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Copyright eContent Management Pty Ltd. Contemporary Nurse (2007) 24: 159161.

EDITORIAL
Being in nursing: Dealing with contemporary practice

he nursing workforce frequently cites dissatisfaction arising from factors external to the control of an individual nurse as impacting on the experience of Being In nursing. These include higher patient ratios; assertions that quality of care is decreased because of substitution by lesser qualified carers; increasing numbers of practice contexts; lack of collegiality between health services and academe; a high attrition rate of experienced nurses from the workforce; inadequate ongoing education; low morale because of increased workplace expectations; decreasing opportunities for use of higher levels of knowledge and skill; increased need for ethical/moral decision making and an increase in demand for responsibility and accountability for nursing practice. In literature related to contemporary health service delivery, it is widely acknowledged that reduced average lengths of stay, an ageing clientele, increased throughput and acuity, developments in health care technology and educational technology, and increasing numbers of learners requiring clinical experience impact on the clinical milieu (McMillan, Conway & FitzGerald 2004). In such a complex environment, it is imperative that the workplace culture is sufficiently safe and supportive to enable nurses to critically analyse situations, identify underpinning knowledge and ideas, and critique their own professional performance. However, the creation of the nursing culture and that cultures response to the demands inherent in contemporary practice is a key responsibility of individual nurses,

as, according to Hall and Hord (2001: 7), one of the seeming paradoxes of response to change is that: Although everyone wants to talk about such broad concepts as policy, systems, and organizational factors, successful change starts and ends at the individual level. The entire organization does not change until each member has changed. While nursing education programs globally recognise that the clinical area is an important, if not the most important, area for practice professions such as nursing, the extent to which there is congruence between what the nursing workforce culture could or should be like, and what it actually is, continues to be cause for concern. It is frequently argued that immersion in practice experience is essential to the development of those undertaking entry-level and continuing professional development because it is where the professional identities of nurses are shaped and developed and where best practice is recognised, fostered, enhanced, modified and adopted. However contradictions between theory and practice, and nursing and educational values, are often highlighted. The workplace culture is determined by the social world of nursing. It is disappointing to continue to read of exemplars where this complex social world does not support the professional growth, learning and development of novice or experienced clinicians. This social world of nursing and nurses is

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Jane Conway and Margaret McMillan

that as a profession nursing has much learning to do in order to develop insights that enable it to reduce and correct errors and minimise risk to the growth of the profession through attrition and disenfranchisement. In addition to supporting nurses in the workplace, there is a need for nursing work to align with contemporary contexts.While workforce planning is essential to allow for attrition between the numbers of entrants into the workforce and those who are in practice at any one point in time, it is also important that workforce planning provide opportunity for a critical examination of who does what work in health care. According to a recent report Modernising Nursing Careers: Setting the Direction (Scottish Executive 2006: 13) the nursing workforce in the United Kingdom will need to: organise care around the needs of patients; ensure patients have a good experience of nursing as reputations of organisations and patient choice will rest on the quality of nursing; work in a range of settings, crossing hospital and community care, and use telemedicine; have the skills and competencies to care for older people and people with long-term conditions, who may have both physical and mental health needs; be able to use preventative and health promotion interventions; work for diverse employers, and take opportunities for self-employment where appropriate; have sufficient numbers of nurses with advanced level skills to meet demand; work as leaders and members of multidisciplinary teams inside and outside hospital, and across health and social care teams; work with new forms of practitioners, for example assistant practitioners and anaesthesia practitioners; deliver high productivity and best value for money.

richly described through the rich exemplars in the paper by Levett-Jones et al. who explore concepts of belongingness and alienation in the experiences of undergraduate nurses during clinical placement. This paper acknowledges that while there is a need to acclimatise students to the world of work, one should question the extent to which workplace culture attracts or disaffects nurses in the workplace. This paper reveals that while some workplaces are supportive and enhance the sense of inclusion into a professional group through a shared set of values and behaviour consistent with these, others are less supportive.The alienation experienced by some of those in the workplace as a result of outmoded practices both technical and interpersonal is evident in the deeply personal accounts within the situations presented. People who have experienced alienation, isolation and professional gate keeping as student nurses will make specific choices about their future work through negotiation of their preferred work environment prior to graduation. That they choose to remain in nursing is testimony to their personal resilience and commitment but does little to address workforce shortage in environments that are toxic, thus perpetuating the workforce shortage in some areas of practice. The implications of a non-supportive culture go beyond that of attrition or avoidance of given work areas. A non-supportive culture has the potential to inhibit organisational learning and the continued development of nursing as a profession. Organisational learning has been characterised as a strategy through which an organisation is able to improve performance and reduce and correct error through the development of insights (Fiol & Lyle 1985). It is a useful framework in which to nest a number of changed approaches to practice and recognises the coexistence of both the mechanistic and functional elements of organisational change as well as the humanistic elements of systemic reform (McAdam & Leonard 1999). We would argue
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Volume 24, Issue 2, April 2007

Editorial
Other papers in this section reveal that despite the recognition that nurses are critical to functional health service delivery and essential to communities, there is a need to continue to re-align nursing care to consumer needs and to recognise that client needs are a driver of nursing services and that clients are increasingly knowledgeable about their own heath care needs and more demanding of quality services. The majority of papers in this volume remain focussed on the registered nurse role. This potentiates the perceived lack of alignment between the espoused consumer-focussed approach to the provision of nursing services and changing nursing roles and functions/nursing work.The roles of registered nurses as supervisors and managers of other workers have yet to be fully accommodated into management, education and practice. Conway and Kearin caution that unless nursing is inclusive of a range roles, functions and positions, other less well educated and regulated categories of worker will be seen to be attractive to employers and governments.There is a need for registered nurses to step up to the mark and accept their responsibility for roles other than direct care giver and enact the strong leadership and change management skills that are essential for contemporary work environments. One of the most challenging aspects of the changing scope of practice is related to the management role. The management of human and other resources is a major function of nurses and may impact on the potential for full utilisation of the scope of nurses roles and functions. Hogan provides a literature view of Australian State and Territory reports about nursing shortages to conclude that while new human resource strategies for recruitment, selection, performance and change management are required to attract nurses to the workplace, the relationship among nurses and their managers is critical to nurses being efficient, productive and satisfied with being in nursing. She highlights

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the need for appropriate investment in strategic human resource management practice to prevent high nurse turnover; ensure appropriate performance development processes are in place and enable recognition and reward for exemplary ethical practice. There are a range of other professional career development opportunities in the workplace that nurses should capitalise upon including peer supervision, mentorship, secondment, reflective practice and self directed learning. Health departments and health care agencies need to develop principles for optimum support mechanisms in partnership with higher education providers of nursing education to manage the transition to the workforce. Jane Conway and Margaret McMillan

References Fiol C and Lyles MA (1985) Organizational learning. Academy of Management Review 10(4): 803813. Hall GE and Hord SM (2001) Implementing change: Patterns, principles, and potholes. Allyn and Bacon: Boston. McAdam R and Leonard D (1999) The contribution of learning organization principles to large-scale business process engineering. Knowledge and Process Management 6(3): 176183. McMillan M, Conway J and Fitzgerald M (2004) A Desktop Study of NursingWorkforce in the Aged Care Sector.The Department of Health and Human Services:Victoria. Scottish Executive (2006) Modernising nursing careers: Setting the direction, accessed at http://www.dh.gov.uk/PublicationsAndStat istics/Publications/PublicationsPolicyAndGu idance/PublicationsPolicyAndGuidanceArtic le/fs/en?CONTENT_ID=4138756&chk=n Til%2Bg on 20 February 2007. Volume 24, Issue 2, April 2007

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