The student nurses view of the future of nursing.  AEJNE Volume 6 - No.1 June, 2000. Jim Kevin, RN BA(NSW) MN (Deakin) Lecturer at LaTrobe University, Bendigo Sharon Kendall RN Grad Dip Hlth Sci (Ed) Mhlth Sci FRCNA Lecturer at LaTrobe University, Bendigo   Abstract Twelve student nurses in their final year of study were asked to discuss their predictions for the future of nursing and their role in that future. Each student was individually interviewed utilising a semi structured approach. Analysis of these responses revealed an overwhelming commitment to the continued incorporation of holism into the care delivered. The respondents also indicated that there will be increasing autonomy in the role of the nurse along with an expansion of duties. The responses also contained a noticeable level of pessimism regarding future resource allocation with a subsequent effect on the quality of care delivered.   Introduction The focus of this paper is on the expectations of nursing students regarding the future of nursing. Students are asked to comment upon their predictions on the role of the nurse in the future. The nursing curriculum has a significant influence on the formation of these opinions. This paper argues that a curriculum should facilitate the formation of reasonably accurate student expectations in order that the student, upon graduation, is not confronted by a career and a work environment which is completely at odds with his or her understandings. Nursing is recognised as being a practice-based discipline but the nursing literature contains many references to the ìtheory-practice gapî (Waterman, Webb & Williams, 1995; Pryjmachuk, 1996; Tolley, 1995; Allmark, 1995; Conway, 1994) which is the perceived difference between the principles reflected in curricula and those reflected by clinicians in practice. After the education of nurses was transferred to the University sector, many authors raised the concern that university-based teaching staff were likely to 'lose touch' with developments in the clinical world (Sims, 1991). As a consequence, it was argued, university curricula may not reflect current practice and philosophy (Sims 1991). If the theory practice gap is not minimised, it can cause difficulties because the principles of practice established in curricula are not well aligned with the principles operating in the workplace. This difference in philosophy can be problematic for a new graduate, which in the extreme, may cause them to leave the profession prematurely. Accordingly, the nurse educator should constantly strive to ensure that theoretical content is designed to adequately prepare graduates and so avoid, or at least minimise, 'reality shock' (Kramer 1974). One method of ensuring that students are being appropriately prepared for practice is to ask them of their definitions of the nurses' role and their expectations regarding the future of nursing. Presumably, the studentsí responses are the result of the education process. These responses can then be compared with those predictions of the future role of nursing located within the literature. If the studentsí expectations reflect trends articulated by nursing leaders then a student will be more equipped to take on their new role and to function in a more effective manner because the educational process has been closely aligned with developments in the practice arena.   Literature review A review of the literature revealed a number of significant nursing issues that are described as probable and desirable directions which the profession should follow. Expansion of Boundaries Many authors describe the expansion of the role of the nurse to incorporate roles outside that of the traditional acute care setting. Such roles include health promotion and teaching in the community (Wass & Backhouse, 1996; Lindsay, 1997). Further, the role of the nurse in community care, especially for the advanced practitioner and the clinical nurse specialist, is also a potential role in the future because new opportunities are being made available for nurses as a result of the expansion of home care (Kelly, 1995; Miller, 1995; Cronenwett, 1995; Hamitic, 1995; DiGiacomo-Geffers, 1997). Such nurses are recognised as having developed a specialist expertise and are utilised as educators and advisers in addition to the role of clinician. Further, an increased involvement in the area of rehabilitation is seen to be increasingly vital to facilitate the earlier release of clients back to their homes. It is argued that the role of the nurse is insufficiently recognised and so not utilised as effectively as may be possible (Waters & Luker, 1996; Theurerkauf & Schuster, 1994). Greater Autonomy An example of greater autonomy is clearly indicated by discussion of the new role of independent nurse practitioners which have been recently identified through a longitudinal study in Australia to be an important new role for the registered nurse (Prenesti, 1996; Tattam, 1995). This role has been particularly targeted for meeting the needs of rural communities (Cramer, 1994; Mensink, 1995) and has been variously described as either working in conjunction with a medical practitioner or perhaps replacing the general practitioner in those more isolated settings in which a doctor is not available. A number of predictions refer to an increase in autonomy for nursing in the future. Practitioners require greater autonomy and need to possess the ability to be critically reflective (Lindsay, 1997; Elliott, 1995; Flarey, 1997; Kiggundu, 1997). A greater autonomy, particularly when linked to the nurse practitioner, facilitates the provision of a variety of services in, for example, women's health (Spatz, 1996), and so further expand the areas in which nursing is practised. Correlating with the notion of increased autonomy, the issue of advocacy (and the difficulties entailed in adopting such a role) remains a central point in discussion of the nurseís role (Ellis, 1995). This also involves increased collaboration with the patient (Spitzer, 1997). The ideal of advocacy is linked to holism and caring which have both gained significant prominence in nursing philosophy over the last decade. New responsibilities There has also been discussion over new responsibilities that are less directly linked to clinical nursing care. One of these new directions is the role of Case Manager (Kiggundu, 1997). Such a role involves autonomy and coordination responsibilities for the care of clients. Further, the development of more senior roles is discussed in relation to the development of nurses in the roles of senior management in such positions as Chief Executive Officer etc. (DiGiacomo-Geffers, 1997; Spitzer, 1997) Increased research activity has also been identified as being increasingly central to the role of the registered nurse (Gebbie, 1997). The increased emphasis on evidence-based practice (Pearson, Borbasi, Fitzgerald, Kowanko & Walsh, 1997; Tisdale, Williams-Barnard, Moore, 1997) also dictates that nurses must be able to consume and conduct research to ensure that the best possible principles of care are being followed. The role of researcher is one which continues to be highly regarded as a role which can facilitate change within the health care delivery system (Bidwell-Cerone, Miller, Haber, Penney, Carter, 1995; Hegyvary, 1997). The implication of research having a more central position in the nursesí duties is that nursing knowledge will be more congruent with the clinical setting Meleis, 1997; Lang, 1997; Hegyvary, 1997) and so ensuring that practice is always effective. A number of authors also believe that there will be (or should be) a bigger participation of nurses in health policy development (Gebbie, 1997; Feetham, 1997; Hegyvary, 1997). The arguments revolve around the notions of empowerment for nurses to make decisions regarding resources to ensure that the clientís needs can be met. Central to these arguments is a strong commitment to ensuring continued quality of care for clients which aligns with the earlier discussion of holism and advocacy. Considering the future role of the nurse from a global perspective, the World Health organisation released a report in 1994 (WHO, 1994). The report suggested that nurses need to address the health needs of people in vulnerable groups. In addition, the report suggested that nurses should consider their reluctance to work in rural areas as these areas were suffering a shortage of health personnel. Summary The main themes that seem to be coming from this literature review is that a client - centred approach continues to be the main focus reflected in these articles. In addition, it also seems to be suggested that this approach can best be achieved if the nurse has a greater autonomy along with the work of nursing being seen to be broader than simply involving hospital based duties to include a community focus, indirect care, policy development, research and management. Upon reflection, this overview of the literature indicates that any future role of the nurse is discussed in terms not only of skills but also in relation to level of independence, political power and greater responsibilities. Further, the traditional medical perspective is well and truly replaced with one of health promotion, client centredness and holism. Method Rationale for and significance of the study An important goal of nursing education is to prepare graduates that are responsive to the challenges that will face them in a seemingly ever-changing health care environment. It is imperative that the new graduate possesses the appropriate knowledge and skills required to function as a beginning level practitioner. The graduate also requires insight into the career philosophy and scope of practice. Examination of the perceptionsí of final year students can provide important information that may impact on curriculum planning and implementation and also future clinical employment. Problem Statement Does the final year nursing student identify trends in the future of nursing which reflect predictions identified in the literature? Theoretical Framework Using Grounded Theory as the theoretical framework, this qualitative study aimed to identify students' perceptions of the future of the discipline and possible roles for new graduates in that future. This methodology is a qualitative approach aimed at understanding, explaining and developing theory which is generally inductive (Morse & Field, 1996, p9; Streubert & Carpenter, 1999, p99). Grounded Theory claims that theory has to be generated by, or grounded in, social reality and that social research should attempt to discover concepts or processes that will promote the understanding of phenomena and point potentially to the problem solving strategies. Grounded Theory states that the resultant theory attempts to identify concepts from the research data rather than attempting to fit the data into an established theory (Hardey & Mulhall, 1994, p67). Important constructs are identified from the data and further analysis develops a theory from these constructs (Streubert & Carpenter, 1999, p99). The sample and procedure The study utilised a convenience sample of twelve (ten females and two males) final year students from a cohort of 120 Bachelor of Nursing students in a regional university in Victoria, Australia. Students were recruited by describing the research project at a lecture and advertising notices on student notice boards. Interested students were asked to contact the researchers to make an appointment for an interview. Ethics approval was obtained from both the School of Nursing and the university. All students were final year students in the final semester of study. The age range of the students was twenty years to thirty- three years with the average age being twenty-three years. The participants were interviewed in a private location within the school after signing an informed consent form. The interviews were semi structured and the use of an interview guide facilitated consistency while allowing an opportunity to explore the feelings of the interviewees. All interviews were audio-taped. The interviews began with the questions: Can you describe the role of the nurse today? What do you think will be the role in the future? What do you think will be the future of nursing as a discipline? The interviews proceeded following cues from the participants. Data analysis Data analysis was conducted based on the Grounded Theory technique of constant comparison along with open, axial and selective coding methods. The constant comparative method lies at the heart of ground theory and is the principle method of data analysis used in data generation. It involves each piece of data being constantly compared with every other piece of data in order to develop codes and categories (Morse & Field, 1996, p9). This method of analysis requires that the data collection, coding and analysis occur simultaneously. Data is coded to create multiple categories. As data is collected it is categorised in terms of its theoretical similarities. This process continues until no new categories or properties are created - this end point is termed saturation (Tulloch, 1995, p33). Validation Credibility was achieved by each researcher individually coding the data and then mutually deciding on the final categories. Auditability is defined as " the ability of another investigator to follow the decision or audit trail." (Henderson, 1995, p5). The final interpretations are offered along with supporting quotes from the literature to allow the reader to decide if the interpretations made are a fair representation of that data. The processes and procedures of the research were clearly defined and auditable. Fittingness or transferability was achieved in this study by detailing implementation of the study and the environment in which it occurred. Analysis of data Initial analysis involved searching the data for common words or themes in the responses to each question. While saturation is not completely achieved due to the limited sample size, some frequent concepts have emerged. Overwhelmingly, all participants identified the concept/philosophy of holism as being an influential determinant in the delivery of nursing care. This principle is demonstrated by the commitment to client-centred care and client involvement in the planning of care. This philosophy is in direct contrast to the pessimism expressed by many regarding the expectation that the future of nursing will be influenced by a reduction in funding and so this will result in less opportunity to practice basic nursing care. 'I'm hoping that it wont, but I think youíll probably get less patient contact, it will probably be more computerised.' 'The workload has increased.You used to have time to sit and talk to a patient but now there are so many other things to be done that you just canít manage the time.' This philosophy was a major reason for the respondents placing a large emphasis on performing what is described as 'basic care'. The participants believed that delivery of nursing care which addressed the common, everyday needs of the client (such as hygiene, grooming and comfort) were still important and should be incorporated into daily care. Most of the respondents noted that this basic care was being performed less and less because of a lack of time during a shift. 'I don't think we should have moved away from the patient, from the person. Like, I think weíve moved away from the holistic thing into the disease thing.' There is a suggestion that a conflict exists between the studentís ideology of care and the philosophy of the health care setting. 'We're going to have more technology and more impersonal touch and because of [Diagnostic Related Groups] and all the rest of it in health care, the way its going with the funding cuts and that, the patients are going to spend less time in hospital and so therefore they're not getting the same amount of nursing care and its going to go into that process of losing services '. The respondents have also clearly indicated that the role will expand to include a well developed, specialist, knowledge base which incorporates acute care, community health, public health and primary care principles. This role expansion also infers that there will be an expansion in skills performed. The respondents also indicated that management responsibilities, coordination issues and more medical procedures were three areas of skill expansion for the nurse in the future. The predictions made by respondents on a future expansion in the role of the nurse mirrors the statements made by many nursing scholars Wass & Backhouse, 1996; Lindsay, 1997; Kelly, 1995; Tattam, 1995; Shelagh, 1999).   'I think it will get more specialised. From a budget point of view I can see that happening. Yeah, they'll have just a certain amount of nurses in charge of quite a few EN's.' The respondents also held the view that more care would occur in places outside of the hospital setting examples offered were district nursing care, and hospital in the home. A major reason for this change was seen to be the reduced length of stay for many clients ñ this view being one of the common themes also located in the literature (Kelly, 1995; Miller, 1995; Cronenwett, 1995; Hamitic, 1995; DiGiacomo ñ Geffers, 1997). 'I think that [nurses] could take on more of consultative role in the community'. 'I think we're the [health team]coordinators'. In terms of the future direction for the role of the nurse, the respondents demonstrated a well developed sense of accountability towards their clients and to their profession. It was suggested that accountability could be further enhanced if nurses were more involved in the decision making processes which influenced health care. Accountability was directly linked to the perception of autonomy and is also a prediction held by many authors (Mensink, 1995; Elliott, 1995; Flarey, 1997).  'I think that having some say in the direction how the money is spent and the philosophy, having some say in it.' The future predictions offered by students indicated that there is a desire for increased autonomy and an acknowledgment that this autonomy should be matched with a need for increased knowledge and a recognition of this knowledge by others in the health care field. Such comments reflect the views contained within the literature (Lindsay, 1997; Prenesti, 1996; Tattam, 1995; Cramer, 1994; gebbie, 1997; Hegyvary, 1997; Feetham, 1997). Related to autonomy is the expectation that nursing will increasingly develop a reliance on specialist areas of practice and that this will require a commitment to ongoing education and professional development. 'Well, I think nursing's going to become more education orientated. Youíre going to have to be constantly educating yourself.' Interpretation of data The participants showed a well developed sense of accountability towards their clients; especially in the area of delivering holistic and quality care. This accountability was also reflected in the desire to be more involved in the decision-making processes which influenced health care. Perhaps a third area highlighted is the effect that health policy has on direct client care. The responses of participants reflected the literature in the areas of a broader focus of care, a more specialist and autonomous professional and a need to have more involvement in decision-making processes. The participants also, collectively, expressed a pessimism about the future direction of the nursing profession if the future is effected by a reduction in resources. Many respondents made a direct assumption that a reduction in resources will result in a lack of time to perform the basic care discussed earlier. This pessimism begs the question of how long a new graduate will remain in a profession in which he or she feels less than fully optimistic. Future research activities This preliminary study has found some congruence between the expectations of a group of final year nursing students and the literature in the area of future directions for the role of the nurse. The hypothesis to now be tested is that students who hold similar views to the literature will be better prepared to meet the demands of their profession when they commence practice. If this hypothesis is true, the implication is that curricula need to ensure that content reflects contemporary views and predictions. Conclusion The respondents reflected many of the themes also found in the literature. If such congruency between expectation and prediction is important in the preparation of nursing students, nurse educators should constantly monitor trends and predictions and to incorporate them into nursing curricula. This suggestion is of particular importance in the presence of the pessimism which was also found in the responses and which may well cause many to leave the profession prematurely if also faced with a role they did not expect to fulfill.   References Allmark P (1995) A classical view of the theory practice gap in nursing. Journal of Advanced Nursing. 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