Professor Sandy Middleton
Director, Nursing Research Institute, St Vincents & Mater Health Sydney and Australian Catholic University
RN, BAppSc(Nursing) (Sydney), MN (Sydney), PhD(Med) (Sydney), FCN, FRCNA
Sandy Middleton addressed graduates from the Faculty of Nursing, Midwifery and Health in the Great Hall, University of Technology, Sydney on Friday 27 April 2012, 10.30am
About the speaker
Our speaker today is Professor Sandy Middleton.
Sandy is the Director of the Nursing Research Institute, a joint initiative between St Vincent's and Mater Health Sydney and Australian Catholic University. She is also Director of the National Centre for Clinical Outcomes Research, Nursing and Midwifery, an Australian Catholic University Priority Research Centre.
Sandy has a particular interest in stroke and implementation research and has been successful in obtaining funding as a chief investigator on 51 grants attracting funding over nine million dollars.
She was awarded a National Health and Medical Research Council grant for the Quality in Acute Stroke Project and was the lead investigator on this recently concluded trial. She is also the lead investigator on the Triage, Treatment and Transfer in acute stroke trial.
Professor Middleton has a Bachelor of Applied Science (Nursing) and a PhD (Medicine) from Sydney University. She is a Fellow of The College of Nursing, where she previously served as a director. She is also a member of the Royal College of Nursing, Australia. Sandy peer reviews articles for the Journal of Advanced Nursing, Contemporary Nurse and Australian Health Review.
It gives me great pleasure to invite Professor Sandy Middleton to deliver the occasional address.
Speech
Chancellor, Vice Chancellor, members of Council, staff, distinguished guests, graduates, families and friends, thank you for this opportunity to address you today.
I would like to acknowledge the traditional owners of the land, the Cadigal and Guring-gai people of the Eora Nation.
As the Chancellor has outlined in her message to you in your program today, the majority of you are poised on the threshold of your careers with unknown possibilities. Who knows where you will be in five years time and what you will be doing. I wanted to take this opportunity to share with you three brief stories that I hope you will keep with you while you advance your career. My address today is centred around the theme of doing the simple things well.
As the Chancellor has told you, I am a registered nurse who works in the area of research, particularly health services research which involves looking at the way nurses care for patients and how we can do this better. I have worked in the nursing profession in a variety of capacities for the last 30 years and I feel very long in the tooth, but very excited for you as I look out at all of you today about to embark on similar journeys.
Of course, I didn't always work in research. Many moons ago, I was a clinical nurse and my area of interest was intensive care. In fact, the intensive care unit at Sydney Hospital is where I first met your Dean, Professor Daly when he was a young student undertaking his intensive care course certificate. Professor Daly was very knowledgeable and wise and always helpful explaining things to the 'new kid on the block'.
Intensive care is often initially overwhelming for a newly graduated nurse; the patients are the sickest in the hospital and surrounded by all the latest technology which is designed to keep patients alive. I loved that technology and learning how to use if properly to help me keep a close eye on my patients. One important lesson I learnt from working in intensive care though is that the equipment wasn't infallible. Occasionally alarms would ring alerting me to potentially dire consequences such as cardiac arrest or the fact that the patient may have stopped breathing but when I investigated further by actually checking the patient before I checked the equipment, I often found that the patient was quite stable but the equipment had malfunctioned, for example a loose connection in one of the cardiac leads. One particular shift, I was alone in the coronary care unit at Sydney Hospital on night duty. This was a small four bedded unit that only had one nurse on nights. I was only about 9 months post-graduation and one of my patients was concerning me. I couldn't quite work it out. His cardiac monitor had a lovely regular rhythm but I just couldn't hear a blood pressure. This was highly odd. Of course, one doubts oneself in these instances, perhaps my blood pressure technique was poor? Was I placing the stethoscope in the correct position? Did I need to get a larger cuff to go around the patient's arm? Importantly, was this patient quite well as the monitor would suggest or quite sick as my clinical assessment would suggest? Should I make a fuss by calling in the medical emergency team at the risk of looking very foolish if this were operator error?
In the end, I did call in my more experienced colleagues and this patient had what is known as electro-mechanical dissociation. A fancy name for the fact that the electrical circuitry of his heart was working fine, as indicated by the normal rhythm on the cardiac monitor but his heart was so damaged mechanically, it was not able to pump the blood around his body. Sadly he died shortly afterwards. This was a very important lesson for me; one that has stood me in good stead in my career and I pass this on to you today. Trust your judgement. Look at your patient, touch them, talk to them. If things don't look right, they probably aren't right. Who knows how technology will develop over the course of your career. This will be very exciting to watch but remember, you can't always rely on expensive technology to do your job for you. The equipment are merely aids to help you keep a close eye on a patient's condition but nothing replaces the thorough assessment skills you have learnt over your three years at University. These skills will always be with you and will prove invaluable.
These basic skills will also be transferable to different settings. This is another wonderful thing about a career in nursing and midwifery. You may wish to work in the Australian health care system but it is likely that many of you will seek to gain experience working overseas. Another option is working in different settings such as rural and remote nursing and midwifery. Some may even work with disadvantaged communities internationally.
A few years ago I travelled to a remote Himalayan Village, well off the tourist trekking route that rarely saw outsiders and helped to run a medical clinic. It was one of the most rewarding things I have done and also one of the most scariest. We set up a makeshift operating theatre and together with a group of doctors, nurses and volunteers with no medical training, who had never worked together before we performed nearly 100 operations. We had no diathermy, no heart monitors and the only piece of technology we had was a pulse oximeter to measure the oxygen concentration in the blood. This was a very challenging time for an ex-intensive care nurse used to having equipment with all the bells and whistles. Again, it was back to basics for me. Observe the patient. There is nothing that can replace good patient observation and these are skills that are with you even when the technology is not; invaluable to me nursing those patients in that remote environment.
The value of good basic nursing care is evident in a large piece of research I have recently had published in the Lancet that involved nearly 2000 patients cared for in 19 hospitals across NSW. We developed three nurse-initiated clinical protocols to manage fever, raised sugar levels and swallowing problems after a stroke. We then worked with clinicians from a variety of health disciplines to get the clinical protocols into routine care delivered by nurses. We found that those patients who were cared for in hospitals who received our clinical protocols were more likely to be alive and independent three months after their stroke. The effect of our protocols was very large; we saved the lives of one in six patients who otherwise would have died or have been dependent. This effect is larger than any known current drug or treatment for stroke and has caused a great deal of interest internationally. This research has also revealed some valuable lessons for nursing care.
Often researchers are seen as being a bit removed from clinical care or of undertaking research that does not have direct clinical relevance to patients. This study was an excellent example of clinically relevant research that actually made a difference to patient outcomes. Furthermore, we weren't testing an expensive drug, nor were we testing a new device or technique or a piece of equipment. So what exactly was it we asked nurses to do? Nurses were asked to take patients temperature and give Paracetamol if it was above 37.5 degrees Celsius; they were asked to measure patients' sugar levels and treat major episodes of elevation with insulin; finally nurses were asked to observe patients for their ability to swallow safely and to refer them to a speech pathologist where there were problems.
I first presented these results at the European Stroke Conference in the late breaking clinical trials session. This is a session dominated by medical practitioners as you can imagine. When they introduce you they say 'This is Dr Middleton' so its often assumed you are a medical doctor. At breakfast the morning of my presentation, one of my Australian physiotherapist colleagues said, 'Sandy, when you get up there this morning, tell them you are a nurse'. This had never occurred to me but this is exactly what I did. I stood up and told them I was a Professor of Nursing at Australian Catholic University and St Vincent's & Mater Health Sydney and to my shock there was a murmur that went around the auditorium. 'A nurse???' Clearly not expected. However, after my presentation a very senior world renowned researcher (who was a doctor) stood up and said 'This study is an excellent example of doing the simple things well'. This phrase has stuck with me as this is exactly what this research has shown. What we were testing was good, evidence based nursing care and I was very proud to be a nurse presenting these results. This was the kind of care that doesn't require the latest technology to provide but the kind of care that does require good clinical nursing skills, good assessment skills and prompt treatment of any anomolies. It is also the kind of care that is very transferable, even to remote settings.
So remember, where ever you choose to take your nursing and midwifery skills, never underestimate the value of observing your patient and doing the simple things well.
