Professor Sandy Middleton
Director, Nursing Research Institute, Australian Catholic University & St Vincent’s Health
Ceremony: 7 May 2019, 2:00pm - Faculty of Health
Speech
Pro Chancellor, Ron Sandland; presiding Vice Chancellor, Ann Dwyer; presiding Dean, Joanne Grey; presiding Director, Christine Burns; members of the University Executive; Academic Board; staff, family, friends and graduates, it’s an honour to be invited here today to deliver this address and I thank the Vice Chancellor for this opportunity.
I acknowledge and pay my respects to the Gadigal people of the Eora nation upon whose ancestral lands the university now stands.
I would like to express my warmest congratulations to all of you upon whom the university has today conferred degrees. You are all entitled to be very proud of your achievements.
Most of you are entering your chosen profession at a time of unprecedented social, economic and technological change. For some of you, the changing nature of life and work may challenge you to reflect on the fundamental pillars or principles of your profession. It could also create opportunities for transforming the way you practise your profession and deliver services to your patients.
But is all change good or even necessary? When changing a workplace or practice, we need to be conscious of not, as they say, throwing the baby out with the bathwater. So, how do we decide what to change or discard and what to retain? It’s the concept of adapting to change while preserving fundamental or core principles that I wish to explore in this address.
I want to take you back to the 1980s. Bob Hawke was the Prime Minister and some of us were dancing to the music of U2 and Madonna, and very few of our new graduates were yet born. I was a newly-graduated registered nurse working at Sydney Hospital. I vividly remember being relieved that I was leaving my student days behind and impatient to get on with it. Being a registered nurse was daunting at the beginning, but you put on the uniform and you take on the role and you assume the responsibilities.
On my uniform, I wore two items which were very important to me on a personal level – a gold fob watch that my parents had given to me when I was a student nurse, and a name badge which I was very proud of because it had ‘sister’ written on it and it signified all my years of study. I also carried multiple items around with me in my pockets, which were, if you like, my tools of the trade: A multicoloured pen, a pair of scissors and a pair of Spencer Wells artery forceps – and eventually I went on to have my own stethoscope.
These items had practical importance because they helped me to perform the fundamental or core nursing practices, aiming to deliver safe, high quality health care to improve the health outcomes of patients. We did this by close observation and appropriate management of core physiological vital signs – respiratory rate, blood pressure, heart rate and temperature.
In the 1980s, our technology was fairly basic. We used glass mercury thermometers, manual blood pressure machines and we recorded observations on paper-based charts. At this time, Australia’s health system was undergoing a significant transformation due to the advances in technology, increasing complexity of patients’ health problems, and changing models of treatment and health services delivery.
In response, nursing was also undergoing a significant period of change, review and reform. Historically, nursing education had been provided by public hospitals and based on the apprenticeship model known as the nightingale system. Student nurses were selected by individual hospital matrons on the basis of their educational and moral standards. They were paid a wage, which often included board, and they were educated in hospital-based schools and trained in the hospital wards.
The role of the nurse was also becoming increasingly complex. As a result, there was a need for a level of formal theoretical education and practical training that extended beyond mere technical competence. These changes, coupled with the drive by nurses for professional recognition and elevation of their professional status, contributed to the need for a transition in the education of nurses from a hospital to a university-based system.
I left school and entered the nursing profession right in the middle of this change. I was one of the first nurses to undertake my nursing education, as opposed to training, at a college of advanced education. There were only 15 of us in my year. We were in the minority and viewed with overt suspicion by medical and other nurses, and we frequently heard, ‘Oh, you come from the college of knowledge.’
This was a huge period of change and people were worried about the clinical competency of university nurse graduates. At times, we also experienced antagonism by hospital-trained nurses and doctors about the greater degree of autonomy that we were displaying, particularly around challenges to traditional practices and assumptions. There was even a quote in the Canberra Times during this period that voiced concern that nurse education in universities would attract people who were more academic but less sympathetic to patient needs.
Despite all of this debate, resistance and opposition, nursing education moved to the university sector, and by 1994, all registered nurse education was based in universities as an undergraduate degree. A new body of knowledge grounded in nursing and validated through nursing research would be the result, and we now have professors of nursing like myself and my colleagues here today.
I eventually went on to specialise in intensive care nursing. Intensive care nursing is particularly challenging as the patients are seriously ill, and nurses have to meet the physical and emotional needs of patients and their families. It’s also a very fast-paced health care environment where nursing practice is interwoven with technology, such as cardiac monitors and ventilators.
Nevertheless, I still wore my nurse’s watch and carried around all the tools of my trade, because they were practical and played an important role in delivering care to and ensuring the safety of my patients.
I recall one particular shift I was alone in the coronary care unit on night duty. One of my patients was concerning me; I couldn’t quite work it out. His cardiac monitor showed a regular rhythm, but I couldn’t obtain a blood pressure reading. This was highly odd. The technology – the cardiac monitor – was indicating that the patient was quite well. I could see the heart rate trace going across the monitor; however, my clinical assessment based on close observation and monitoring of his vital signs was suggesting otherwise, that this patient was really quite unwell.
I went with my clinical judgement and called in the emergency response team. The patient was diagnosed with a condition known as electromechanical dissociation, which means that the electrical circuitry of his heart was working fine, as indicated by his normal rhythm on the cardiac monitor, but his heart was so damaged mechanically that it was not able to pump the blood around his body. Sadly, he died soon afterwards.
And what I learned from this experience was that you can have all of the expensive, cutting-edge technology at your fingertips and receive patient clinical data from monitors, but the fundamental nursing skills of routine observations of vital signs and initiating action on the basis of abnormal observations are still highly relevant. I still needed my watch, my pen and my scissors in this technological environment.
I’m now working with colleagues from Queensland University of Technology on a multi-site trial introducing a bundle of core assessments for all patients at the beginning of each shift, coupled with improved team communication. How old fashioned, really, as this is the way we used to practise in my training days in the Nightingale wards. We’ve given all the nurses their own stethoscopes and they’re being asked to use manual blood pressure machines, rather than relying on the automated machines that use the actual mean arterial pressure to estimate systolic and diastolic pressure. Like all modern trials, this one has a fancy acronym, and it’s called ENCORE. However, I jokingly call this the Back to the Future Trial for its focus on more core assessment skills.
I eventually left clinical practice to pursue a career in research. One of my research areas is working with patients who’ve had a stroke. My research has shown that patients who are cared for in stroke units and who are closely monitored for fever, high blood sugar levels and swallowing difficulties are significantly more likely to be alive and independent three months after their stroke. This is all due to the effect of good nursing care and nurses performing three simple things well.
These are the same fundamental or core practices that were important when I started out in nursing over 30 years ago and continue to be so today. The equipment may have changed – we now use tympanic thermometers that are placed in the ear rather than glass thermometers to measure temperature. To measure glucose levels, we use machines at the bedside – point of care testing, rather than sending the blood sample to the laboratory as in the old days. But while it’s wonderful to have all these innovative pieces of technology, at the end of the day, the fundamental guiding principle is to always check your patient.
I still have my first name badge and my nurse’s watch and my scissors and my artery forceps and my stethoscope. When I look at these items, it’s as if I’m gazing into diorama of nursing from the late 1980s. They also remind me of the journey I’ve taken in nursing. I’ve been fortunate to witness many changes, including the transfer of nursing education to the tertiary sector, the expansion of clinical practice opportunities for nurses, including development of the role of the nurse practitioner, and the growth of evidence-based nursing and research-based practice.
In summary, my main message to you today are firstly, as professionals, you’re going to face constant change through your career. Change is part of our natural condition, so we need to adapt and embrace change. But that doesn’t mean that we have to do so without considering the context and questioning the merit of value of those changes. Does it improve patient care, is it evidence-based and will it benefit my patients?
Secondly, at university we are taught the core values and fundamental practices of our profession and we need to use these to guide us through our career journey and to navigate change. The UTS values of discover, engage, empower, deliver and sustain will guide you well.
I congratulate you all and wish you every success for your future careers and leave you with a quote from Charles Darwin: ‘It is not the strongest of species that survive, nor the most intelligent, but the one most responsive to change.’
Thank you.
About the Speaker
Professor Middleton is the Professor of Nursing and Director of the Nursing Research Institute, St Vincent’s Health Australia (Sydney) and Australian Catholic University.
She was the lead investigator on the breakthrough National Health and Medical Research Council-funded ‘Quality in Acute Stroke Care’ cluster. Her trial demonstrated decreased death and dependency following implementation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing post-stroke, winning multiple international awards for this work.
In 2014 Professor Middleton’s research was recognised and was awarded the NSW Premier’s Public Sector Award for Improving Performance and Accountability, and the NSW Health Nursing and Midwifery Award for Excellence in Innovation Research – the highest NSW accolade for a nurse researcher.
Her research has also been recognised through her induction in to the Sigma Theta Tau International Nurse Researcher Hall of Fame.
Professor Middleton is a Registered Nurse, having graduated with a Bachelor in Applied Science in Nursing, Master of Nursing and a Doctor of Philosophy in Medicine from the University of Sydney.
