In what role situation would you have depicted them?

2. What aspects of the above picture would you like to change? What parts do you feel should stay the same? Consider the ways in which your image of your profession and roles has changed over the course of your studies.

3. Discuss these fi ndings with your study group.

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As a graduate, you will encounter a variety of other nursing roles within your immediate team in the workplace. These may include the assistant in nursing (AIN), enrolled nurse (EN), clinical educator (CNE), clinical nurse consultant (CNC), nurse practitioner (NP) and nursing unit manager (NUM). Staff assuming these roles will have attained varying levels of education and have differing knowledge and skill sets. Additionally, they are required to work within varying scopes of practice identifi ed in their role descriptions and competencies. As a new graduate, an understanding of the assistant in nursing and enrolled nurse roles is important as you will gradually fi nd yourself being responsible for supervising these staff in clinical practice.

Exercise 6.2 suggests that you review the ANMC competency standards for the registered nurse and compare these with those that guide the practice of the enrolled nurse. This activity will provide you with a clearer understanding of the competencies of a group of health workers that you will often supervise in practice and to whom you will delegate responsibilities.

EXERCISE 6.2 � Understanding Role Dimensions through Competency Standards

1. Review the competency standards for registered nurses and enrolled nurses. 2. Identify how the standards diff er between these two levels. 3. Discuss the implications of these diff erences for the registered nurse role.

While Exercise 6.2 will broaden your understanding of the registered nurse role, your understanding will be greatly enhanced by exploring with a clinical nurse the application of these standards in practice. Exercise 6.3 explores how the national competency standards are expressed in the workplace.

EXERCISE 6.3 � Exploring How Competency Standards are Integrated in Clinical Practice

1. Interview a second- or third-year graduate. 2. Explore with the graduate the meaning of the relevant competency standards. 3. Ask the graduate how these competency standards are addressed in their present role. 4. Compare the responses of the graduates interviewed. 5. Discuss the factors that promote or hinder integration of the competency standards in

practice.

Tertiary Role Acquisition

Tertiary socialisation occurs when you enter specifi c work situations as an employee. 13 At this point, you will be required to demonstrate the expected behaviours associated

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with your professional role. It is often the case that the beliefs, values and behaviours developed through primary and secondary socialisation do not fi t easily or exactly into the institution where you have chosen to work. As role acquisition is a lifelong process, you have entered a new and important phase of learning that focuses on acquiring the values and norms relevant to the clinical context. Your professional identity is formed during this phase, and the values and attitudes learnt in other phases of socialisation may be changed or modifi ed.

Patients and members of the healthcare team will infl uence your behaviour during transition. Knowing who these role partners are, and their areas of responsibility and skill, is important for effective communication, team functioning and the delivery of person-centred care. Role partners are shown in Fig. 6.1 .

Each member of your team will be affected in some way by what you say or do, and will have attitudes and beliefs about what to expect from you in your new graduate role. Sometimes these attitudes and beliefs will differ from your own expectations of your role and you will experience role confl ict. Part of successful preparation for practice should include an exploration of the role of interdependent others in your prospective workplace. Exercise 6.4 assists you in identifying your team members and what their role responsibilities involve.

EXERCISE 6.4 � Identifying and Understanding Team Member Roles

1. Write a list of the diff erent roles you would expect to interact with as a registered nurse. 2. Draw a table identifying the roles and specifi c responsibilities. 3. How do you perceive these roles will interface with your role?

ROLE STRESS

It is almost impossible for graduates to avoid some level of role stress when you consider the complex socialisation processes involved in learning how to work competently as a graduate. 15 Furthermore, new graduates often report that they feel unprepared for the workload, shift work and managerial responsibilities associated with their role. 1,4,6,7,12 Many studies also indicate that graduates have diffi culty maintaining what they consider to be excellence in nursing care in the face of workload expectations, and that this can result in strong feelings of stress, inadequacy, guilt and disillusionment. 1,4,6,7,12

The responsibility for determining educational standards and clinical practice requirements for undergraduate nursing courses rests with the Nursing and Midwifery Board of Australia. While universities focus on educating students in relation to the competencies in their fullest sense, and embrace the theoretical and ideological aspects of nursing, the clinical sector continues to expect profi cient ‘hands-on’ practitioners upon graduation. 4,7,13 Students attending clinical practicum as part of their university study are allocated to a mainly supernumerary role where they have time to consider

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their theoretical knowledge and how this informs their clinical actions. However, as graduates, they still need time to adjust these values to the reality of the hospital workplace. This can result in role stress as they attempt to grapple with the level of profi ciency needed in the often resource- and staff-constrained clinical settings. 15,16,17 Moreover, this high expectation by clinicians in healthcare facilities for all graduates to be competent and accountable for clinical decision making can be even more stressful for those graduates who have an initial qualifi cation. 14 This discontinuity between sectors leads to a general lack of recognition of the graduate as a new clinician and a misunderstanding of the graduate ’ s educational preparation. 18 Pressure is often exerted by the healthcare team to control and regulate the behaviour of novices in line with the traditional norms set by the clinical sector.

It would be a great loss to our professions if frameworks for practice developed at university, such as critical thinking, refl ective practice, evidence-based practice and cultural safety, were abandoned by the graduate in order to ‘fi t in’ with a controlling

ALLIED HEALTH(Occupational

therapy,pharmacy,

physiotherapy,social work)

SUPPORT STAFF

NURSING STAFF

MEDICAL STAFF

Patient

(Cleaning, laundry,maintenance)

Figure 6.1 �

Role partners

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social environment. There is room to move on both sides; that is, for new graduate clinicians, clinical nurse educators and academics to work together to implement innovative programs and strategies to redress the discontinuity. An example of such a strategy can be the design of clinical practicums in the fi nal year of the degree, which provide students with experiences that mirror the reality of the hospital workplace they will encounter on graduation. 14 This can, for example, include the allocation of several patients of different dependency levels so that students can learn to plan and complete their caring practices competently within the expected timeframe. Clinical experiences such as this may offer the best opportunity for maintaining the theoretical frameworks for practice while still achieving the requirements of their professional role, especially if these students are also given adequate support and understanding during this practicum by staff while they learn to cope with the pressures and expectations of the workplace. Role stress can be reduced if tertiary programs endeavour to prepare graduates more realistically for transition, and the industry eases the process of transition for new graduates by respecting their achievements and supporting their beginning practice. 14–16,19,20

Types of Role Stress

Four types of role stress have been identifi ed – role incongruity, role confl ict, role ambiguity and role overload – and it would be unusual for new graduates not to experience some degree of strain on commencing work. 17 Role strain is the outward expression of stress that can be evident in your behaviour. 17 You may feel frustration, tension or anxiety in response to role stress, which may result in distancing, denial and avoidance. 17 These negative effects can eventually have an impact on your capacity to provide quality person-centred care and your relationships with others, and so it is important to try to identify and address these symptoms when they occur. 6,17

Role incongruity

This aspect of role stress is largely cognitive and is related to the dissonance in values or self-concept between the graduate and their workplace. 17 Case Study 6.1 illustrates role incongruity where the graduate ’ s personal skills or values about their role may not align with the requirements of the role as expected by the health facility. Role incongruity can be lessened in situations where the work environment and workplace culture encourage open communication and reciprocal exchanges between staff. 17 Your interpersonal skills, respect for others, a willingness to listen and self-refl ection are important considerations here.

CASE STUDY 6.1

During the fi rst few weeks of his new graduate program, Daniel developed a good rapport with the clinical nurse educator (CNE) on his ward and felt comfortable sharing his perceptions about how he was managing with her. He said he felt overwhelmed by the expectations of other team members about his capabilities. He was also concerned that he was unable to provide the

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standard of person-centred care he expected of himself given the time constraints on this busy ward. Although he felt comfortable with his level of knowledge, he struggled to apply his knowledge when he was feeling so stressed.

REFLECTIVE QUESTIONS

1. What could account for the diff erences in Daniel ’ s perceptions about his performance and those of the CNE?

2. What could Daniel do to better manage his expectations of himself? 3. What additional support could Daniel access at work to manage his stress?

Many nurses resolve their role incongruity by developing a pragmatic and multidimensional understanding of nursing values and their professional self-concept. When this occurs, the nurse is able to integrate the nursing values that incorporate holism and caring for the humanistic needs of the patient with their professional role, while maintaining loyalty to the institution, its work values, rules and regulations.

New graduates are also vulnerable to workplace incivility. 21 Examples of uncivil behaviour include a staff member dismissing your ideas or comments, belittling you or making demeaning remarks to you. This inappropriate behaviour can leave you feeling demoralised and may lead to feelings of not belonging or of anger. An effective strategy to manage change or adapt to diffi cult situations is to develop resilience. 18,21 Ensuring you stay connected with people you know and trust, and talking to them about the issues that concern you, is one way of developing resilience as this allows you to gain perspective about the situation and consider strategies that may be helpful for you. This also helps you to determine how important the issue is and the degree of infl uence you may have to change the situation. Another way that resilience is developed is by being patient with yourself as you adapt to your new workplace. If you can do this, then you are accepting that your experiences may be challenging, but with time and perseverance you may feel that you are accepted in your new role and workplace. Being positive rather than cynical and trying to view diffi cult situations as a challenge that you can ultimately overcome also help to build resilience. 18,21

Some graduates, however, are not able to move on and may decide to leave their profession or to capitulate their own values fully to the values of the institution and workplace culture. 19 It is up to each individual to refl ect on the continuing expectations of their role. Unless graduates are prepared to refl ect honestly on their practice, it is diffi cult to resist task-oriented and ritualised care based on the bureaucratic ideals of effi ciency and conformity.

Role confl ict

Role confl ict involves the recognition of the urge to act differently to your normal behaviour in response to different role pressures. 17 Compliance with role pressure from one source will make compliance with another diffi cult, and may affect both behaviour and feelings. This confl ict can occur within the new graduate or between two or more individuals who have different perceptions of how the role should be enacted. 17 One

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example of role confl ict encountered is when graduates feel pressured because of competing priorities. Confl icting situations can arise during times when the ward may have inadequate or less experienced staff. Case Study 6.2 demonstrates the confl ict a graduate can experience between work and personal role pressures.

CASE STUDY 6.2

Margaret ’ s elderly mother, Mary, who lives in a retirement village, had a fall during the night and broke her hip and arm. Mary was admitted to the emergency department at the hospital where Margaret worked. Mary was due for surgery the next morning. Margaret wanted to stay with her mother, as she was fearful she might not survive the anaesthetic. However, she was rostered on for the morning shift and knew that if she didn ’ t go to work the ward would be short-staff ed. She was also anxious that the nursing unit manager would not be supportive of her decision if she didn ’ t go to work.


1. What do you think you would do if you were in Margaret ’ s situation? 2. What would you say to your nursing unit manager if you were unable to work because of a

personal matter? 3. What workplace resources are available to staff when they are faced with the need to take

time off work or need support through an unforeseen personal situation?

If work role requirements are not completed at the set times expected during the shift, then role confl ict may develop between the graduate and any other interdependent role members. One way to avoid this type of role confl ict is to organise a plan at the beginning of the shift concerning which aspects of the work role need to be actioned within set periods of time. Staff will be more supportive if they see there is a determined effort to complete aspects of the role within an expected timeframe. Another example of role confl ict is where confl ict is caused by personal demands that have an impact on the work role.

Because of a general misunderstanding of the nursing role, particularly with regard to relatively recent changes in nurse education and career development, graduates often face this type of role confl ict. It is in the interest of the nursing discipline that these situations are negotiated in a way that promotes the status of nurses and enlightens the understanding of others.

Role ambiguity

Situations arise for new graduates where expectations by team members are not clearly expressed, leaving graduates feeling confused and uncertain of their role behaviour. 20 Expectations of the new graduate may be unstated and only found when refl ected in the values and behaviour of other staff. These expectations include the impressions that role partners have developed about the position of new staff members, and these may

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Role overload

This type of role stress occurs when graduates are unable to meet all of the expectations of their role. 20 Aspects of their work that new graduates often fi nd diffi cult include time management, adapting to shift work, lack of managerial abilities, and getting through the volume of work required in times when staff shortages are a common occurrence in the healthcare sector. 12,14 Case Study 6.3 presents an example of role overload that new nurses may experience in attempting to meet time management commitments on the ward.

CASE STUDY 6.3

Maryanne loved her fi rst ward in the graduate nurse program. She fi tted in well with other members of the team. She also felt knowledgeable and was very satisfi ed with her growing competence in providing person-centred care. Her second rotation was completely diff erent. Staff weren ’ t friendly, and she sometimes felt belittled in front of the patients. The clinical nurse educator noticed she had started to lose confi dence and was often teary. She took Maryanne aside to talk to her.


1. Have you ever felt like this? 2. What could you do to turn this situation around? 3. Who would you turn to for support?

Exercise 6.6 will encourage you to challenge your perceptions and expectations of your clinical role and can be utilised for continuing professional development.

EXERCISE 6.5 � Examining the Infl uence of Role Partners’ Expectations

1. Refl ect on a situation experienced during one of your clinical placements where you perceived your practice was inconsistent with what other staff expected.

2. Give a brief account of the situation. 3. In retrospect, what do you feel the expectations of your role partners were? 4. Were these expectations stated or unstated norms of the clinical setting? 5. Explore the eff ect of your role partners’ expectations on your nursing practice and self-

concept during this incident and since. 6. What did you learn from this experience?

be adapted for each new employee. Exercise 6.5 may be useful in determining the unstated role expectations that exist in your prospective workplace.

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To prepare yourself for this particular role stress, it may be helpful for you to experience a facilitated clinical block that includes exposure to shift work and managerial responsibilities similar to those undertaken by new graduates.

It is important that you recognise the symptoms associated with the four types of role stress and seek support to balance their negative effects. One important piece of advice is to fi nd out as much as possible about the institution you are joining, as this may assist in making your transition much smoother. Of particular note is whether or not the facility offers supportive initiatives such as orientation, supervision and preceptor programs.

If you recognise that you are feeling role strain, it is your responsibility to develop a number of personal coping strategies. These may include: seeking assistance from other staff, graduate peers and/or family and friends; activating your existing coping mechanisms; or simply having fun and maintaining activities outside the work role.

Maintenance of Role Relationships and Self-concept

Finding support from role models or peers and learning to manage your emotions and relationships more effectively during transition can make a signifi cant difference to your self-concept as a beginning graduate. Your self-concept is the way in which you see yourself: it is related to your emotional and social intelligence and is important because it infl uences your behaviour towards others. Your beginning professional self-concept, which is your sense of who you are as a professional upon graduation, has developed through your interaction with others, principally your lecturers, clinical facilitators, peer group and patients. Once these reactions are internalised, they become part of your image of yourself and set up your self-expectations. 15,17 In your beginning practice, you will attempt to meet these expectations.

Self-esteem is enhanced by positive feedback from others that supports and aligns with the expectations you hold for yourself in the role of a registered nurse. If you receive negative responses about your role, your self-concept may be called into question and you may experience a degree of self-doubt. Fig. 6.2 presents activities that may assist you in maintaining your self-esteem during times of self-doubt in your role. 13

A positive self-concept can only be maintained over time if your role partners and peers acknowledge your contribution. 21 One useful strategy that will help you in this

EXERCISE 6.6 � Refl ection on Time Management

Refl ect back on your student role activities during clinical practice.

1. How did you prioritise your work? 2. Were the strategies you used eff ective? 3. What might you do diff erently as a new graduate?

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regard is to fi nd a supportive role model. A role model is someone you admire and identify with, someone whose professional characteristics you value. 15 If you are able to form a relationship with this person, you could approach your role model for advice and support in times of stress. Role models can also act as mentors and assist you in achieving your career goals. 22 This relationship should be positive, constructive, developmental and grounded in reality. It should enhance your self-esteem and make you feel more accepted as a new graduate. A good mentor can contribute to your role satisfaction. 14–16,22

A support network made up of your peers can be another useful asset in maintaining a healthy self-concept during transition. 1,4 In most instances, when you commence employment you will attend an orientation program with other new graduates. This is an opportune time to discuss with these colleagues the notion of forming your own support network. By meeting on a regular basis, either face-to-face or online, this group could help you cope with your new role and the changes you will have to face in adapting your self-concept to the reality of the workplace. Mutual sharing of the highs and lows can be extremely useful in relieving role stress. In addition, forming a new-graduate group can be helpful in raising issues with management and lobbying for changes within the institution that would be of benefi t to new graduates.

As you are well aware, how you feel and relate to others is closely aligned to your emotions; and as transition is often a period of heightened emotions, developing your emotional intelligence is another invaluable means of coping and of managing your relationships with team members. Emotional intelligence, as defi ned by Goleman, is characterised by fi ve attributes: (1) self-awareness; (2) self-regulation; (3) motivation; (4) empathy; and (5) social skills. 23 These attributes allow us to recognise the early signs of emotional stress in ourselves and to control subsequent behaviour with others, and this is particularly useful when our self-concept is under threat. Emotional intelligence helps us to understand the emotions of others and to behave towards them with this understanding in mind. 23 You can become more emotionally intelligent by critically refl ecting on your behaviour and focusing on the part your emotional reactions played in motivating that behaviour. 18,24,25 This refl ection, in light of further reading on emotional intelligence, will heighten your self-awareness.

Reflect on positive aspects of your practice as a nurse

Search out other nurses who will provide support and encouragement

Involve yourself in work projects that will offer you a sense of achievement

Develop supportive personal affirmations based on your known strengths

Recognise that it is unrealistic to expect to be liked by all your colleagues or to succeed at

everything you do

Figure 6.2 �

Advice for maintaining positive self-esteem

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CONCLUSION

This chapter has discussed aspects of role theory that will help you in preparing for transition. The acquisition of the graduate role is a social process that undergoes primary, secondary and tertiary phases. During the primary phase, signifi cant people in your life were infl uential in shaping the values and beliefs within you that motivated you to study. You are now almost at the end of your secondary phase of socialisation, where a university program has provided you with the knowledge, skills and dispositions appropriate for practice as a registered nurse. During this phase, your ideals and values about the nursing role have been enhanced through academic study and clinical exposure. The primary and secondary phases of role acquisition have been synthesised to form your professional role expectations. Your expectations will now undergo another stage of development during transition.

Transition is a period of highs and lows, when the realities of the clinical setting and the expectations of your role partners will exert pressure on your present image of yourself as a graduate. Transition is not an easy process, but the role stress that may occur can be moderated by thoughtful preparation, formal and informal support strategies, and developing and maintaining a positive self-concept and personal resources, including emotional intelligence. We hope that this chapter has provided you with useful strategies to improve role stress and strain and smooth your personal experience of transition.

ACKNOWLEDGMENT

The author would like to thank and acknowledge Esther Chang, Katherine Milton-Wildey and Suzanne Rochester for their contributions to this chapter in previous editions of the text.

RECOMMENDED READING Hart B , Brannan JD , DeChesnay M . Resilience in nurses: an integrative review . J Nurs Manag

2014 ; 22 ( 6 ): 720 – 34 .

Mellor P , Gregoric C , Gillham D . Strategies new graduate registered nurses require to care and advocate for themselves: a literature review . Contemp Nurse 2016 ; 53 ( 3 ): 390 – 405 .

Walton JA , Lindsay N , Hales C , et al . Glimpses into the transition world: new nurses’ written refl ections . Nurse Educ Today 2018 ; 60 ( 1 ): 62 – 6 .

REFERENCES 1. Hofl er L , Thomas K . Transitions of new graduate nurses to the workforce: challenges and

solutions in the changing healthcare environment . N C Med J 2016 ; 77 ( 2 ): 133 – 6 .

2. Benner P . From novice to expert: excellence and power in clinical nursing practice . Menlo Park : Addison-Wesley ; 1984 .

3. Duchscher J . A process of becoming: the stages of new graduate professional role transition . J Contin Educ Nurs 2008 ; 39 ( 10 ): 441 – 50 .

4. Walton JA , Lindsay N , Hales C , et al . Glimpses into the transition world: new nurses’ written refl ections . Nurse Educ Today 2018 ; 60 ( 1 ): 62 – 6 .

5. Vaughan GN , Hogg MA . Social psychology . Sydney : Pearson Education Australia ; 2017 . p. 296 – 305 .

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INTRODUCTION

Registration as a registered nurse brings with it considerable professional rights as well as obligations. Graduation from your nursing program is the foundation for your professional practice as a registered nurse. Registration is the formal regulatory recognition that you have successfully demonstrated competence at a suffi cient level to commence your professional career as a nurse. It is the fact that you are registered that enables you to call yourself a registered nurse. Only when you are registered are you able to do this, as the title is protected. 1 The testamur that states you have successfully graduated from a nursing program is only part of the evidence required for registration.

LEARNING OBJECTIVES

When you have completed this chapter, you will be able to:

▲ explain the way in which a ‘protective regulatory jurisdiction’ functions ▲ identify how the elements of a regulatory authority ’ s safety and quality framework provide a

guide for registered nurses in their daily practice ▲ discuss the registered nurse ’ s responsibilities in relation to the following:

> competence to practise > recency of practice > professional indemnity insurance > criminal record checks > mandatory reporting

▲ refl ect on the importance of both technical and non-technical skills in relation to patient safety

▲ discuss the importance of boundaries for professional practice.

CHAPTER 21 �

Transition into practice : the regulatory framework for nursing Amanda Adrian and Mary Chiarella

KEYWORDS: protective regulatory jurisdiction , regulatory safety and quality framework , professional conduct and competence , technical and non-technical skills , regulatory oversight

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While you have to demonstrate competence to practise at the beginning of your career to become a registered nurse, it is expected that you will continue to grow and develop professionally. To this end, you are expected to exhibit the level of competence appropriate to a registered nurse with the level of skill, knowledge, attitude and experience at the equivalent stage of your professional career. 2

This chapter focuses on the elements of professional regulation that contribute to the quality and safety of healthcare for the community, and the obligations of and guidance available to registered nurses to develop professionally, practise ethically and be able to demonstrate continuing competence throughout their professional career.

THE CONCEPT OF A PROTECTIVE JURISDICTION

In Australia, New Zealand and many other countries of the world there is an increasingly sophisticated government-supported regulatory system for many different health professionals, not just nurses. In Australia, in 2019, there are 15 categories of health practitioners regulated, as set out in Box 21.1 .

The primary purpose of the Australian (and most other) regulatory schemes is to protect the community from people who are not ‘suitably trained and qualifi ed to practise in a competent and ethical manner’. 3

The area of law that governs the regulation of health practitioners’ conduct and practice is known as a ‘protective jurisdiction’ and is part of the legal system known as ‘administrative law’. Administrative law is defi ned as ‘… the legal principles governing

BOX 21.1 � Categories of health practitioners regulated in Australia as at March 2018

1. Nurses and midwives 2. Aboriginal and Torres Strait Islander health practitioners 3. Chinese medicine practitioners 4. Chiropractors 5. Dentists and allied dental personnel 6. Medical practitioners 7. Medical radiation practitioners 8. Occupational therapists 9. Optometrists 10. Osteopaths 11. Paramedics 12. Pharmacists 13. Physiotherapists 14. Podiatrists 15. Psychologists.

Source: Australian Health Practitioner Regulation Agency (AHPRA). Online. Available: https://www.ahpra.gov.au [Viewed 13 March 2018.]

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333CHAPTER 21 Transition into practice: the regulatory framework for nursing

the relationship between the government and the governed’. 4 The legislation that governs the regulation of health professionals – and therefore the agencies, boards and other instruments created by it – all exist to protect the community from the risk of harm. This is sometimes rather a surprise for health professionals, who imagine that their registration is intended to protect the interests of the professions. In some ways, of course, health professionals are protected if they heed the advice and work within the regulatory frameworks, but that is a byproduct of the protective jurisdiction, not its intent. This form of occupational regulation provides: ■ mechanisms to determine who should enter a profession ■ mechanisms for the oversight and accreditation of the education of health

professionals ■ the establishment of codes and standards for professional education, conduct, ethics

and practice ■ an avenue for consumers to have complaints against nurses and midwives

addressed. 5

The criteria for which health professions should be included in the scheme were determined most recently in Australia in 2008 through the Intergovernmental Agreement for a National Registration and Accreditation Scheme for the Health Professions, where it was agreed that a profession was to be included in the scheme if: 1. it was supported by a majority of jurisdictions (Australian Government and the

states and territories) 2. it could be demonstrated that the occupation ’ s practice presents a serious risk to

public health and safety that could be minimised by regulation. 6

Nurses and midwives have been regulated in Australia and New Zealand since the end of the 19th century and early 20th century because it was clearly identifi ed that the intimacy and therapeutic nature of nursing and midwifery practice, if not practised ethically and with the necessary knowledge, skill, care and judgment, could pose a risk to people. 7

THE DIFFERENCE BETWEEN STUDENT REGISTRATION AND PROFESSIONAL REGISTRATION

When you enrolled in your nursing program of study with the intention of becoming a registered nurse, the university or college you enrolled in had to ensure that the particular education program you were enrolled in was accredited and approved by the National Board for the entire period you were enrolled in the program.

The Nursing and Midwifery Board of Australia (NMBA), the National Board for the professions of nursing and midwifery created under the Health Practitioner Regulation National Law (‘National Law’), does not accredit these education programs. Instead, the NMBA has delegated this responsibility to the Australian Nursing and Midwifery Accreditation Council (ANMAC), ‘an external accreditation entity’ 8 independent of the NMBA.

ANMAC has a number of delegated functions under the National Law, including developing accreditation standards for nursing and midwifery education programs leading to registration or endorsement. 9 These accreditation standards must be

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approved by the NMBA before they can be used to assess and accredit education programs that the education provider can offer as leading to registration or endorsement. 10,11 The accreditation standards that govern the conduct of education programs leading to registration or endorsement set out the requirements for universities and colleges, covering matters such as: ■ the governance of the education program including which education providers may

offer the program; and the minimum level of qualifi cation that must be achieved for registration as a registered nurse

■ the conceptual framework that underpins the program ■ the way the program is developed and structured ■ the content of the education program ■ varied and appropriate approaches to student assessment ensuring the student

specifi cally meets the competency requirements for a beginning practitioner against contemporary practice standards

■ the teachers, facilities, equipment and teaching resources available to students ■ the management of workplace experience ■ managing risks for the program and students, and quality improvement. 12

ANMAC is also responsible for accrediting all nursing and midwifery education programs leading to registration or endorsement in Australia using the accreditation standards to assess the programs. 12 Once again, it is the responsibility of the NMBA to approve the programs accredited by ANMAC as qualifi cations for the purposes of registration or endorsement. 13

A third delegated function carried out by ANMAC is the monitoring of accredited education programs to ensure the university or college continues to comply with the accreditation standards during the period of accreditation, 14 which is usually 5 years. Universities or colleges risk having conditions placed on their accreditation status, or having accreditation revoked, if they do not continue to meet the approved accreditation standards.

To ensure that these obligations under the National Law can be met between the two independent organisations, a regulatory partnership exists between the NMBA and ANMAC, enabling both organisations to carry out their separate regulatory functions. This partnership is based on good communication and understanding of the separation of the powers of each agency, while meeting the common objectives of the National Law of protecting the community and ensuring a fl exible and sustainable health workforce in Australia. 15

In Australia, the NMBA also requires that nursing students who are undertaking an accredited and approved university or college program are registered before they begin the clinical component of their program. Registration as a student of nursing is quite different from registration as a qualifi ed nursing health professional. It is not your responsibility to obtain registration as a student. It is your education provider that has to provide the NMBA with the list of students undertaking the pre-registration program on the day of census for the university. This notifi cation must occur prior to any students undertaking clinical placements or other activities where students may ‘have contact with members of the public’ 16 and where there is ‘potential risk that contact may pose to members of the public’. 17 While the emphasis remains on protection of the

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community, as it does for your individual professional registration as a registered nurse, registration as a student is primarily a notifi cation and risk management strategy for the National Board, the education provider and any clinical services provider where students may be on clinical placement. Most student matters relating to competence are still managed (quite appropriately) by the education provider. However, the university or college is required to notify the NMBA of any impairment or criminal matters relating to a student that may pose a risk to the public.

MEETING THE REGISTRATION STANDARDS

When you have successfully completed your education program and wish to apply for registration as a registered nurse, the onus is on you to provide the evidence that, in addition to your academic qualifi cations, you meet all the relevant standards to practise as a new graduate and beginning practitioner. On initial registration, these standards are the English language standard, 18 the professional indemnity insurance standard 19 and the criminal history registration standard. 20

Renewing your registration each year requires you to attest that you are continuing to practise competently and ethically, and that you continue to meet the initial standards for registration. However, in addition, you are required to maintain and develop your professional knowledge, skills and expertise by also meeting the recency of practice 21 and continuing professional development standards. 22

Many regulatory authorities also provide guidance for health professionals to practise safely and ethically and meet the expectations of the community and the professions. This is one of the four functions of a regulatory authority; the others being accreditation of programs, setting standards for practice, and managing complaints or notifi cations about registered health professionals. 5 This guidance in Australia is set out in a safety and quality framework and includes a number of key policy statements.

ELEMENTS OF A SAFETY AND QUALITY FRAMEWORK FOR PRACTISING NURSES

Regulatory authorities and governments develop a signifi cant number of such policy statements and guidance documents to provide advice to health professionals in relation to safety and quality. Arguably, these documents provide a useful framework that health professionals can use to guide their practice. A policy framework such as this provides a structure for grouping linked subject matter (such as codes, standards, policies, guidelines and statements), enabling a focus on a concept that has many facets, such as quality and safety. Safety and quality frameworks for health professionals are generally made up of similar fundamental components. For the purpose of this chapter, we shall look predominantly at those components developed by the regulatory authority – in this case, the Nursing and Midwifery Board of Australia. These components include strong statements about the standards expected of the nurse or midwife in relation to professional conduct, ethical behaviour and standards for practice.

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Professional Conduct

Professional conduct is the manner in which a person behaves while acting in a professional capacity as a nurse or midwife. It is generally accepted that, when performing their duties and conducting their affairs, professionals will uphold exemplary standards of conduct, commonly taken to mean standards not generally expected of lay people. 23 The Code of Conduct for Nurses 24 forms one of the key elements of the safety and quality framework for the nursing profession in this country.

The Code is to be used for the purposes outlined in Box 21.2 .

The domains, principles and values contained in the new Code of Conduct for Nurses are set out in Box 21.3 .

Ethical Behaviour

In 2018, the NMBA adopted the International Council of Nurses (ICN) Code of Ethics for Nurses , 25 rather than developing a separate one for nurses in Australia, as the regulatory authorities here have done previously.

BOX 21.2 � Uses of the Code of Conduct for Nurses

The Code will be used: ■ to support individual nurses in the delivery of safe practice and fulfi lling their

professional roles ■ as a guide for the public and consumers of health services about the standard of

conduct and behaviour they should expect from nurses ■ to help the NMBA protect the public, in setting and maintaining the standards set out

in the code and to ensure safe and eff ective nursing practice ■ when evaluating the professional conduct of nurses. If professional conduct varies

signifi cantly from the values outlined in the code, nurses should be prepared to explain and justify their decisions and actions. Serious or repeated failure to abide by this code may have consequences for nurses’ registration and may be considered as unsatisfactory professional performance, unprofessional conduct or professional misconduct * , and

■ as a resource for activities which aim to enhance the culture of professionalism in the Australian health system. These include use, for example, in administration and policy development by health services and other institutions; in nursing education, in management and for the orientation, induction and supervision of nurses and students.

Source: Nursing and Midwifery Board of Australia (NMBA). Code of conduct for nurses . Melbourne: NMBA, 2018:4. Online. Available: http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx [Viewed 25 March 2019.]

* As defi ned in the National Law, with the exception of NSW where the defi nitions of unsatisfactory professional conduct and professional misconduct are defi ned in the Health Practitioner Regulation National Law (NSW).

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BOX 21.3 � Domains, principles and values from the NMBA Code of Conduct for

Nurses (2018)

DOMAIN: PRACTISE LEGALLY

1. Legal compliance Nurses respect and adhere to their professional obligations under the National Law,

and abide by relevant laws.

DOMAIN: PRACTISE SAFELY, EFFECTIVELY AND COLLABORATIVELY

2. Person-centred practice Nurses provide safe, person-centred and evidence-based practice for the health and

wellbeing of people and, in partnership with the person, promote shared decision-making and care delivery between the person, nominated partners, family, friends and health professionals.

3. Cultural practice and respectful relationships Nurses engage with people as individuals in a culturally safe and respectful way, foster

open and honest professional relationships, and adhere to their obligations about privacy and confi dentiality.

DOMAIN: ACT WITH PROFESSIONAL INTEGRITY

4. Professional behaviour Nurses embody integrity, honesty, respect and compassion.

5. Teaching, supervising and assessing Nurses commit to teaching, supervising and assessing students and other nurses, in

order to develop the nursing workforce across all contexts of practice. 6. Research in health

Nurses recognise the vital role of research to inform quality healthcare and policy development, conduct research ethically and support the decision-making of people who participate in research.

DOMAIN: PROMOTE HEALTH AND WELLBEING

7. Health and wellbeing Nurses promote health and wellbeing for people and their families, colleagues, the

broader community and themselves and in a way that addresses health inequality.

Source: Nursing and Midwifery Board of Australia (NMBA). Code of conduct for nurses . Melbourne: NMBA, 2018. Online. Available: http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx [Viewed 15 March 2018.]

The ICN describes the Code of Ethics for Nurses as:

… a guide for action based on social values and needs. It will have meaning only as a living document if applied to the realities of nursing and health

care in a changing society. To achieve its purpose the Code must be understood, internalised and used by nurses in all aspects of their work. It must be available to students and nurses throughout their study and work

lives. (p 4) 25

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The ICN Code of Ethics for Nurses contains four elements. These are set out in Box 21.4 . Each element has a set of explanatory statements specifi cally identifi ed for three groups: practitioners and managers, educators and researchers, and national nursing organisations.

In other countries, such as New Zealand and Singapore, the codes for professional conduct and ethics have been combined. Both approaches have strengths and weaknesses, and it is a policy choice for the relevant regulatory authority.

Standards for Practice

Standards for practice are the core competency standards by which performance is assessed to obtain and retain registration as a registered nurse or midwife. These

BOX 21.4 � Elements of the ICN Code

1. Nurses and people The nurse ’ s primary professional responsibility is to people requiring nursing care. In

providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected.

The nurse ensures that the individual receives accurate, suffi cient and timely information in a culturally appropriate manner on which to base consent for care and related treatment.

The nurse holds in confi dence personal information and uses judgement in sharing this information.

The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations.

The nurse advocates for equity and social justice in resource allocation, access to health care and other social and economic services.

The nurse demonstrates professional values such as respectfulness, responsiveness, compassion, trustworthiness and integrity.

2. Nurses and practice The nurse carries personal responsibility and accountability for nursing practice, and for

maintaining competence by continual learning. The nurse maintains a standard of personal health such that the ability to provide care

is not compromised. The nurse uses judgement regarding individual competence when accepting and

delegating responsibility. The nurse at all times maintains standards of personal conduct which refl ect well on the

profession and enhance its image and public confi dence. The nurse, in providing care, ensures that use of technology and scientifi c advances are

compatible with the safety, dignity and rights of people. The nurse strives to foster and maintain a practice culture promoting ethical behaviour

and open dialogue.

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3. Nurses and the profession The nurse assumes the major role in determining and implementing acceptable

standards of clinical nursing practice, management, research and education. The nurse is active in developing a core of research-based professional knowledge that

supports evidence-based practice. The nurse is active in developing and sustaining a core of professional values. The nurse, acting through the professional organisation, participates in creating a

positive practice environment and maintaining safe, equitable social and economic working conditions in nursing.

The nurse practices to sustain and protect the natural environment and is aware of its consequences on health.

The nurse contributes to an ethical organisational environment and challenges unethical practices and settings.

4. Nurses and co-workers The nurse sustains a collaborative and respectful relationship with co-workers in nursing

and other fi elds. The nurse takes appropriate action to safeguard individuals, families and communities

when their health is endangered by a co-worker or any other person. The nurse takes appropriate action to support and guide co-workers to advance ethical

conduct. (pp. 2–4)

Source: International Council of Nurses (ICN). Code of ethics for nurses . Geneva: ICN, 2012:2–4. Online. Available: https://www.icn.ch/sites/default/fi les/inline-fi les/2012_ICN_Codeofethicsfornurses_%20eng.pdf [Viewed 25 March 2019.]

BOX 21.4�Elements of the ICN Code—cont’d

standards cover the application of knowledge, skill, judgment and care in the practice of nursing or midwifery. In Australia, these standards have traditionally been known as ‘national competency standards’. However, as they are being reviewed and updated by the NMBA, they are referred to as ‘standards for practice’. 26 The purpose of these standards is to provide an evidence base to describe the core standards for practice for each professional group within nursing and midwifery. The standards are regularly updated and reviewed, and can be used by educators, governments, nursing and midwifery professionals, employers and regulators to prepare and assess the performance of a nursing and/or midwifery professional. It is critical that you examine your own practice against the standards for practice each year when you renew your registration. This refl ection can assist you in developing your continuing professional development (CPD) program for the next year.

Decision-making Framework

Nurses, particularly registered nurses, often lead a team of health professionals and other workers. This team may include other registered nurses, enrolled nurses and assistants in nursing, as well as other staff such as porters and care assistants. In addition, nurses work closely with other health professionals such as medical practitioners, physiotherapists, pharmacists and other allied health personnel. Work

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sometimes fl ows seamlessly between these groups based on issues such as the context of practice and patient needs. However, it is sometimes diffi cult for nurses to make decisions as to when to make and accept delegations of care, and the purpose of the NMBA ’ s decision-making framework (DMF) 27 is to provide advice and guidance in relation to making and accepting delegations.

Nonetheless, the DMF makes clear that:

These template tools establish a framework for decision making that is based in competence. They do not condone or authorise the substitution of less qualifi ed health workers for nurses or midwives when the knowledge and

skills of nurses or midwives are needed. No nurse or midwife may be directed, pressured or compelled by an employer, or other person, to engage

in any practice that falls short of, or is in breach of, any professional standard, guidelines and/or code of conduct, ethics or practice for their

profession. (p 4) 27

Boundaries of Professional Practice

Professional boundary violations have been a recurrent source of notifi cations to regulatory bodies for many health professions in the past. 28 Previously, the nursing and midwifery regulatory authorities commissioned research into an advisory document to assist nurses and midwives to make decisions in relation to managing professional boundaries. Recently, the advice relating to professional boundaries has been incorporated into the Code of Conduct for Nurses , under the principle of ‘Professional behaviour’. The section on professional boundaries begins by explaining that:

Professional boundaries allow nurses, the person and the person ’ s nominated partners, family and friends, to engage safely and effectively in professional

relationships, including where care involves personal and/or intimate contact. In order to maintain professional boundaries, there is a start and end point

to the professional relationship and it is integral to the nurse-person professional relationship. Adhering to professional boundaries promotes

person-centred practice and protects both parties. (p 11) 24

The behaviours expected of a nurse to maintain professional boundaries are set out in Box 21.5 .

Application of the Safety and Quality Framework to Clinical Practice

These documents have been developed to assist nurses in their daily practice. They are not prescriptive but principle based, and their intent is to enable nurses to refl ect on the complex and sometimes diffi cult professional and ethical issues they encounter in clinical practice. It is strongly recommended that you familiarise yourself with these documents. Should you ever be called to account for your practice, these are the documents that will inform the standards against which you would be judged.

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REGISTERED NURSE RESPONSIBILITIES IN RELATION TO REGULATORY STANDARDS AND MANDATORY NOTIFICATIONS

Each year when nurses come to renew their registration, they must complete a statutory declaration (this is usually online for the majority of health professionals in Australia) confi rming they comply with the continuing professional development standard, 22 the recency of practice standard 21 and the criminal history registration standard. 20 They also agree not to practise unless they know they have adequate

BOX 21.5 � Behaviours expected of a nurse to maintain professional boundaries

To maintain professional boundaries, nurses must: a. recognise the inherent power imbalance that exists between nurses, people in their

care and signifi cant others and establish and maintain professional boundaries b. actively manage the person ’ s expectations, and be clear about professional

boundaries that must exist in professional relationships for objectivity in care and prepare the person for when the episode of care ends

c. avoid the potential confl icts, risks, and complexities of providing care to those with whom they have a pre-existing non-professional relationship and ensure that such relationships do not impair their judgement. This is especially relevant for those living and working in small, regional or cultural communities and/or where there is long-term professional, social and/or family engagement

d. avoid sexual relationships with persons with whom they have currently or had previously entered into a professional relationship. These relationships are inappropriate in most circumstances and could be considered unprofessional conduct or professional misconduct

e. recognise when over-involvement has occurred, and disclose this concern to an appropriate person, whether this is the person involved or a colleague

f. refl ect on the circumstances surrounding any occurrence of over-involvement, document and report it, and engage in management to rectify or manage the situation

g. in cases where the professional relationship has become compromised or ineff ective and ongoing care is needed, facilitate arrangements for the continuing care of the person to another health practitioner, including passing on relevant clinical information

h. actively address indiff erence, omission, disengagement/lack of care and disrespect to people that may refl ect under-involvement, including escalating the issue to ensure the safety of the person if necessary

i. avoid expressing personal beliefs to people in ways that exploit the person ’ s vulnerability, are likely to cause them unnecessary distress, or may negatively infl uence their autonomy in decision-making (see the NMBA Standards for practice), and

j. not participate in physical assault such as striking, unauthorised restraining and/or applying unnecessary force.

Source: adapted from Nursing and Midwifery Board of Australia (NMBA). Code of conduct for nurses . Melbourne: NMBA, 2018. Online. Available: http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx [Viewed 25 March 2019.] Sam

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professional indemnity insurance arrangements. 19 All these standards can be subject to audit. 29 Although not a requirement on initial registration, on renewal, registered nurses are expected to have undertaken 20 hours of CPD every year, relevant to their context of practice; 22 and must have undertaken the full-time equivalent of 3 months’ practice within the past 5 years to be able to claim they have met the recency of practice requirements. 21

All registered health professionals and employers in Australia have a legal obligation to make a mandatory notifi cation if they have formed a reasonable belief that a health practitioner has behaved in a way that constitutes notifi able conduct in relation to the practice of their profession. 30 ‘Reasonable belief’ is a term commonly used in legislation, including in criminal, consumer and administrative law. The Australian Health Practitioner Regulation Agency (AHPRA) has detailed information about notifi able conduct on its website, where AHPRA also provides helpful advice on the defi nition of a ‘reasonable belief’: 31

For practitioners reporting notifi able conduct, a ‘reasonable belief’ must be formed in the course of practising the profession. The following principles

are drawn from legal cases which have considered the meaning of reasonable belief.

1. A belief is a state of mind. 2. A reasonable belief is a belief based on reasonable grounds. 3. A belief is based on reasonable grounds when: i. all known considerations relevant to the formation of a belief are

taken into account including matters of opinion, and ii. those known considerations are objectively assessed. 4. A just and fair judgement that reasonable grounds exist in support of a

belief can be made when all known considerations are taken into account and objectively assessed.

A reasonable belief requires a stronger level of knowledge than a mere suspicion. Generally it would involve direct knowledge or observation of the behaviour which gives rise to the notifi cation, or, in the case of an employer,

it could also involve a report from a reliable source or sources. Mere speculation, rumours, gossip or innuendo are not enough to form a

reasonable belief.

A reasonable belief has an objective element – that there are facts which could cause the belief in a reasonable person; and a subjective element

– that the person making the notifi cation actually has that belief.

A notifi cation should be based on personal knowledge of facts or circumstances that are reasonably trustworthy and that would justify a

person of average caution, acting in good faith, to believe that notifi able conduct has occurred or that a notifi able impairment exists. Conclusive proof

is not needed. The professional background, experience and expertise of a practitioner, employer or education provider will also be relevant in forming

a reasonable belief.

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The most likely example of where a practitioner or employer would form a reasonable belief is where the person directly observes notifi able conduct, or, in relation to an education provider, observes the behaviour of an impaired student. When a practitioner is told about notifi able conduct that another

practitioner or patient has directly experienced or observed, the person with most direct knowledge about the notifi able conduct should generally be

encouraged to make a notifi cation themselves. (pp 5–6) 31

Notifi able conduct, in relation to a registered health practitioner, is defi ned in the National Law as meaning that the practitioner has: a. practised the practitioner ’ s profession while intoxicated by alcohol or drugs; or b. engaged in sexual misconduct in connection with the practice of the practitioner ’ s

profession; or c. placed the public at risk of substantial harm in the practitioner ’ s practice of the

profession because the practitioner has an impairment; or d. placed the public at risk of harm because the practitioner has practised the

profession in a way that constitutes a signifi cant departure from accepted professional standards. 32

CONCLUSION

During your nursing education program, you will study a number of subjects dealing with law and ethics. While emphasis is often placed on the law surrounding matters such as negligence, consent and other legal doctrines and ethical dilemmas, it is important to recognise that the safety and quality framework for clinical practice has comprehensive guidance that will ensure you attain and maintain ongoing competence to practise and will, if adhered to, concomitantly reduce the risk of committing legal and ethical misdemeanours. Obviously, you may still be exposed to situations requiring diffi cult decisions. In addition, you may still witness others making or not making decisions that will challenge you professionally, or which may have legal implications and may raise ethical dilemmas. The protective jurisdiction for the regulation of health professionals is primarily there to protect the community from harm. However, if you can demonstrate that you practise nursing according to the codes and standards, you will also generally be protected from any regulatory censure.

CASE STUDY 21.1

EN1, an enrolled nurse working in an aged care facility, administered the wrong medication to Mrs G, an elderly female resident. EN1 had been registered for 14 years at the time of the incident.

Shortly after the incident, EN1 spoke to another enrolled nurse (EN2), telling him about the mistake. She told him she was looking for the RN1, who was contacted and told about the mistake. EN1 noted she was tired and fl ustered at the time and made a careless mistake.

RN1 did not check what medication should have been administered to Mrs G; nor did she request a medical practitioner come to assess Mrs G. She also failed to make any notes, or ensure that notes were made of an assessment of Mrs G ’ s condition after the incident. Each of

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these steps were part of the internal protocol required by the aged care facility in its Medication Management Policy.

RN1 told EN1 not to tell anyone about the medication incident, assessing the situation to be under control and feeling sorry for EN1, as the enrolled nurse had had a few situations that had arisen relating to her performance recently and management was on her back.

EN1 did not document any further observations she made of Mrs G, from the time of the medication incident until the time of Mrs G ’ s death. In addition to her failure to document these further observations of Mrs G, she had multiple opportunities to tell somebody about the medication incident. She did not tell RN2, the registered nurse who came on night duty at about 11.00 pm. At about this time, Mrs G was discovered to have had a fall. RN2 examined Mrs G in EN1 ’ s presence and documented her observations. EN1 still did not inform the registered nurse of the medication incident, so RN2 was therefore not aware of all the possible reasons for Mrs G ’ s fall. There was yet a further opportunity for this to happen when EN1 phoned RN2 at the facility at about 1.00 am, after she had gone home, to enquire about Mrs G ’ s health. She was told Mrs G was resting. She still did not mention the medication incident.

Mrs G died the next day. However, it was later agreed that giving her the wrong medication had no bearing on the cause of death. Immediately after Mrs G ’ s death, there was an email exchange between EN1 and RN1, where, despite EN1 ’ s misgivings, RN1 urged her to say nothing about the incident and EN1 agreed.

EN2 reported the incident 2 days after Mrs G ’ s death. 33


1. Using the relevant codes, standards and guidelines that are part of the safety and quality framework for registered nurses in Australia, identify potential breaches of these instruments that may lead to a fi nding of unsatisfactory professional conduct or professional misconduct being made against RN1.

2. If you were working as a registered nurse and EN1 came to you about the medication incident, what would your responsibilities be?

3. What other resources should be available to assist you in situations such as this?

Source: adapted from NMBA v Palmer and Ghazy [2016] SAHPT 7. Online. Available: http://www.healthpractitionerstribunal.sa.gov.au/download.cfm?downloadfi le = 4C827E10-9007-11E6-BEA9020054554E01&typename = dmFile&fi eldname = fi lename . [Viewed 22 March 2018.]

CASE STUDY 21.2

RN3 was employed as a nurse at a private acute mental health facility.

Ms A was a female inpatient at the hospital for 2 months when RN3 was working there. Ms A had previously been admitted to the hospital for periods ranging from days to weeks over the past 6 years.

On the day prior to her most recent admission, Ms A was suff ering from a severe episode of depression. She had been driving her car with the intention of committing suicide, either by driving off a cliff or into a tree. She called her treating psychologist, who told her that she was to

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admit herself to the hospital the next day or the psychologist herself would take out an involuntary treatment order against her. Ms A slept in her car that night outside the hospital so that she could admit herself the following day; which she did.

RN3 was the nurse who admitted Ms A. He had not been responsible for any care of Ms A on her earlier admissions to the hospital. He completed a nursing admission assessment of Ms A, in which he recorded that she: was a known patient to the hospital; had been admitted three times that year; suff ered with anxiety and depression; was being admitted that day for depression, suicidality and a gambling addiction; and that she had suicidal thoughts and a plan to end her life.

Ms A was discharged approximately 2 months later and subsequently admitted again nearly 6 weeks after that discharge. RN3 was assigned to provide nursing care to Ms A on at least one occasion during this admission. On this day, Ms A gave him her mobile phone number to pass on to a former member of the hospital staff who had previously assisted her with gambling addiction issues.

During the course of that same evening, RN3 sent a text message to Ms A informing her that he had passed on her number to the former staff member as requested.

Within 20 minutes of that fi rst text message, RN3 commenced exchanging text messages with Ms A, which quickly took on a fl irtatious tone. They included references to RN3 ‘tucking in’ Ms A. A further message sent at 10.53 pm said: ‘Night. If you want to, text me any time; but keep it quiet.’

By the following morning, the conversation moved from fl irtatious to suggestive. By late afternoon, it had progressed to graphically sexual. By early evening, it had progressed to the possibility of them meeting, quite apparently for the purposes of some sexual encounter. Soon after, RN3 instructed the patient to ‘change and get leave’.

Over the next 5 days, RN3 and Ms A had a number of sexual encounters with numerous graphic sexual text exchanges in between, until Ms A ’ s discharge more than 2 weeks later.

Ms A said she had sexual intercourse for the fi rst time with RN3 the day after discharge. In text messages 2 days later, RN3 started to raise concerns that others might know of the relationship, requesting: ‘If anyone asks, please deny.’

However, an incident report made by Ms A ’ s psychologist on that same day records that several weeks earlier, Ms A had contacted her psychologist, asking her whether, if she was involved with a staff member, she would need to report it. When told by her psychologist that she would have to report it, Ms A indicated that she no longer wished to talk about it.

RN3 was subsequently dismissed and over the following months continued to be in contact with Ms A, even borrowing money from her and continuing to beg her not to tell anyone about their relationship. Indeed, he requested Ms A to contact the hospital and tell them she made the whole story up.

Although he was no longer working at the hospital, RN3 and Ms A went on to have an ongoing sexual relationship and regular contact over at least the following 12 months. 34

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1. Using the relevant codes, standards and guidelines that are part of the safety and quality framework for registered nurses in Australia, identify the areas that may give guidance in relation to RN3 ’ s professional conduct in this situation.

2. Would the situation be diff erent if Ms A did not have a mental health condition? 3. What are our professional obligations if we know of a colleague or friend who is a registered

nurse having a personal relationship with a person who is/has been in their care?

Source: adapted from NMBA v Isgrove [2015] QCAT 522. Online. Available: http://www8.austlii.edu.au/au/cases/qld/QCAT/2015/522.rtf [Viewed 25 March 2018.]

CASE STUDY 21.3

RN4 was referred by the NMBA to a tribunal after he was convicted of multiple criminal off ences over several years.

In 2013, the NMBA was notifi ed that the police had found RN4 in possession of medications prescribed between 2006 and 2013 in the names of current and former patients of the health service where he had been employed.

An Immediate Action Committee of the NMBA suspended RN4 ’ s registration on the grounds that his conduct posed a serious risk to the public.

In October 2013, RN4 was found guilty of multiple charges in the Magistrates’ Court of Victoria, including: ■ 21 instances of theft, including theft of animals and medications ■ four instances of stalking ■ six instances of intentionally damaging property ■ three instances of aggravated cruelty to an animal ■ one instance of burglary ■ one instance of failure to store ammunition correctly ■ fi ve instances of possessing a drug of dependence.

In February 2015, RN4 was convicted of further multiple off ences in the Magistrates’ Court, including: ■ three instances of making a false document to the prejudice of others ■ one instance of reckless conduct endangering serious injury ■ two instances of recklessly causing injury ■ two instances of false imprisonment ■ two instances of intentionally causing injury.

The tribunal found that RN4 had engaged in professional misconduct, as he had been convicted of multiple criminal off ences over several years. The tribunal reprimanded him, cancelled his registration and disqualifi ed him from applying for registration for at least 3 years. 35


1. Using the relevant codes, standards and guidelines that are part of the safety and quality framework for registered nurses in Australia, identify the areas that may give guidance in relation to RN4 ’ s professional conduct in this situation.

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2. When should a registered nurse ’ s conduct outside of the work situation be taken into account in relation to their professional practice?

3. What are our professional obligations if we know of a colleague or friend who: > has been convicted of driving under the infl uence and has not reported this conviction

to the NMBA > has been stealing drugs for their personal use from facility supplies > has been selling these drugs to other colleagues with a drug habit > is growing cannabis for personal use on their apartment balcony?

Source: adapted from NMBA v Brewer (Review and Regulation) [2017] VCAT 384. Online. Available: http://www.austlii.edu.au/cgi-bin/sinodisp/au/cases/vic/VCAT/2017/384.html [Viewed 26 March 2018.]

RECOMMENDED READING Chiarella M . Professional regulation of nurses and midwives . In : Chiarella M , Staunton P , editors .

Law for nurses and midwives . 8th ed . Sydney : Elsevier ; 2016 . p. 229 – 64 .

Nursing and Midwifery Board of Australia (NMBA) . Code of conduct for nurses . Melbourne: NMBA ; 2018 . Online. Available : http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx . [ Viewed 15 March 2018 .]

International Council of Nurses (ICN) . Code of ethics for nurses . 2012 . Online. Available : https://www.icn.ch/sites/default/fi les/inline-fi les/2012_ICN_Codeofethicsfornurses_%20eng.pdf . [ Viewed 25 March 2019 .]

REFERENCES 1. Section 113 of the Health Practitioner Regulation National Law Act as in force in each state

and territory in Australia; hereafter referred to as the National Law .

2. Nursing and Midwifery Board of Australia (NMBA) . Framework for assessing national competency standards for registered nurses, enrolled nurses and midwives . Melbourne: NMBA ; 2013 . Online. Available : http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Frameworks/Framework-for-assessing-national-competency-standards.aspx . [ Viewed 13 March 2018 .]

3. Section 3(2)(a) of the National Law .

4. Finkelstein R , Hamer D . Butterworths’ concise Australian legal dictionary . 5th ed . Sydney : LexisNexis Butterworths ; 2015 .

5. Chiarella M , White J . Which tail wags which dog? Nurse Educ Today 2013 ; 33 ( 11 ): 1274 – 8 .

6. Council of Australian Governments (COAG) . Intergovernmental agreement for a national registration and accreditation scheme for the health professions . Canberra: COAG ; 2008 . Online. Available : https://www.coaghealthcouncil.gov.au/NRAS . [ Viewed 25 March 2019 .]

7. Chiarella M . The legal and professional status of nursing . Edinburgh : Elsevier ; 2002 .

8. Section 43(1)(a) of the National Law .

9. Section 46 of the National Law .

10. Section 47 of the National Law .

11. ‘Endorsement’ is an additional step to initial registration. For example, a registered nurse may be endorsed as a nurse practitioner if he or she meets the qualifi cation requirements outlined in section 95 of the National Law .

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