Ms “Median” profiles

1 January 2014

We profile two nurses still nursing 20 plus years on after graduating in the early 90s when jobs were even tougher to get than now.

A few years ago, the Nursing Council drew up a profile of the “median” New Zealand nurse based on their workforce statistics. She was a ‘she’ (the vast majority of New Zealand nurses are), aged in her mid-40s, probably Pākehā and worked 0.8 in a ‘med/surg’ role for one of the three Auckland district health boards.

FIONA CASSIE went searching for Ms Median and found Adrienne Batterton from Counties Manukau District Health Board and Melissa Lee from Waitemata DHB. At 42, both are a little young for the profile. Their stories are individual but commonalities emerged from the two interviews.

Both have 20 years in health behind them, both are mums of similar aged children, both have just started (or about to start) postgraduate study, and both say patient acuity and ward nursing is tougher than ever before but – while patient expectations are also higher – the patient experience and safety have improved for the better.

Taking the next step after 20 years

Two decades on, nursing is the same but harder, says North Shore Hospital nurse Melissa Lee.

Nursing in North Shore Hospital for the past 20 years – 17 in the same acute orthopaedic ward – Melissa Lee has seen many nurses come … and many go.

Still nursing at the hospital where she and her classmates did their clinical training, she can’t think of any of her year that are still on deck. At least four are now in medical sales.

But Lee says she still enjoys nursing and the teamwork on the ward and works four shifts a week to fit around her primary school-age family. Though she also finds nursing more demanding clinically than ever before, with higher acuity patients and greater patient-centred care, and more demanding professionally, with the need to keep up her portfolio and be involved in auditing and research.

The demand is to the point that next year she hopes to do some postgraduate study to build her research and writing skills – her first formal study since graduating from the then-AIT nursing school back in 1993 – and confesses to being more than a little nervous about stepping back into academia.

Lee worked in retail and banking before beginning her nursing training in July 1990. “I’d left school early, and I wanted to do something more meaningful.”

When she graduated in 1993, nursing jobs were scarce, and with graduates facing the catch-22 of needing experience to get a job, Lee jumped into the deep end and became a bureau nurse at Auckland Hospital. From Auckland, she went to the North Shore bureau, and finally, about a year after graduating, she gained her first full-time position at North Shore’s Ward 6.

She recalls that first job as physical hard work – the average nursing ratio was six patients to one nurse and health care assistants were still to come.

“I do remember having a pair of gumboots with my name on the side. It was a hard slog that I can vividly recall, particularly as it was a medical ward and I would be doing showering and basic cares till about 1 o’clock.”

It was also a chance for Melissa, then in her mid-20s, to consolidate her nursing practice before moving across to ward 7, where she remains 17 years later.

Lee says she imagined herself back then taking

up her studies again and in time moving up the nursing ranks.

But after having the first of her children at 30, she found it busy enough being both a mum and a nurse in a demanding ward environment, and she has stayed in her comfort zone on the ward floor.

“It is a very taxing job; you get here and hit the ground running from the morning until 3.30pm, and then you have to get home and do your other job,” says Lee.

It is also not an easy climate to change jobs with so many new graduates and others keen to find posts.

Now 42, she works four rotating shifts a week on the ward and juggles that with family. She looks fondly at the new graduates, “full of energy enthusiasm and charging around … I remember being like that, but 20 years down the track, it is quite tiring.”

The full-on demand of an acute ward catering for patients such as road crash or fall victims sees very few senior nurses left on the team, says Lee. Most have moved into clinic work, education, or left the hospital altogether “because they get burnt out.”

“The pressure is on now; patients have a lot higher acuity and are a lot more dependent.”

The nursing itself is more patient-focused, more multi-disciplinary, and more technical, with the use of vacuum dressings and senior nurses now assessing and treating wounds.

The patient load is unchanged, though, with Lee having five patients the day she talks to Nursing Review and six the day before. There are now two health care assistants on the ward, which helps a lot, but the nurse is still responsible for their patients.

She says new graduates can sometimes be overwhelmed after their evidence-based training to “find the reality is that it is still a very heavy, physical job” alongside the need to provide clinical reasoning to back your practice.

Having just updated her nursing portfolio, she says the professional expectations of nursing today can be a bit overwhelming for “oldies” like herself, even though she’s only 42.

Today’s ward 7 has a lot of new graduates and a lot of overseas-trained nurses.

“I can be on a shift with me and seven Indian nurses from Kerala – and they are wonderful nurses. There are also lots of nurses from the Philippines and China. All wonderful nurses, but it takes them some time to get up to speed with the culture.”

“But it’s a very demanding job – and after 20 years, I still get the same pay as someone who has been nursing five years.”

“Nursing is probably the same but harder – there are more expectations on a nurse now,” says Lee. “There are a lot more people at the top monitoring you – putting in new policies and procedures and not really seeing the time that you have to do all these things.”

Workload management tools like TrendCare also mean that if there is ever some spare capacity on the ward, then a staff member may be pulled out to help some other ward.

So what has improved over the two decades?

“I think the way we involve patients and their families in their care and care planning is better. Also, patients know their rights. So for the patient, the experience is better now.”

If she had her time over, would she make the choice to go nursing again?

“I’ve got an 11-year-old daughter, and I’m not encouraging her to go nursing … which is a bit sad.”

But she adds that the graduates who join her team are still loving nursing and are really well-educated and keen on the profession. “So there are still a lot of pluses.”


Drawn back to the bedside

Counties Manukau DHB nurse Adrienne Batterton struggled to get her first bedside nursing job in the early 90s, exchanged clinical work for health management ‘Civvy Street’ in the new millennium, and then two years ago, returned to the bedside as a clinical nurse. Patient safety better but nursing more demanding

When Adrienne Batterton sat state finals in 1991, the job market for new grad nurses could only be called dire.

Just a handful of her classmates had jobs to go to, and she wasn’t one of them. It was the year of the “mother of all budgets”, fiscal frugality was the climate of the day, and graduates struggled to get a shoe in the door of the big hospitals.

Batterton had first started studying business but kept getting “extremely distracted” by the nursing texts in the library. “It was the science of nursing that first fascinated me.” So she switched to nursing training at the then-Carrington Technical Institute (now Unitec) in time to graduate into one of the toughest nursing job markets for many a decade.

It sounds like déjà vu for the early 2010s. “Even back then, we talked about there being a seven year cycle in nursing. There’s either no nurses and lots of jobs or there’s no jobs and heaps of nurses. It was never very stable.”

“But we all felt that if we hung in there and did some fill-in jobs that the DHBs – or CHES (Crown Health Enterprises) as they were called back then – would eventually give us a job.”

Meanwhile, the later fashion of graduates crossing the Tasman to seek work was yet to emerge. Instead, the trend in the early 1990s was to look to the USA with the help of the Nurses Society. The starting salary of the equivalent of nearly NZ$100,000 compared to around $24,000 back home was also a drawcard.

So Batterton and four nursing mates, having had no luck in New Zealand, made a flying visit New York in 1992 to sit the American licensure exam NCLEX before flying home to cross their fingers and wait up to eight weeks for the results.

Love and NWH change fate

Batterton was the only one of the five to pass, but while she was waiting, fate intervened in the form of National Women’s Hospital and love. Firstly, National Women’s offered her two days work a week, which she jumped at as a foot in the door. Secondly, she met the man who is now her husband.

Looking back two decades on, she doesn’t regret her decision to stay put in Auckland. She says she always believed nursing would open up opportunities for her, and she initially envisaged this would happen through travel.

“But my nursing career has offered me a multitude of opportunities and they have all been in my own backyard – I didn’t have to go very far at all.”

The first of those opportunities was stepping up slowly and surely into a full-time position at National Women’s Hospital. She says while she was a “little bit bullet-proof” in her early 20s, her major recollection of those initial years was the collegiality and the teamwork, plus a more hierarchical nursing structure and some of the last of the “old school scary” nurses.

Batterton says her early ambition was to be a charge nurse and she was “very lucky to have an amazing charge nurse at the time who supported me in that, and it was very encouraging.”

It was in the days of Jocelyn Peach being director of nursing at Auckland, and Batterton says she took all the opportunities for in-house management courses; external postgraduate study was not the push at the time. She moved into an after-hours clinical nurse advisor role and then moved into an operating theatre role to widen her experience.

“I pretty quickly worked out that wasn’t for me … I absolutely despised theatre nursing, but luckily for me, a charge nurse role in women’s health opened up at what is now Counties Manukau DHB. I’ve basically been at Counties ever since.”

Batterton says she was lucky again with her next boss as when she and her husband tried to start a family it unfortunately did not go smoothly for them. They decided to adopt, and in the meantime, she found continuing clinical nursing in women’s health just became “too difficult”.

“My boss wouldn’t just let me plod along and wait for that to happen – she said come and do this while you are waiting.” The “this” was becoming a project manager for South Auckland’s acute hub project – which at that point was the biggest emergency department in Australasia – “a really exciting but slightly daunting job”.

“I can remember having some incredibly deep, dark doubts about my ability to do that job, but as it happened, I really loved it. It was one of the best jobs I’ve had.”

During her next job as acute care services manager, the couple adopted their son (now 11).

“One week I was on the job and next week I wasn’t,” recalls Batterton with a laugh.

After her parental leave, she decided she didn’t want to go back to full-time work. So she rang a nursing colleague working in procurement and for the next eight years worked 0.7 as a procurement specialist for the DHB-owned shared services organisation, healthAlliance. During that time, the family adopted their daughter (now 8) – again followed by another rapid exit from the workforce for parental leave – and returned to the procurement role.

Jump in patient acuity an “eye opener”

“In 2010, I started to get the feeling there was more to life than contracts and buying big bits of machinery, and what I was really interested in was going back to nursing.”

Yet again, her timing was not favourable, with the nursing job market tight following the global financial crisis (GFC), but in 2011, she successfully spotted a job as a clinical specialty nurse in quality and risk for surgical and ambulatory care (SACS) back at Counties.

The only sticking point was that having not nursed for more than a decade, she had to do a return-to-work course to regain her annual practicing certificate

The eight-week course, with about 20 local and overseas-trained nurses, was a “real eye opener” for Batterton, who couldn’t believe the patient acuity during her Middlemore clinical placement in a general medical ward.

“In the first two days I thought ‘oh my god!’” recalls Batterton, but she kept reminding herself how many fantastic nursing jobs would re-open to her once she had her APC.

“The patients were so sick and the complexity of care they required was just much higher,” says Batterton of that eye-opening exposure to a modern medical ward.

“Ten years earlier, I reckon they would have been HDU patients – the patients were having massive surgery and had so many co-morbidities and needed complex interventions. It was drastically different from a decade before … though you have to allow for different specialties – women’s health is women’s health and high-end general surgery is always more higher acuity – but this was noticeable.”

She persevered and now works as 0.3 in the quality and risk nursing role after taking on a 0.4 clinical nurse specialist role in the acute pain service in May. The traditional path for her new CNS role is through post-anaesthetic/recovery nursing, but because of her senior nursing experience, the pain service was open to giving her a go as she could learn the clinical content.

“I work 27 hours a week for both of my roles and the study requirements were 20 hours a week above that for a 30 point paper … with two kids, it was full on … a real challenge, says Batterton.

“I just have to keep in my mind that anything that hard has to be worthwhile. Things that come easily are generally not that worthwhile.”

Though extra study is now an accepted part of today’s nursing culture, her previous role as a charge nurse manager in the late 90s had also been “full on”, but a major difference was postgraduate study was never discussed and in-house courses were the norm.

Patient safety better but nursing more demanding

She doesn’t regret her return to clinical nursing. “I love it. Counties has a really unique culture and if that culture works for you it’s fabulous … and it works for me. I really love it.”

The make-up of the nursing workforce has changed over the decades but the nursing ethos remains the same. “The team work never fails to astound me. Some things never change.”

“The most overwhelming thing that I’ve noticed, in terms of improvement, is patient safety. We’ve got much more wrap-around intervention bundles now on how to guide care; on top of your nursing gut instinct, there are also things like early warning systems, care pathways, deteriorating patient algorithms, and on-call patient-at-risk (PAR) nursing teams.

“We are also now a lot more patient-focused or patient-centric in what we do.”

That doesn’t mean care rationing is happening on hospital wards.

“I remember care rationing when I was a new grad as well … it’s not a new concept in nursing,” says Batterton.

“To me, care rationing is just another term for prioritisation of tasks. On the days when you have five very sick, high acuity patients to look after, you prioritise to get the job done and keep the patient safe. That hasn’t changed at all.”

Batterton says it would have been wonderful to think you could give everybody a wash in bed or full nursing care services ‘like the old days’ but is convinced that patients are safer today than they were in the good old days.

She says some people see the use of algorithms and pathways as a “dumbing down” of nursing. “But I say working with a tick box doesn’t absolve you of any responsibility to think critically. It doesn’t absolve you from assessing the patient and taking accurate and timely interventions.”

Batterton says another thing that’s changed is patient expectations. “I think they want case management rather than nursing care sometimes.”

Nursing may be no easier than ever before but Batterton doesn’t believe it has lost its heart or ethos.

“I think the art of nursing is really alive and kicking – I see it every day when I do my clinical work. There are the nuances; there are the grey areas and the critical thinking and decision-making. There’s absolutely a place for people with loads of experience to bring the art of nursing to the bedside. Patients know that, and see that, and they comment when it happens.”