An Overview of Issues in Nursing Education

Dick Johnson
Barbara Preston
The Australian Council of Deans of Nursing

01/12
October 2001

Higher Education Division

© Commonwealth of Australia 2001
ISBN: 0 642 77222 3 (Internet copy)
DETYA No. 6761HERC01A

This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of the source and no commercial usage or sale. Reproduction for purposes other than those indicated above, require the written permission from the Commonwealth available through ausinfo. Requests and inquiries concerning reproduction and rights should be addressed to the Manager, Legislative Services, ausinfo, GPO Box 1920, Canberra ACT 2601.

This research was commissioned by the National Review of Nursing Education funded by the Department of Education, Science and Training and the Department of Health and Ageing.

The views expressed in this report do not necessarily reflect the views of the Department of Education, Science and Training or the Department of Health and Ageing

Contents

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Abbreviations and acronyms

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Acknowledgments

This project was funded by the Evaluations and Investigations Programme of the Department of Education, Training and Youth Affairs. It was under the auspice of the Australian Council of Deans of Nursing and was based in the School of Nursing at Deakin University which provided administrative support and assistance.

The advisory team for the project comprised:

• Associate Professor Pauline Nugent, Head of School of Nursing, Deakin University and Chair of the Australian Council of Deans of Nursing;

• Professor Jill White, Dean Faculty of Nursing and Midwifery, University of Technology Sydney and Executive member of the Australian Council of Deans of Nursing;

• Ms Elizabeth McDonald, Department of Education, Training and Youth Affairs, Higher Education; and

• Ms Christianna Cobbold, Assistant Secretary, Health Capacity Development Branch, Department of Health and Aged Care.

The advisory team was appointed by the Department of Education, Training and Youth Affairs as a consultative body to work in an advisory capacity on matters such as scope of the project and methodology. Advisory team meetings were held 3 monthly.

Appreciation is expressed to members Australian Council of Deans of Nursing who contributed to the project through assistance with identification of appropriate reports and participation in discussion groups.

Appreciation is expressed to Ms Kate Duyvestyn, Ms Carmen Mills, Ms Helen Hamilton for the production of this report.

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Executive summary

Soon after the complete transfer of registered nurse education into the higher education sector in 1993, Professor Janice Reid led a review of nurse education (1994)¹. Seven years later, two national reviews have been initiated, one into nursing generally, by a Senate committee, and one into nurse education by the Federal Government. Between these two dates a large number of smaller studies were carried out, partly into aspects of nurse education and partly into questions of supply and demand.

This project commissioned by the Department of Education, Training and Youth Affairs, (DETYA) provides an overview of the more recent of these reports and aims to synthesise the outcome to provide a national picture of the issues. The project was overseen by a Steering Committee comprising representatives from DETYA, Commonwealth Department Health and Aged Care and Australian Council of Deans of Nursing, (ACDN). A number of issues come up frequently in the reports, either as the specific focus of a report or as an aspect of a wider ranging study. These are:

• The changing context of nursing—increasing complexity, pressure; changes of clientele—the aged, the community;

• Dissatisfaction with conditions of work—shift work, frequent changes, overloads, lack of appreciation by superiors and colleagues, lack of child care. Pay is an issue, but not as big as several others;

• Transition from university to employment—the first year, especially the first few months of employment;

• The practicum—finding clinical placements, and funding them. Clinical supervision. Different expectations of academics and clinical supervisors; lack of communication;

• Specialisation—training for it, credentialling of it, specialist and advanced practice; and

• The supply of nurses; issues of recruitment and retention. Why do people enter nursing, and (more urgently) why do qualified nurses leave the profession?

The numerous reports which have focussed on workforce emphasise the need for a national approach to nursing workforce strategies. State and Territory reports have been insular in their recommendations for:

1. Consistency and accuracy of data collection in relation to workforce numbers;

2. Family friendly and flexible work environment;

3. Partnerships between universities and health services in relation particularly to clinical practice and successful graduate transition programs; and

4. Recruitment strategies.

Reports from speciality areas have highlighted the need for career enhancement strategies including postgraduate courses. The sheer volume of work in this area and its segmental and insular nature further emphasise the importance of a national approach.

Some issues are not addressed in the reports:

• Leadership development, management, interpersonal relations - what sort of person is the good supervisor or the good director of nursing? How are they to be developed?

• Evaluation of on-line education for nurses;

• Indigenous issues evaluation of education of indigenous nurses, and education of nurses to care for indigenous clients;

• Education of nurses for multicultural society; dealing with minority groups;

• Issues in education for rural and remote area nursing: limited opportunities for continuing education, staff development, acquiring further qualifications; range of expectations put on the rural/remote area nurse;

• The trend towards specialisation and specialist credentialling;

• Quality of graduates; this is usually seen as a matter for registration boards, but some boards simply accredit universities on the basis of documents and do not assess the quality of the graduates;

• Teaching quality in schools/faculties of Nursing. That does not mean this issue is not addressed; such reviews are carried out within the school or faculty and would not be published by it or the university. There are also many reports of quality teaching within the Australian Universities Teaching Committee (AUTC) and its antecedents;

• Expectations/attitudes of incoming students; comparison with new graduates;

• Links between nursing and non-traditional medicine; and

• Evaluation of double degree programmes.

The workforce studies are usually carried out by government agencies rather than by universities, and focus on estimating and achieving an adequate supply of nurses to meet predicted needs, both for general nurses and in special fields of nursing. These studies are hampered by some inconsistencies of approach and inadequacies in the data.

1. Nursing Education in Australian Universities Report of the National Review of Nurse Education in the Higher Education Sector - 1994 and beyond. AGPS 1994

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1. Overview of recent and current reviews of aspects of nursing and nurse education in Australia

1.1 Introduction

The Deans of Nursing in Australian universities are aware of a large number of reports and reviews of various aspects of nursing education in recent years. They have participated in and/or requested their undertaking and believe that it would be an advantage to have a conspectus to identify common elements in them, divergences or inconsistencies between them, and gaps in their coverage. The Deans identified over forty such studies, carried out usually by nursing academics, sometimes with a focus on a single university, sometimes on issues within a State and occasionally nationally. Each of these has been read and summarised. In this overview they are grouped into the categories of reviews of educational programmes, and workforce studies. This overview sets out the common elements and issues addressed in the reports and mentions some areas which are not addressed. Appendix B lists the reports studied and Appendix C provides the summaries of the educational programmes.

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1.2 The context of nursing today

Health care has become far more complicated and difficult in the last 15 to 20 years than it used to be. As one senior nurse has put it: ‘The people now in general wards were in intensive care fifteen years ago’ and many people cared for in hospital 15 years age are now cared for in the community. The people who are now in intensive care would have died fifteen years ago’. Nursing in hospitals is more intense, more stressful, and far more scientifically based than it used to be. Much more technology is used in hospitals, and the nurses have to know how to use it.

Because of the cost of hospital care, hospital staff from managers to nurses in the wards are under pressure to discharge patients as early as practicable. That meant people in hospital beds are in general sicker and are there for shorter stays than they used to be; for instance, in a base hospital in a rural city the average length of stay is three days, and 70 per cent of patients stay one day. There is thus extra stress on the nurse, and less chance to balance this with the human satisfaction of getting to know a patient and watching a recovery. Another contribution to stress is the decline in the numbers of support staff; between 1991 and 1996 the number of enrolled nurses (EN) went from 39 485 to 24 559. Between 1993 and 1998 the numbers declined by 21 per cent. There has also been a compounding effect of a reduction in non nursing staff eg support from ward clerks. The nursing workforce is expected to be very specialised and very efficient.

At the same time, the places of work for nurses are changing. General hospitals remain the main institutions of employment, but between 1991 and 1996 there was a 47 per cent decrease in the number of psychiatric hospitals as people with psychiatric problems were absorbed into the general community; and an 80 per cent increase in the number of community health centres. Community health and home care are now major fields of activity for nurses. The numbers of midwives increased by 39 per cent and mental health nurses by 11.3 per cent while those in the area of developmental disability increased by 55 per cent. Nursing homes and aged care are another large and growing area of employment for registered nurses (RN), enrolled nurses (EN) and assistants in nursing (AIN). In rural and remote areas nurses continue to function, but without as much support from doctors as previously; doctors are notoriously hard to recruit to such practices. The nurse in these areas is required to be multiskilled, but is given little leave or other opportunity to become so qualified.

The educational standard of entrants to university nursing courses has risen and is now, at the minimum, equivalent to the general entry level for university health science courses; while at the top, students in the top 10 per cent of school leavers are entering nursing. Nurses of this calibre, with university degrees and the habits of mind which degree courses inculcate, are less likely to tolerate aspects of health care management which nurses of previous generations had to accept. This can lead to tensions between practitioners and may contribute to the rate of separation of nurses from the profession - an issue dealt with more fully below.

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1.3 Conditions of work

Several of the reports covered by this project deal with the question of retention of qualified nurses in the nursing workforce and touch more or less heavily on the conditions of work. In so far as the dissatisfaction of nurses reaches the newspapers it is presented as a dispute over pay; but pay is not a major reason for leaving the profession. Nurses, like teachers, ministers of religion, social workers and many other occupational groups, know in advance that they are never going to make big money, and they do not enter the profession with that expectation. They leave the profession because they are no longer prepared to put up with the conditions of shift work, with frequent changes of schedule and inability to plan their own days and weeks satisfactorily. They are tired of being overloaded with work and with emotional stress. Low pay is an extra irritant, not a primary motive.

Nurses complain that in a heavily female profession their workplaces do not provide adequate childcare. They complain, often and bitterly, in one questionnaire and interview after another about poor management practice and a general lack of appreciation. One nurse who left the profession and has no intention of returning said, of her current workplace: ‘When I leave at the end of the day, the boss says "Goodnight, and thank you"; that never happened to me in twelve years in nursing’. Clearly, whatever happens in the education of nurses and nurse managers, there is room for programmes to deal with these issues.

Particularly disturbing is the number of nurses who leave nursing in their first year of employment. They have spent three years in university education, with a total of 40–55 per cent of their courses in practical work in hospitals and other health care settings. Their first employers, typically major hospitals, often expect them (in a phrase so over used as to become a wry joke) to ‘hit the ground running’, to be instantly adept at all the requirements expected of an experienced ward or theatre nurse. No other profession expects the neophyte to be adept; the new recruit to an architectural firm is not called upon to plan a skyscraper, the new engineer to design a major bridge or steelworks. Nurses used to be trained by apprenticeship in hospitals, so it was to be expected that by the end of their training they were adept at the skills needed in that hospital. University based courses are to provide nurses with greater depth of understanding of health care, and the on-the-job skills should be developed on the job. The studies covered in this report suggest that after about six months of employment with an intelligent employer the graduate nurse has learned the requisite job skills; those who have unintelligent employers with unreasonable expectations may well leave the profession.

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1.4 The practicum

Every university nursing course in Australia has a component of practical work in health–care settings for its students across the years of the course. This is an attempt to prepare graduate nurses better for employment, and in educational terms an attempt to marry theoretical knowledge with its practical applications. Although it is obviously a commonsense measure, it is one of the commonest sources of inquiries and reports. Ten out of the twenty reports listed under ‘Educational programmes’ in Appendix B are concerned with the clinical component in some way.

Busy nurses in the hospitals tend to see the students as extra hands to help, not as learners who need help and to the extent that they need help they are a distraction from the nurses’ main tasks. The university staff have expectations of the hospital, the hospital staff have expectations of the university, that each party sometimes fails to fulfil. The university wants its practicum at a particular time of year, which might not always suit the hospitals where the practicum is to be accommodated. The issue of competition is a concern particularly when there are two or more schools/faculties of nursing in the city, as there is in every mainland State capital, and all are seeking hospital placements at once which may or may not be met.

There are also costs involved in the hospital providing clinical supervisors for the students, and hospital and university do not always agree on costs and payment. However there are many new models of clinical education that are being adopted throughout Australia.

The ten reports mentioned above and summarised for this paper address these questions and solve them, for one university or another. Universities generally could well learn from these small-scale solutions.

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1.5 Specialisation

As the nursing profession develops in understanding and practice it naturally develops areas of special knowledge and expertise. In keeping with modern trends in professional education, courses to prepare people for such specialisations are developed and people want awards or credentials attached to such courses. Just as we have diplomas and masters degrees in commercial law and international law and several other fields of law, so are we seeing awards for named specialities in nursing and midwifery. This trend seems certain to continue. There is some danger that anomalies and inconsistencies of standards will develop unless some body such as the Council of Deans or the Australian Nursing Council is able to take action to ensure that an award with a particular title means the same no matter from which university it comes. It also becomes imperative to provide nurses with opportunities to access such courses and credentials.

A related development, just emerging in Australia, is the establishment of the categories of Advanced Nurse and Nurse Practitioner. These are nurses whose scope of practice is beyond that of senior clinicians and with legal authority for practices beyond the usual boundaries for nurses. Some of the reports included in this overview relate to this innovation. As this class of nurse expands, there will be increasing need to devise suitable programmes to prepare nurses for this role.

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1.6 Labour force issues

This review is concerned with nurse labour force studies in as far as they have implications for enrolments in initial and post-initial nurse education, and the nature (content, structure, location) of nurse education programs in universities.

A number of States have put substantial resources into labour force studies – general and specialist workforce projections, and surveys to investigate the issues involved in the successful recruitment and retention of nurses. Many of these studies are reviewed in this report. However, the usefulness of much of the work has been limed by problems of data quality and methodology. The recent Victorian Nurse recruitment and Retention Committee: Final Report (Bennett, 2001) noted that:

The Committee has been hampered by the lack of available nursing workforce data. A review of local and international literature has shown that many state and federal governments have identified lack of workforce data and lack of integrated nurse labourforce planning as major impediments to addressing nursing workforce shortfalls (p. 1).

and:

The first, and probably most important [concern in the literature on the nursing workforce], is the lack of a coherent workforce planning model which enables prospective adjustment of nursing supply to fit demand (p. 30-31).

Workforce projections (and related studies) are inherently difficult and controversial. However, some methods are more suitable than others in particular circumstances, and often the quality of the necessary or useful data can be improved.

The conclusions of workforce projections and related studies often have little influence on policy and practice. The reports and studies reviewed touch on several possible reasons for this. First, there may not be a strong strategic policy connection between those responsible for commissioning and receiving the report (usually a State department of health), and those who are actually responsible for implementing explicit or implicit recommendations (usually university administrations at the central or faculty level, operating within a framework of policy and negotiation with the Commonwealth Department of Education, Training and Youth Affairs). Second, the study may have several widely differing scenarios or options with no clear indication of which is to be preferred as a basis for practical policy, and why. Third, the conclusions or recommendations may be very different from the current practice or the common sense judgement of stakeholders (for example, if graduate numbers are suggested to be several times more, or significantly less, than current levels), and the document may not include convincing supporting evidence and argument for its conclusions or recommendations. Fourth, the methodologies of workforce projections are at best difficult to follow, and in most of the studies considered in this report key aspects of the methodology or derivation of the values of inputs are not transparent or are questionable. A lack of transparency of methodology, let alone apparent data or methodology problems, can weaken the credibility of a study’s conclusions with those responsible for policy implementation.

Some major methodological and data problems with some workforce studies include:

• a range of problems related to estimating or projecting future values for attrition (or separation) rates, including: not taking account of age profiles; and not consistently determining values for both separations and re-entry;

• problems of not adequately accounting for graduates’ availability or suitability; and not accounting adequately in subsequent periods for graduates unable to gain desired positions in an initial period; and

• projected future workforce size is very difficult to estimate, and judgements must be made regarding appropriate (or likely) mixes of staff with different qualifications and work roles, work intensity, industry structure and work organisation, and other matters.

Data problems include: timeliness of data (especially the time lapse between data collection and publication of the major Australian Institute of Health and Welfare (AIHW), nurse workforce surveys); inadequate response rates for surveys (including the AIHW survey); lack of distinction in some data collections between ENs and RNs; problems with definitions of specialties; a lack of information about those with nursing qualifications who are not registered; and problems of data management, especially in individual States. The Northern Territory Taskforce for the Recruitment and Retention of Nursing Staff reported on the lack of consistency in data collection, the lack of data systems, and the lack of data in usable form (Bowden 2001, p.6). The Taskforce made eight recommendations to improve data systems in the Northern Territory, and to provide in the future the types of data it considers essential for workforce planning (pp.10–11).

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1.7 Gaps: issues not addressed in reports

There are a number of issues relating to nurse education which are not addressed in the range of reports we have studied. One of these (which is treated in one of the discussion papers for the New Zealand review) relates to the development of the skills of management and interpersonal relations. What sort of person is the good nurse, the good supervisor or the good director of nursing? How are they to be developed? Given that a significant source of stress in hospital-based nursing is such relationships with superiors and peers, as reported in some of the reviews, it is a serious omission. Human relations and the skills of management figure in the curriculum of other departments in a university as they do in schools of nursing, but there are no reports of studies in this area.

Another area which seems to have received no attention is the on–line education of nurses, whether at the undergraduate or postgraduate level, or in continuing education. This is an area currently receiving attention in the universities and amongst policy makers and politicians. On–line provision is resulting in much activity in nursing course development and is especially suited at least to the continuing education needs of nurses: they should value its flexibility of time and place of access; they are likely to have access to computers in many workplaces; their workplaces may well be far from metropolitan areas. At the same time, on–line education poses particular problems in course development and delivery and system maintenance. Yet there do not seem to have been reports or evaluations of initiatives to provide on-line learning for nurses at any level.

There are no reports on teaching quality in schools/faculties of Nursing. That does not mean this issue is not addressed; such reviews are usually carried out within the school or faculty and would not be published by it or the university. There are also many such reports submitted to AUTC, or its antecedent bodies, from schools and faculties of Nursing. However, there is concern amongst some senior nurses about the quality of graduates. This is usually seen as a matter for registration boards, but some boards simply accredit universities on the basis of documents and do not directly assess the quality of the graduates. There would seem to be scope for an assessment and report on their quality, since the quality of nurses is a matter of safety of patients.

Some areas of most mainland States have significant indigenous populations who need nurses. There are cultural differences between these clients and the mainstream population, and nurses need to be educated to recognise, respect and work within these differences, but none of the reports studied addresses this matter. Australia also needs to encourage the education of indigenous nurses, which might well require special measures, but there are no reports of such initiatives, let alone evaluations of them. However the ACDN is aware of many such initiatives.

Similarly, nurses need to be educated to relate to the many minority groups in our pluralistic society, but there are no reports of such initiatives, nor studies of what might be done or needed.

Australia has huge rural and remote areas which require the presence and practice of nurses. This is recognised in the educational programmes of some schools of nursing, but there are few reports on the particular needs of nurses in these areas. There are no reports on their limited opportunities for continuing education or staff development, or the possibility of their acquiring further qualifications. There are no reports on the range of expectations put on Remote & Rural Area (R&RA), nurses and how those expectations are being fulfilled or might be better achieved and there is no reference in the reviews to the Commonwealth funded university departments of Rural Health and the role they may play.

As in all professions, nursing is experiencing a trend towards specialisation and specialist credentialling. There are no reports on the educational implications of this for better or worse. The rural and remote area nurse faces special difficulties in trying to get such credentials, but this problem is not documented or covered by a report, the extent of the need is not assessed and the possible ways of meeting it are not canvassed in any reports we have seen.

Student nurses and recent graduates not infrequently withdraw from nursing altogether, saying that nursing is not what they expected when they enrolled. It would be informative to have some studies of the expectations and attitudes of incoming students, and a comparison with new graduates. This could provide the basis for future recruitment campaigns either by individual institutions or the profession as a whole.

One development of relatively recent years has been the growth in fields of health care beyond the traditions of Western science, such as acupuncture, naturopathy, homoeopathy and various therapies which often have an Asian origin. The medical profession is devoting cautious but increasing efforts to understand and evaluate these. Do they (including the many varieties of massage) have any implications for the practice of nursing? There appear to be no investigations on these lines.

A feature of university education generally in Australia over the last decade or more has been the growth in the number of combined or double degree programmes, sometimes in combinations which seem surprising at first sight. Has this trend affected nurse education? If so, what is its extent and what are the combinations, and where are the evaluations? Here again there are no reports.

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1.8 The New Zealand review of undergraduate nurse education

It is interesting to compare the Australian experience and views with the issues arising from consultations in the NZ review. The main value of the NZ material for Australian use appears to lie in its wide and perceptive treatment of the changing context of nursing and the attributes required of the nurse of the future. The nursing curricula issues are similar to those noted in Australian reports: the handling of the practicum, the first entry to practice after graduation, multicultural sensitivities are also similar.

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1.9 Conclusion

Section 1 has provided a broad introduction to the issues prevalent in nursing education in contemporary Australia. In the following sections the data on which the broad issues raised in this section are based are presented in detail by way of summaries and commentaries of a range of reports and studies.

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2. Labour force issues in reports

2.1 Introduction

This part of the project is primarily concerned with nurse labour force studies in so far as they have implications for enrolments in undergraduate and post registration nurse education, and the nature (content, structure, location) of nurse education programmes in universities. The major studies only were selected for review and those identified by ACDN; however other reports have been acknowledged.

Much of the literature and discussion on the nursing labour force rests on the assumption that education and training for nursing lead inevitably into a nursing career. In fact, nursing has become a stepping stone to careers, usually with some human relations aspect, for instance, in the travel and hospitality industries or in retailing and management. The nursing qualification offers both a sound preparation and a fall back employment qualification in case of need. Workforce planning, to be realistic, needs to allow a fair amount of ‘wastage’ between the numbers graduating and the numbers practising. The idea expressed in some studies that an ‘excess’ of graduates that initially failed to enter the work force immediately after graduation would enter the profession a few years later, is not soundly based.

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2.2 Methodological problems

Broad or macro level nurse supply and demand projections studies are explicitly concerned with the numbers of graduates in nurse education programmes and, therefore, with intakes and net attrition during courses. However, there are some methodological and data related difficulties with many of these reports. These difficulties are discussed below.

In policy and strategic reports, such as Rethinking Nursing, the report of the National Nursing Workforce Forum (held in Canberra in September 1999), in its executive summary and recommendations, there is a tendency not to draw out implications for numbers of students, especially for undergraduate nurse education.

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2.2.1 General supply and demand projections

Problems encountered with data are presented.

• Lack of transparency due to commercial-in-confidence claims;

• Problems with attrition rates:

  • not taking account of age profiles (assuming equilibrium);
  • inappropriate data/assumptions re those qualified not working as nurses (see AIHW commentary);
  • not being clear about attrition (turn over) from a particular employer, compared with the industry as a whole, and non use of ‘net separations’ (problem is indicated by uncritical/unqualified reporting of annual separation rates of 20 per cent or more. This includes not taking account of the sort of information collected and analysed in the ‘recruitment & retention’ studies); and

• Other data problems.

  • Provision of alternative scenarios (eg. Projections of 'high', 'constant', 'low' supply), with no evidence-based discussion of probabilities of the different scenarios, thus the implications for policy on matters, such as nurse education intakes, are uncertain.
  • Sometimes a reluctance to countenance the need for increased intakes into nurse education programmes (and thus increase overall supply). This might be presented as a concern with ‘quality’ rather than ‘quantity’; a concern with ‘distribution’ or ‘service delivery’ rather than overall supply. These are set up as ‘either/or’, rather than being seen to be inter-related.

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2.2.2 Recruitment and retention studies

In general, studies and projects concerned with ‘recruitment and retention’ are remarkably unconcerned with the numbers of graduates from nurse education courses. The main ‘recruitment’ focus tends to be on attracting back nurses that have previously worked in the specialty or jurisdiction concerned. Reference to nurse education tends to be focussed on the qualitative nature of courses, so that nurses are better prepared, and less likely to leave (this is part of the ‘retention’ agenda, rather than ‘recruitment’).

Problems encountered with data are presented.

• Weaknesses in samples (drawn from Registration Boards so those not currently working as nurses would at least be those wanting to maintain some connection with the profession as they maintain their registration);

• Frequently the focus is narrow - on recruitment only from those qualified but not working as nurses. There is little consideration of graduates at source or the number of graduates as a key factor in recruitment, (but, when graduate numbers are a concern, the strategy favoured is increasing student demand for places via media campaigns, rather than actually increasing provision); and

• Lack of critical analysis of attrition/retention – including, low attrition not necessarily a good thing (for patient care and professional job satisfaction), and high attrition not necessarily a bad thing, or it may be simply unavoidable if, say, the workforce is mostly close to retirement age.

There is a general problem with both types of studies being carried out without reference to each other. Reference is made to concerns with, and developments regarding, consultation, coordination and collaboration between the Commonwealth and the States/Territories, and among the States/Territories.

Sections 3 and 4 following, provide a review and summary of the selected reports, labour force studies, reports and reviews. In section 3 the reports are grouped according to the type of report either national and State/Territory strategic reports; according to the subject, that is, nursing specialist reports or according to the method used, that is, survey based reports

In the subsequent section reports are grouped according to the State/Territory where they were carried out.

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3. Work force studies reviewed

3.1 National strategic reports

One of the major national Nursing strategic reports in recent years is Rethinking Nursing: a report of a national workshop held in Canberra in 1999. A review and commentary follows.

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3.1.1 Rethinking nursing: national nursing workforce forum

Report of a forum held on 21-22 September 1999, Commonwealth Department of Health and Aged Care, Canberra.

The Commonwealth convened this forum ‘with the aim of identifying the challenges facing nursing into the future, and helping to facilitate some appropriate responses’ (p. 5). Those attending included representatives of the nursing workforce, employers, educators and regulators.

Recommendations of the forum arose from consideration of how the ‘vision for the future’ for nursing, developed by the forum, could be realised. Major recommendations of relevance to nurse education included:

• the establishment of an Australian Nursing Workforce Advisory Committee, to report to and be resourced by the Australian Health Ministers Advisory Council (AHMAC), and with a brief to develop a ‘national nursing workforce strategy that would provide a focus for national data gathering and evaluation, and would focus on key nursing issues, including . . . education and preparation of the nursing workforce’; and

• liaison between the Commonwealth and States and Territories to ‘ensure there are extra university places where there are shortages (some of these could be funded)’ (p. 3).

Key challenges identified at the forum included:

• a worldwide shortage of nurses (in Australia especially in rural and remote areas and certain specialties);

• difficulties in recruitment and retention of nurses;

• the nursing workforce not being representative of the broader community; and

• concern that nursing education is not sufficiently responsive to workplace needs.

The report of the forum includes background information about the Australian health system, the nursing workforce, attraction to and retention in nursing, and nurse education. Transcripts of major speeches are also included.

Some of the significant issues of relevance to nurse education raised in the background information and addresses to the forum include:

• The Commonwealth has a broad leadership role in health, little direct responsibility for the nursing workforce, though it funds registered nurse education though universities (p. 15).

• The Commonwealth provides universities with one-line funding, and universities are free to allocate that money as they determine. However, the Commonwealth does take a particular interest in nurse education (Tom Karmel address, pp. 53, 55), and

• There is an international shortage (or impending shortage) of nurses, which is being attributed to the: increasing need for nurses.

The age of today’s nursing workforce; increasing age of nursing students when they graduate; perception of nursing as a female occupation and thus not attractive to men (Kirsten Stallknecht address, p. 43).

The report does not make explicit in its executive summary or its recommendations important implications for nurse education in universities that are considered elsewhere in the report. For example, in the executive summary, two of the four key challenges identified are ‘a worldwide shortage of nurses’, and ‘difficulties in the recruitment and retention of nurses’. It is commented that ‘this raises issues about the status and working conditions of nurses, as well as broader societal issues, such as the increased range of career options for young people, especially women’ (p. v). There is no reference here to the numbers of graduates of initial nurse education programmes, and the financial and other issues involved. Yet the supply of graduates (not just from Australian universities) could be considered a key factor in responding to a worldwide shortage, and in responding to recruitment difficulties in Australia. Similarly, in the recommendations, student places are only mentioned in reference to specialties. However, these quantitative matters are central to the agenda of the recommended Australian Nursing Workforce Advisory Committee. Implications for the nature of courses are also not drawn out. The ‘vision for nursing in the future’ includes an:

increasing emphasis on integrated care, chronic disease management, and disease prevention and on encouraging and supporting health lifestyles’; ‘professional boundaries being redefined’; ‘new technologies . . . will change the way health care is delivered’; ‘nurses will need to be more flexible’; ‘nurses will work collaboratively with other professions and with the community in a consumer-focussed and culturally sensitive way … (pp. 1-2).

While it is noted that ‘nurses’ education and training and skill mixes will change’ (p. 1), there is no reference to the nature of nurse initial and post-initial education under the heading ‘realising the vision’ (p. 3).

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3.2 State and territory strategic reports

The following are reviews and commentaries on the major State and Territory strategic reports.

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3.2.1 Victorian nurse recruitment and retention committee: final report

Prepared for the Victorian Minister of Health by the Nurse Recruitment and Retention Committee (Margaret Bennett, Chair). Victorian Government Department of Human Services, Melbourne, May 2001 (210 pp.) http://nursing.health.vic.gov.au/recruit.pdf

The Nurse Recruitment and Retention Committee was established by the Victorian Government in February 2000 ‘to address the current shortage of nurses in Victoria’ (p. 1). The terms of reference, in summary were:

• To review local, national and international experience and measures to address nurse recruitment and retention; and

• To consider a range of strategies for improving recruitment and retention of nurses, including the areas of undergraduate recruitment, undergraduate educational programmes and clinical practice opportunities, access to continuing education, access to refresher courses, particular needs of rural and regional Victoria, workplace reform, and work role reform opportunities (p. 113).

The main report is in two sections:

• The scope of the problem – covering nurse shortages (international, national and in Victoria, data sets and indicators), problems in nursing (workload, unsafe working environment, equipment availability, career structure, support for nurses, education costs and access, family issues, specific issues for rural nurses, specialty issues, management); and

• Strategies – covering attracting nurses into the workforce (image of nursing, undergraduate recruitment, attracting nurses back in to nursing, injured nurses), education of nurses (undergraduate education, postgraduate education, graduate nurse programmes, continuing education, study leave, the ‘training and development grant’), retaining nurses in the workforce (the workplace, working conditions, specialty issues).

In addition to the main report, there are appendices that include substantial reports on quantitative and qualitative findings from a survey of registered, non-working nurses, and reports of open consultation forums and focus group consultations.

The Committee considered many substantive issues concerning the effectiveness and professional satisfaction of nurses which have implications for the quality of patient care as well as the recruitment and retention of nurses.

The Victorian Government’s response to the report was released in June 2001, and is at http://nursing.health.vic.gov.au/govresp.pdf.

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3.2.2 Northern Territory taskforce for the recruitment and retention of nursing staff: final report

M. J. Bowden (Chair), Territory Health Service, Northern. Territory Government, February 2001 (71 pp.)

The Territory Health Services Taskforce for the Recruitment and Retention of Nurses was commissioned in October 2000. It was to: ‘develop urgently Territory-wide strategies for the support, recruitment, retention and deployment of nursing staff that would ensure the continued safe and effective delivery of the range of services provide by or through Territory Health Services’ (p. 6). Noteworthy features of the Northern Territory nursing workforce reported include:

• 1 340 full time equivalent nurses are required to match current (2001) workload and work practice arrangements;

• a high rate of 57 per cent in annual turnover of nurses, with a 127 per cent turnover in Central Australia (predominantly Alice Springs Hospital) (p. 20); and

• 49 per cent of nurses were over 40, and only 17 per cent under 30.

Data problems made the work of the Taskforce more difficult, especially the lack of consistency in data collection, the lack of data systems, and the lack of data in usable form (p. 6). The first eight recommendations of the Taskforce deal with improvements in data systems (pp. 10–11).

Recommendations are made for strengthening partnerships with universities to allow Central Australian students to undertake most of their pre-registration nursing education near their home location (through Alice Springs Hospital), as well as supporting clinical placements locally.

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3.2.3 Queensland ministerial taskforce: nursing recruitment and retention. final report

Queensland Health, September 1999 (121 pp.) www.health.qld.gov.au/publications/hau/qh_nrr.pdf (Accessed 11 July 2001).

The Ministerial Taskforce, Nursing Recruitment and Retention was commissioned in August 1998. Its terms of reference were to:

• Undertake a comprehensive review of the pre and post registration education, training and staff development needs of nurses to better match workforce planning needs;.

• Develop guidelines for the management of nursing resources and workloads; and

• Promote the introduction of family friendly rostering and management practices.

Expert working groups were formed to consider five topic areas:

• Corporate Approach to Nursing —including nursing resource management, professional training and development provision, performance management state wide, and the differences for implementing initiatives for nursing in metropolitan, provincial, rural and remote areas;

• Best Practice Model for Recruitment — marketing, advertising and selection processes;

• Undergraduate/Graduate Transition Support— undergraduate nursing education and support for the graduate year (transition support);

• Supply Strategies —current and future number of nurses and qualifications needed to meet workforce needs; and

• Flexible Work Environment — models of nursing service delivery, skill mix, patient dependency, workloads, rostering practices, family friendly and flexible work practices, rewards and opportunities, and career structure.

Data were collected through a range of methods, and validated through triangulation methodologies. Rigour was sought to best ensure credibility, fittingness and auditability (p.17), though limitations of data and method were recognised (p.18).

The Taskforce report includes 59 recommendations (pp.7–11), more than a third of which have some bearing on nurse education in universities. Major issues covered by those recommendations include:

• Promotion of and support for student participation in pre-registration nurse education, including work experience in nursing and marketing to secondary school students (R. 1); scholarship system to support employment of nurses in rural and remote areas (R. 2); implement a Nursing Career Advisory Service to, among other things, promote nursing as a career and advise undergraduates, new graduates and postgraduate nurses (R. 3);

• Nursing student intake numbers, with recommendations to maintain the current level of 1 200 pre-registration intakes for the next five years to ensure 800-900 nursing graduates are available each year (R. 4), and to develop a standing committee representing Queensland Health and the tertiary sector to match post-graduate courses to industry needs (R. 8); to systematically evaluate nursing workforce requirements for cardiac, aged care, rural and community nursing as a priority, using Queensland Health’s ‘Nursing workforce - a framework for evaluating the balance between supply and demand’ (R 26); and for the Health Advisory Unit (Nursing) adopt a role in assessing the analysis of workforce planning data on an annual basis for the formulation of strategic advice and direction (R. 27);

• Clinical educational experience, with a recommendation that Queensland Health reiterate its commitment as a provider and allocate resources appropriately (R. 5);

• Partnerships between the health and higher education sector, with a recommendation that a representative standing committee to address on-going issues be established and resourced by Queensland Health (R. 6);

• Pathways for pre-registration and postgraduate programmes, including Enrolled Nurse (and Assistants in Nursing) to Registered Nurse transition (R. 11-14);

• Establishment of Clinical Professor of Nursing positions (R. 16); and

• Induction of graduates into the nursing profession, with recommendations that recruitment processes meet graduates’ needs (R. 17), and that transition support funding be reviewed (R. 19) and be adequate (R. 20).

This recruitment and retention study gave considerable attention to quantitative issues of nurse supply and demand, making explicit the implications for enrolments in pre-registration and post-graduate nurse education programmes. Queensland Health’s Nursing workforce - a framework for evaluating the balance between supply and demand is supported as having been ‘successfully applied to the midwifery workforce’ (that study is reviewed separately in this report), and it is noted that ‘other workforce analyses methodologies had been unsuccessfully applied to nursing in Queensland Health’ (p. 38).

The document includes some rich qualitative data from workshops, focus groups, submissions and the expert working groups, covering matters such as: clinical placement of undergraduate nursing students; graduate transition processes (including the role of preceptors); nurses’ working conditions and practices; and career structures.

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3.2.4 NSW nursing recruitment and retention taskforce report

[recommendations on the web at: www.health.nsw.gov.au/nursing/rrrecs.]

Two of the eighteen recommendations of this report directly concern nurse education. They are:

• Recommendation 9. That local health services and universities be encouraged to strengthen partnerships with each other in relation to undergraduate and post-graduate course development, clinical practicum and research infrastructure to ensure workforce needs at local level are accommodated within university planning frameworks (page 7: section 3.4); and

• Recommendation 18. That the NSW Health Department develop a range of strategies/incentives to increase nursing recruitment (including increased access to undergraduate education programmes) and retention in the rural sector (page 10: section 4.4).

Other issues covered by the recommendations included: workloads, flexible work practices, work environments, management and support practices, professional and management networking and sharing of best practice, and promotion and public relations.

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3.3 National projects on nursing specialisations

Reports reviewed in this section look at issues in nursing specialities including aged care, intensive care and mental health.

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3.3.1 Aged care nursing workforce issues project

A Commonwealth Department of Health and Aged Care funded project being undertaken by the School of Nursing at La Trobe University (principal consultant: Professor Alan Pearson). www.health.latrobe.edu.au/Health/Schools/NUR/projects/work/index (accessed 3 May 2001).

The project is investigating issues surrounding the recruitment and retention of nurses in the aged care sector (both residential and community settings) – specifically nurses who have left the workforce, nurses returning to aged care, and nurse refresher courses in the aged care sector. The project is in response to difficulties that the industry reports in recruiting and retaining suitably qualified staff for residential aged care facilities, and indications that a significant proportion of qualified nurses are not currently working in nursing.

The project involves literature reviews (see below); the examination of similar studies; submissions, especially from qualified nurses who are currently not working as nurses; a survey of a national, random sample of nurses who have not renewed their registration/enrolment; and meetings and forums with stakeholders. Findings and recommendations will be reported to the Commonwealth Department of Health and Aged Care.

The project will identify the current level of qualified nurses who have left the profession (across the disciplines), and reasons why they left; identify the factors that would encourage qualified nurses to return to aged care sector, and consider the implications of this. Strategies will be designed to facilitate the return of nurses.

Two literature reviews have been completed, and are available on the project website.

Nurse returners project. Critical literature review: models of refresher training for nurses re-entering the aged care centre (15 pp.)

The literature reviewed includes fields of nursing outside aged care, from countries other than Australia, and going back at least a decade — because of the scarcity of recent literature that specifically addresses refresher training for re–entering aged care nurses in Australia. Eighteen studies were reviewed. Only two were related to the aged care sector, and only three were based in Australia.

Types of participants, types of interventions, and outcome measures were reported on. Some general findings and conclusions were that:

• Programmes unanimously reported providing beneficial outcomes for both the participants and health institutions in providing a cost effective strategy to increase the pool of available competent nurses in a relatively short period of time (p. 12);

• Course flexibility, and staff encouragement and support are very important (p. 13); and

• Profound nursing shortages appeared a major driver of agencies’ (especially hospitals’) eagerness for refresher programmes (p.11), though the actual numbers of graduating nurses are modest (p.13).

The central finding is the lack of relevant, useful evaluations of nurse refresher programmes specifically designed to address the nursing shortfall in the Australian aged care sector (p.13). From this literature review there is little that is directly relevant to university-based nurse education, but there are implications for research.

Nurse Returners Project. Critical Literature Review: Attrition and Recruitment of Qualified Nurses in Aged Care (24 pp.)

The review examined the ‘best available information regarding the attrition of qualified nursing staff from aged care’ and ‘strategies which should be considered to facilitate their return’ (p. 3). It was thus not concerned with the initial recruitment of nurses into aged care (after graduation from initial or specialist nurse education programmes, or from other areas of nursing).

Again, there was little literature that was Australian or directly concerned with nurses in the aged care sector. Eleven recent Australian studies and projects relevant to nurse recruitment and retention are summarised, with particular emphasis on findings about, and implications for, aged care (pp. 16 – 21). These are reviewed separately in this report. With the exception of AIHW’s Nursing Workforce reports, State authorities have conducted these other studies and projects.

There is detailed consideration of theoretical and methodological literature, as well as empirical findings, on employee turnover from disciplines of management, psychology, sociology as well as nursing.

Some matters relevant to nurse education in universities include:

• One study argued that nurses who would be most suited to working in long-term care need to be sought out, and there should be collaboration with schools of nursing in identifying them (p. 6);

• One study ‘argued for levels of articulation between levels of nursing qualifications to provide clear pathways for career development and a reward system that recognises education, experience and productivity’; need for consensus in nursing competencies in long-term care, and using these competencies as the basis of models that recognise past experience for credit waivers, to encourage and facilitate career development’ (p. 9);

• Stress was the central factor in attrition, and ‘chronic and profound nursing shortages compounded the stress experienced by overworked nurses’ (p. 12); and

• A range of matters concerning the nature of professional work, professional relationships, models of aged care (‘wellness’ rather than ‘curative’, and being ‘person-centred) are discussed, and may have implications for curriculum and pedagogy in nurse education in universities, but such implications were not made explicit.

The literature concerned with recruitment was primarily focussed on refresher courses, and was dealt with in the companion literature review (see above). It was noted that there is ‘little high quality research reported in the literature currently retrieved on alternative effective recruitment strategies or on recruitment in general in the field of aged care’ (p. 14). Five papers specific to aged care are reviewed, and other matters are incorporated in the summaries of general Australian nurse workforce studies and projects referred to above.

Two of the papers directly looked at initial nurse education and the recruitment of recent graduates. Findings include:

• A successful process involving twenty aged care facilities and organisations in NSW to promote aged care in schools, and develop new graduate education programmes with tertiary recognition; the organisations also formed a consortium to coordinate recruitment and prepare the workplaces and workplace preceptors for the arrival of new graduates, with an emphasis on the support and encouragement of new graduates (p. 14);

• Students who were followed through their nursing course comment that theoretical education in gerontological nursing was inadequate, inappropriately placed in the course, and of low status (p. 15); and

• Factors likely to encourage students to work in residential aged care after graduation include: ‘a positive clinical experience; a positive experience with a preceptor; and meeting patients with many different conditions, thereby presenting opportunities to learn a lot and provide individualised care’ (p. 15).

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3.3.2 A consensus driven method to measure the required number of intensive care nurses in Australia

By G. F. Williams and T. Clarke (2001), Australian Critical Care, vol. 14 (3), pp. 106–115.

In this paper a methodology is developed and applied to determine the current annual requirement for newly qualified critical care nurses for intensive care units (ICUs). The methodology is comprehensive and transparent, and could be applied to other nursing specialisations.

The paper begins with noting the increase in the number of intensive care unit (ICU) beds, and the apparent shortage of nurses to staff them. The lack of fit between supply and demand of nurses to Australia’s ICUs could be due not only to issues regarding individual nurses and units, but a general lack of policy direction.

The method draws from published data (such as Australian Institute of Health and Welfare’s Nursing Labour Force and published research papers); accepted standards (such as Australian and New Zealand College of Anaesthetists – Faculty of Intensive Care, Minimum Standards for Intensive Care Units), and consensus views of a panel of sixteen critical care nursing expert leaders from around Australia (to consider issues such as nursing ratio standards, mixes of nurse roles and specialisations, usual number of years nurses work in intensive care, effects of leave). Using this base data and standards, the answers to seven key questions are explicitly calculated. The questions are:

1. What is the average number of full time equivalent (FTE) nurses required to staff an ICU bed?

2. How many FTE nurses are required to staff ICU beds across Australia?

3. How many qualified and unqualified ICU nurses (FTE )are required to staff Australia’s available and physical ICU. beds?

4. What is the required replacement factor of ICU nurses per year (ICU qualified and unqualified) to manage the attrition rate?

5. What are the costs of maintaining a steady flow of qualified critical care nurses to ensure a propensity for qualified critical care nurses remain at the bedside?

6. What are the minimum nursing costs of keeping one ICU bed operational for one year in Australia?

7. What is the estimated total nursing cost (indirect and direct) of maintaining available ICU services in Australia?

Each element in each of the seven calculations is set out.

Regarding nurse numbers (question 3), they conclude that:

• Australia does not have an Intensive Care bed shortage but an Intensive Care nurse shortage and that there is a strong correlation between the number of ICU nurses available and the number of ICU beds available at any given time (p. 118).

Regarding newly qualified critical care nurses, they conclude that:

• It is important to note that Australia requires 1 000 newly qualified critical care nurses for ICUs each year. Australia’s universities produce approximately 500 per year, therefore suggesting further difficulty maintaining and supporting any growth in ICU bed demand and service in the foreseeable future.

Comment and suggestions are made about data quality (such as the need for a uniform definition of a ‘qualified’ critical care nurse, and the time-lag in availability of AIHW data).

As the methodology is comprehensively and transparently set out in the paper, it is now available for application for other professions, and for recalculation for intensive care nurses as new data (or standards) become available.

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3.3.3 Articles arising from a scoping study of the Australian mental health nursing workforce 1999

By M. Clinton and M. Hazelton (2000)

‘Scoping mental health nursing education’, Australian and New Zealand Journal of Mental Health Nursing, Vol. 9, No. 1, pp. 2–10.

‘Scoping the Australian mental health workforce’, Australian and New Zealand Journal of Mental Health Nursing, Vol. 9, No. 2,, pp. 56–64.

‘Scoping practice issues in the A mental health workforce’, Australian and New Zealand Journal of Mental Health Nursing, Vol. 9, No. 3, pp. 100–109.

‘Scoping the prospects of Australian mental health nursing’, Australian and New Zealand Journal of Mental Health Nursing, Vol. 9, No. 4, pp. 159–165.

This comprehensive and detailed set of articles draws on extensive consultations around Australia, submissions from stakeholders, and surveys of international literature and experience. The work is oriented to consumer outcomes, and evidence-based policy and decision-making. It draws from the first national scoping study of the mental health workforce in Australia, prepared for the Commonwealth Department of Health and Aged Care, and focuses on the problems of recruiting and retaining mental health nurses and the current challenges facing mental health nursing education.

Findings of direct relevance to nurse education in universities include:

• There is clear evidence that due to funding cuts, rationalisation of educational profiles and the inability to attract teachers of mental health nursing to academic positions, Australian universities, despite their achievements in developing nurse education and related research, are less than completely successful in preparing undergraduate students for their role as beginning practitioners of mental health nursing;

• The take up rate of postgraduate places in mental health nursing courses is inadequate to meet the future needs of specialist mental health services;

• Postgraduate education in mental health nursing is in need of rationalisation and reform; and

• Attempts to involve universities and health authorities in delivering courses in mental health nursing have not been entirely successful.

Other findings include: the increasingly stressful and difficult nature of mental health nursing practice, especially as a consequence of changes in mental health practice; the need for mental health services to move away from paternalistic models of delivery; the need to develop, recognise and support advanced nursing practitioners; and the inadequacy of planning and development of the mental health nursing workforce.

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3.4 Survey based projects

Reports reviewed in this section utilise survey methods as part of the data collection strategies.

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3.4.1 New South Wales workforce research project report

Nursing and Health Services Consortium 2000, New South Wales Health Department, Sydney.

This 73 page report was prepared for the NSW Health Department by the Nursing and Health Services Research Consortium (incorporating the Sydney Metropolitan Teaching Hospitals Nursing Consortium and the NSW College of Nursing), and published in September 2000.

The project method involved a survey in May 2000 of the more than 30 000 NSW registered and enrolled nurses who had indicated they were not working as nurses in an earlier (1998) survey or whose employment details were unknown, and for whom complete address details were available. One third responded. Telephone interviews were conducted with 98 respondents.

The report includes a thoughtful discussion of broader theoretical issues that should be taken into account. It is noted that, ‘the construction of nursing as a traditionally ‘feminine’ occupation implies that any shifts in the prevailing attitudes to women and work will have significant consequences on nursing as a profession’ (p. 11). It is concluded that ‘the development of strategies to redress the declining interest in nursing as a profession requires an approach that not only addresses specific workplace conditions (salary, hours) but also places these conditions in the context of current attitudes of Australians to careers and lifestyle’ (p. 12).

Results are provided in detail in the body of the report and appendices. ‘In line with the demographic profile of the respondents, nurses identified family responsibilities and lifestyle issues around shiftwork as the main reasons for leaving nursing’, and flexibility and choice around working hours were important incentives to return to the nursing workforce in NSW (p. 9).

There are some implications for nurse education in universities.

Respondents were asked about the incentives to return to work as nurses. After items related to ‘suitable working hours’ (67 per cent of responses to the item) and ‘better pay’ (30 per cent), ‘support in education’ was the most commonly cited (26 per cent). Specific examples cited in the report are: ‘paid to attend refresher course; flexibility in refresher course such as part-time and more offered in rural areas; staggered shifts to ease return to work or mentor system; time for ward in-service’ (p. 32). Many respondents expressed uncertainty and apprehension about how to return to nursing, and were unaware of services and support available (p. 37).

It appears that no respondents cited generally poor initial nurse education as a reason for leaving nursing or being dissatisfied with nursing, though there were no particular options that prompted such responses. However, there was a comment that ‘university training needs larger practical component’ (p. 37). There was concern expressed about deployment in situations in which they were not experienced (such as an intensive care nurse sent to a medical ward).

The lack of incentives for further education, and the costs to nurses of further education were commented on (p. 36).

There is an indication of the tightness of the nursing labour market in that for the ‘main reason for currently not nursing in NSW’, only 1.6 per cent cited ‘no jobs in preferred area of nursing’, and 1.3 per cent cited ‘no nursing jobs near where I live’ (p. 57). These were cited among the average of three to four ‘other reasons’ for not currently nursing in NSW by 7.0 and 1.5 per cent respectively.

There are several problems with this study in terms of its usefulness in informing nurse education policy and practice. First, it covers both enrolled nurses and registered nurses (and midwives), with enrolled nurses 17 per cent of respondents. Most of the reporting of substantive findings does not differentiate between enrolled and registered nurses/midwives.

Second, like other studies that use registration board databases as sources for study populations, the usefulness of this report is limited by this fact. It is especially limited by the failure to discuss the implications of using such a group of respondents. It does not include those with nursing qualifications who are no longer registered. There is little data on those who have qualified as registered nurses, but are not currently registered. However, a 1989 Australian Bureau of Statistics (ABS), labour force supplementary survey collected data on persons who had ever qualified as registered nurses (March to July 1989 Career Paths of Qualified Nurses Australia, ABS Cat. No. 6277.0). This survey found that 19 per cent of those who had ever qualified were not currently registered, and that the rate increased with age. AIHW data indicates that about 87 percent of currently registered nurses are employed in nursing, and that more than 90 per cent are in the nursing workforce (that is, working as nurses, on extended leave, or looking for work in nursing). (Though the original sample selection for this study appeared to indicate that around one third of registered and enrolled nurses in NSW in 1998 were not working as nurses, in response to the 2000 questionnaire 41 per cent reported that they had in fact worked as nurses during 1998, which leads to a figure very close to the AIHW figure for NSW). Thus, of those who are qualified to be registered nurses, it appears that roughly twice as many are not currently registered as are registered. More pertinent to the study being considered here (with all respondents currently registered), the question to ask those who have left nursing is why they have maintained registered status. It is not surprising that those who have taken time out for family responsibilities, and plan to return (even if for only occasional casual relief employment), maintain registration. Similarly, maintaining registration is no surprise for those who have taken up administrative, policy or academic positions associated with nursing. Others may maintain registration as protection in an unexpected event such as being called upon to assist an injured person.

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3.4.2 Attracting nurses back in to the nursing workforce

Prepared by BIZTRAC, Faculty of Business and Public Management, Edith Cowan University for the Health Department of Western Australia, (Health Workforce Reform Division) September 1997 (35 pp.).

A questionnaire designed by the Workforce Planning and Development Section of the Health Workforce Reform Division was mailed to a sample of nurses who applied for re-registration for 1997. Just under half (553) responded.

The questionnaire included items on respondents’ age; last nursing position; level, area of work; geographic location; year left that position; reasons for leaving (eighteen options, including ‘other’ provided, with space for comments); whether respondents would consider returning to nursing; when, what would attract them back and what is their preferred area of nursing practice.

The report provides tabulations of responses to individual items. However, with no cross-tabulations or other analysis, and a lack of relevant data from other sources, interpretation is difficult in important areas.

Not surprisingly, as more than half of these registered nurses not currently working as nurses are aged in their thirties, and 98 per cent of them female, more than half of them cited ‘family responsibilities’ as a reason for leaving nursing. For many of them, lack of family friendly conditions (childcare, appropriate shifts) were a reason for leaving nursing, and what would attract them back into nursing are parallel. However, as three quarters of the respondents were considering returning in one to five years, it is unclear how decisive the matters listed in response to ‘what would attract you back into nursing’ would be.

Other elements, in addition to a more family-friendly workplace, the report indicates may lessen separation and enhance re-entry include: improved pay, better career opportunities, better job design (for example, less paperwork, more support staff), and support and professional recognition.

There are some conclusions that can be drawn that are relevant to this project. After ‘family responsibilities’, the most commonly cited reason for leaving the nursing workforce, listed by almost one third of the respondents, was ‘increased demands and workload due to nursing staff shortages’. The report notes that ‘most respondents made the comment that staff shortages not only increased their workload but also affected patient care and their psychological well-being’ (p. 16). This points to a ‘vicious cycle’ of shortage, when shortage leads to poor working conditions, leading to increased separations (including, most probably, increased absenteeism of those employed), exacerbating the shortages, and so on. The report does not explicitly draw any conclusions about the need to increase the supply of nurse education graduates in response to the staff shortages, though this could be a reasonable conclusion. However, it would need to be known whether the problem was inadequate general supply, or a lack of recruitment because of agencies’ financial constraints, or some other reason.

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3.4.3 Junior registered nurses labour force survey

Prepared by BIZTRAC, Faculty of Business and Public Management, Edith Cowan University for the Health Department of Western Australia, November 1998 (39 pp.).

This project has similarities to the earlier work of the same authors reviewed above. However, the respondents were quite different, and the structure of items in the questionnaire makes comparisons difficult except at a high level of generality.

In mid 1998 Western Australian junior registered nurses in the first two years after graduation were surveyed by mail to investigate factors contributing to retention and attrition. A 43 per cent response rate was achieved (360 respondents).

The questionnaire was developed in consultation with the Western Australia Health Department and the Nurses Board. Items covered: basic demographic data; initial nursing education (which university attended); additional tertiary study (whether related to nursing); current employment (whether nursing, hours of work, workplace type and location, and area of nursing with eleven options); a very diverse range of fifty opinion and preference items covering attitudes to nursing, likes and preferences about the nature of their work and conditions, career and personal aspirations and expectations (on an eight point scale of agreement); how long respondents expect to remain in nursing; matters that would influence whether they choose to leave or stay in nursing (family commitments, pay, work environment, staff shortages, career opportunities, and so on); factors that would encourage respondents to stay in nursing (specific cases of the preceding matters); and, for those currently not working as nurses, matters that influenced their decision to leave, and factors that would attract them back (these two items paralleling the previous two).

Some of the major findings included (as ordered in the report):

• Respondents ‘appear to view nursing as a short-term career’, only 57 per cent reported that they felt it likely that they would be in nursing in five years, and only 31 per cent in ten years (pp.1 and 15). However there was no comment in the report on the likelihood that their current perception would match the reality of retention (and re-entry). The net separation rates entailed by the junior nurses’ responses are an annual average of 8.6 per cent in the first five years, and 9.1 per cent in the following five years. Both rates, especially the latter, are very high relative to the underlying rates indicated by ABS Census data discussed in the text of this report. Thus this finding could be taken as some indication of levels of lack of long term career commitment to nursing (though not necessarily any lack of commitment to current work), but treated with great caution as a possible indicator of likely future quantitative separation rates;

• Remuneration was a significant issue, with three pay-related items eliciting the strongest agreement of the fifty attitudinal items, and rating first or second on the items that would encourage nurses to stay or influence decisions to leave. However, as the survey was carried out after a period of industrial disputation over nurses’ pay the issue may not have been as prominent at another time, (pp. 1, 12, and 15-17);

• The work environment was a major concern (p. 1). Staff shortages were a significant, explicit item as a factor that would (or did) influence a decision to leave nursing (pp. 15 and 17). ‘Increased staff levels to reduce workload’ was second (after increased pay) as a factor that would encourage nurses to stay (p. 16), and third (after increased pay and reduced stress) as a factor that would attract nurses who had left back to the workforce (p. 18). The prominence of staff shortages (and probably related matters such as ‘stress’) as a factor in retention and re-entry points to vicious circle, where emerging shortages are exacerbated by the effects of existing shortages; and

• Family issues did not rate very highly though there were many relevant items in the questionnaire — probably because nearly three quarters of the respondents did not have dependents. However, there was quite strong agreement with the statements that ‘I would like to continue working after I start a family’, and ‘I would leave nursing if may work hours interfered with my family life’. The authors of the report commented that ‘it is encouraging that nurses have indicated that they would like to continue nursing after starting a family but the down side is this is dependent on suitability of hours offered to them’ (p. 2).

There were a number of items that touched on matters related to pre-registration and continuing nurse education. However, it is difficult to interpret them in ways that can inform decisions about the nature of nurse education in universities.

Regarding pre-registration nurse education, there was strong agreement with the statement, ‘The "real world" (of nursing) is nothing like I expected when I was at uni’, and strong disagreement with the statement ‘I think university prepared me well for nursing’ (pp. 12 and 13). However, there were not items that indicated whether the professional skills and understandings developed at university were adequate or appropriate, or exactly what it was that university did not prepare them for. The emphasis given by respondents to issues of pay, stress, staff shortages, effects of health system restructuring, lack of support from management, and perceived lack of promotion opportunities, may indicate that some of these are the matters for which they were not prepared (that were different from their expectations). How, and how much, universities (or induction programmes for beginning nurses) should deal with such matters are not easy issues to resolve.

Regarding continuing professional education, a quarter of the respondents had undertaken or were undertaking additional tertiary study, two thirds of those indicated that their study was in nursing. There was strong agreement with the statement ‘Additional training in some areas would be of assistance’ (p.12), and ‘more training opportunities’ rated quite high as a factor that would encourage nurses to stay (p.16) and return to nursing if they have already left (p.18) —ahead of rostering and other work organisation matters, but behind pay and reduced stress and workload. However, there is no indication whether this refers to short, on–the–job training, or more substantial or specialist study at university.

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4. Labour force projections reviews

Labour force studies are generally State based projects because most nurse employment is State based. The following represents a review and commentary of reports undertaken in States and Territories and lists other reports not reviewed.

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4.1 Victoria

4.1.1 Nurse labourforce: requirements and supply projections Victoria 1993-2003

Prepared by R. van Konkelenberg for the Victorian Department of Human Services, September 1993 (20 pp.).

This report provides an update of a similar 1991 report, and covers the period 1992–2003. Its publication date precedes the general period for studies reviewed in this report, but it is listed here because it was evaluated in 1998 (see following), and the methodology used is the basis of other reports in Victoria and Tasmania.

The report was prepared at the time of severe adverse economic conditions, sharp reductions in government funding, and restructuring of the health industry and of higher education in Victoria. This affected assumptions used in developing the projections, and actual outcomes. Some relevant matters are discussed in the following review, where this report is referred to as the 1993 Report.

The only explicit recommendation was for a reduction in intakes to at least less than 2000 (from the reported 1993 intake of 2 326 —a reduction of 14 per cent), and a suggestion that the intake ‘can be as low as 1 400 to 1 700’ (a reduction of 30 to 40 per cent p. 9). Actual intakes through the second half of the 1990s averaged around 1 880, according to DETYA Selected Higher Education Statistics.

The report discussed the balance between RNs and State Enrolled Nurses (SENs), and developed scenarios based on differing ratios.

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4.1.2 Evaluation of Nurse Labour Force Planning: Final Report

Prepared for the Victorian Department of Human Services (Public Health and Development Division) by Health Outcomes International Pty Ltd, November 1998 (50 pp.)

The Victoria Department of Human Services commissioned Health Outcomes International Pty Ltd (South Australia) to evaluate 1991 and 1993 nurse labour force studies (see above). The studies had been carried out under the auspices of the Victorian Department of Human Services, using a ‘re-engineered version’ of a package developed by Ron van Konkelenberg of South Australia. Dr Konkelenberg was undertaking a third study for the Department (see following) as this evaluation was being carried out.

The terms of reference required the evaluation to determine the extent to which the studies provided an accurate prediction of nurse labour force needs in Victoria, and to evaluate the extent to which the underlying assumptions for the studies were valid (p. 1). The evaluation process involved extensive consultations with stakeholders as well as analysis of the studies’ methodologies and conclusions in relation to international literature and subsequently available data. The impact of the ‘predictions’ on the different organisations, and the uses made of them by stakeholders, were also investigated.

Major findings and conclusions include:

• It was recommended that such studies cover only about three to five years, rather than ten (p. 3);

• Matters such as the introduction of casemix-based funding and the stringent funding cuts had a major impact on actual outcomes, but could not have been foreseen or accurately modelled (p. 4);

• Different issues affecting rural nurses compared with urban nurses should be taken into account within the model.

Whilst the trend within the metropolitan networks of Victoria is for nursing staff to specialise, the rural sector demands the opposite of its nursing staff . . . the emphasis is for nursing staff to have general skills in a range of areas including accident and emergency services, midwifery, general nursing, aged care services, theatre skills and high dependency nursing skills. (p. 4);

• There is a lack of understanding of the nature of and responsibilities for the AIHW Nurse Labourforce database, which was a major data source for the projects. It was suggested that better communication and consultation processes occur;

• The majority of those interviewed in the evaluation process indicated that they had a limited understanding of the methodology and other aspects of the models. It was suggested that ‘future studies can do much to ensure relevant skills and knowledge transfer takes place, and that the modelling process is transparent’ (p. 6);

• The evaluation team made no technical criticism of the model, finding that ‘the assumptions underpinning the 1991, 1993 and current nurse labour force planning studies are reflected in the international literature’ (p. 8);

• The model used in 1993 is outlined. However:

The detailed mathematics upon which the model has been developed was not disclosed to the evaluation team as it represents commercial in-confidence material. Nevertheless, the principles upon which the model has been formulated appear consistent with other supply and demand models used in manufacturing and other industries, as well as those documented and used by other bodies in projecting health labour force requirements identified by the evaluation team through the literature search (p. 19–20);

• As one of the terms of reference for the evaluations team’s work was, ‘Gauging acceptance of the existing tool/model . . .’, it is not surprising that:

The apparent lack of transparency in terms of the mechanics of the model was a concern in terms of the key stakeholders’ understanding of the existing tool/model (p. 20).

The evaluation team accepted the commercial in-confidence restriction, but went on to recommend a structured training course in the application and utility of the model for staff of the organisations utilising the outcomes of the model (p. 20). However, if significant elements of the model remain inaccessible to critical evaluation on technical grounds or on substantive grounds, the process will not gain from potential expert and informed input, and users must remain sceptical of conclusions if those conclusions arise out of a ‘black box’, the workings of which have not been independently examined.

Of those elements of the model that are described in the evaluation report there are several that appear open to critique (or, perhaps, further explanation or investigation).

One very significant element is net separation (‘net loss’ or ‘net attrition’) rates. Separation rates are one of the most significant aspects of any supply/demand projections. A basic assumption of the studies was that ‘the nursing profession is a predominantly female workforce which has specific workforce participation patterns such as casualisation rates, part-time employment, attrition rates, etc’ (p. 21). Yet there appears to be no recognition that these patterns vary significantly according to age. For example, for the 1993 ‘baseline scenario’, ‘the net loss of RN labour force of 5.49 per cent was revised to a net loss of 2 per cent based on expected improvements in the economy’ (p. 24). This is an accurate report of the original assumptions (see 1993 Report, p. 3), yet generally an improvement in the economy leads to an increase in net separation rates in occupations such as nursing because alternative employment opportunities become available for both those currently working as nurses and for potential re-entrants to nursing. There is no explanation or discussion of this anomaly in the evaluation report or the original 1993 Report (where the 2 per cent rate net separation rate is maintained through the period to 2002 – see p. 14). From a methodological point of view, it is not appropriate to assume that the state of the general economy is the only significant factor in changes in net separation rates for a predominantly female occupation with a very peaked (not flat) age profile, especially for projections over a ten year period. Developments in the age profile are generally the major factor over the long term, while changes in the economy (including increased or decreased funding for nursing, perhaps leading respectively to increased attractiveness of nursing work, or to redundancies) are probably more likely to account for short term fluctuations in net separation rates. At key times the age profile may be the major factor in very short term changes in net separation rates, such as when a sharp peak in the age profile just enters the common retirement age. The age profile would indicate a low net separation rate early in the period (but still above 2 per cent), increasing later in the period as the age peak moves out of the low net separations late thirties to early forties age range. The difference in demand for new recruits resulting from different assumptions about net separation rates can be seen from applying the rates to the headcount of just over 33 000 RNs used in the projections. A net separation rate of 2 per cent is 660, 3 per cent is 990, and 5.49 per cent (the rate estimated to be prevailing in 1993) is 1 811.

A second element in the 1993 Report model that needs critical consideration is the proportion of graduates who will gain employment as nurses in the jurisdiction concerned. This is important from the perspective of university nurse education. All 1993 scenarios assumed that ‘more than half of RN students would not be employed in nursing in Victoria after graduation’ (p. 24). This value appears to be based on actual transition data for 1992 completions. The 1993 Report, and the evaluation, had commented on an ‘oversupply’ of graduates at the time. The total number of employed RNs had fallen sharply from 43 600 in 1990 to 39 900 in 1993 (AIHW, Nursing Labourforce 1999: Preliminary Report, p. 5), thus a low transition rate would have occurred largely because of a lack of available positions, rather than because of the preferences of graduates. A number of data sources (such as the 1991 and 1996 ABS Censuses, and the Graduate Careers Council’s Graduate Destination Survey reports) indicate that there are usually high rates of transition from course completion to employment as a nurse — probably between 70 and 90 per cent. While ‘oversupply’ was projected in the 1993 Report to continue unless intakes were reduced (which is not surprising as 2 per cent net separation rate was assumed for the full ten years), to build into the model a low transition rate because of oversupply is circular, and leaves unaccounted for the potential supply of those seeking, but unable to obtain, nursing positions. It is more clearly inappropriate to assume a constant 50 per cent transition rate for scenarios leading to balance or shortfall, such as those scenarios involving reduced intakes into pre-registration courses as recommended in the 1993 Report. Graduates unsuccessfully seeking positions in nursing in one period need to be accounted for as potential entrants in subsequent periods. Not all will remain available, so an appropriate net separation rate needs to be applied to that ‘pool’, accounting for those who decide to take up another occupation or activity, perhaps move to another State or overseas, temporarily or permanently (for the use of such a method that takes account of recruitment to other States, and the national as well as local situation of projected surplus, balance or shortage. It is possible that the graduates not employed in nursing are accounted for in a ‘not working pool’ and are potential ‘re-entrants’ thus accounting for the very low net separation rate (see above). However, this is not explained in either published document, and would only be appropriate for a period following substantial oversupply, not for all scenarios over the ten year period.

A third element is the university intake patterns for pre-registration courses. The ‘baseline scenario’ has the ‘university intake patterns for future years set at 2 326’ for each year of the period 1993 to 2003 (1993 Report, pp. 2 and 12). Yet, according to DETYA Selected Higher Education Statistics, there were only 1 865 commencing basic nursing students in Victoria in 1995, and an average of 1,882 over the following five years. This discrepancy was not commented on by the evaluators when they prepared their report in 1998. It could be interpreted as implementation of the recommendation of the 1993 Report, except that the reductions were occurring in association with university rationalisations already underway in 1993.

A fourth element is the assumption that nurses with specialist qualifications will not be available for general nursing positions (see diagram of the ‘inter–relationship between general and specialist workforce’, p. 19). This is not discussed in the published 1993 Report, though it is part of the model used, according to the evaluation report. Many nurses with specialist qualifications are working in what are formally general RN positions — for example, according to 1996 ABS Census data, slightly more qualified midwives are working as RNs than as midwives.

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4.1.3 Nurse Labourforce Projections Victoria 1998–2009

Prepared for the Victorian Department of Human Services (Public Health and Development Division) by Dr Ron van Konkelenberg of Fresbout Pty Ltd, March 1999 (28 pp.).

This study was commissioned in May 1998.

It uses the general methodology of the 1993 report (see above), and key input values and details of the methodology are not provided, so comment is limited. The projections are for ten years to 2008. Demand and supply are projected to be in balance if the number of nursing positions is held constant. A range of alternative scenarios is provided. On the supply side these involve increases in losses of 25 per cent and decreases in losses of 25 per cent and 50 per cent (though the actual projected loss rates for the preferred scenario are not provided), and increases in graduate output by 1 500 and 1 800 above about 1 280 (including ENs with RNs, it appears). Different scenarios for demand (requirements) are provided according to low and high demographic change in Victoria.

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4.2 Queensland

4.2.1 Midwifery workforce planning for Queensland

By the Workforce Planning and Analysis Unit, Organisational Development Branch, Queensland Health, August 1998 (63 pp.).

This report contains five distinct papers:

1. The first paper, Modelling the future demand of the midwifery workforce, draws from data on the overall confinement rate for women in each five year age group, projects the number of females in each age five year age group in each Queensland district, and estimates ‘drainage’ (confinement at facilities outside the home district), to project the number of confinements (locally and State-wide) from 1996 to 2011. The number of confinements in Queensland is projected to increase by 14 per cent between 1996 and 2011, with a decrease in the number in rural and remote areas, and an increase in urban areas, especially in the areas surrounding Brisbane (p. 20).

2. The second paper, A profile of registered nurses authorised to practise midwifery in Queensland (January, 1998), sets out findings from a survey of a random sample of nurses registered with the Queensland Nursing Council and authorised to practise midwifery in Queensland. A response rate of 63 per cent of the 1 119 delivered questionnaires was achieved. Major findings include:

• There are about 3 600 practising midwives in Queensland;
• About 60 per cent of midwives in Queensland were trained in Queensland (p. 23);
• Major reasons for studying midwifery have changed over time: the majority of those who completed their study more than twenty years previously has done so ‘to gain more qualifications’, and other major reasons were ‘to work as a clinical midwife’ and ‘to use knowledge gained in midwifery course in another area of health care’; in contrast, more than three quarters of those who had gained their qualifications in 1995-1997 had done so ‘to work as a clinical midwife’, and the next most significant reason was ‘to gain a broader base knowledge in nursing (eg. to work in rural areas)’ (p. 25);
• Typical age at completion of a midwife course has increased from about 25 to about 30 since the mid 1980s (p. 24);
• RNs now typically work for about five years before undertaking a midwifery course (p. 25);
• Of those working in a job that requires the role of a clinical midwife, more than 50 per cent are spending less than half their time actually performing the role of clinical midwife (p. 28);
• Overall, 86 per cent of RNs who have studied midwifery in Queensland and are authorised to practice in Queensland have actually gone on to practice midwifery in Queensland, but only about 32 per cent of RNs authorised to practice midwifery in Queensland are currently working as a midwife in some capacity in Queensland (p. 26) (note that the sample did not include those with midwifery qualifications who were not registered with the Queensland Nursing Council, and thus understates those with midwifery qualifications who are not practicing midwifery, though those not maintaining registration would generally be much less likely to return. to midwifery);
• Of the 68 per cent not working as a midwife (about 7 500 individuals), just over half are currently working as a RN in Queensland (p. 33);
• Of the 68 per cent not working as a midwife, 63 per cent ‘are interested in returning to midwifery in Queensland in the future’ (p. 36);
• About 1 600 individuals are both interested in returning to midwifery and have either completed their midwifery course or practised midwifery within the previous five years (p. 42); and
• Of those not currently working as a midwife, the major factors that would encourage then to return to (or enter) work as a midwife are: employment opportunity in a suitable location, opportunity to utilise training/skills, flexible hours, and access to a refresher programme (especially for those who have never worked as a midwife) (pp. 37-38).

The paper reports that the ‘typical total length of service’ (including work as a midwife outside Queensland) is about 10 years (p. 30). A statistical method is used to arrive at the conclusion that ‘we can expect to get about 11 years service from a midwife at the beginning of her career’ (p. 39). The paper concludes that:

Given that the typical length of service is about 11 years we should be aiming to replace just under 10 per cent of the total required midwifery workforce each year. At present there are about 3 600 active midwives in Queensland, so we should be replacing about 360 a year though training and re-entry.

Currently about 120 midwives are being trained per year in Queensland. This means that a lot of reliance is being placed on the reserve pool to replenish the midwifery workforce (p. 40).

There are methodological issues involved in the method of estimating (future) separation rates, and in the use of a survey of individuals registered with the Queensland Nursing Council to gain data on the ‘reserve pool’ and more generally on those who have left midwifery. Some matters specific to this study are taken up below.

3. The third paper, Queensland Health’s midwifery workforce – a profile (January, 1998), reports on a census of the 2 600 practising midwives working for Queensland Health. The census found that:

• The ‘geographical distribution of the midwifery workforce reflects the geographical distribution of confinements in Queensland’ (p. 51);
• About half were working full time (p. 53);
• About half spent all their work time in the clinical midwife role – those in rural and remote areas tending to spend less of their job time in the role of midwife (p. 53); and
• The average age is about 41, but the peak in skewed, unimodal age profile is around 36 years (p. 55).

The census also sought information about vacant midwifery positions. There were about 125 (100 FTE) vacancies, with facilities in rural and remote areas tending to have the higher vacancy rates (p. 55).

4. The fourth paper was, Estimating the resource in the pool of midwives who are not currently practising midwifery – consultation with a panel of experts. A panel of experts in midwifery were asked to rank (as if for a vacant midwifery position) hypothetical midwives who were characterised by number of years registered as a nurse, number of years since first authorised to practice midwifery, number of years working in midwifery and in nursing generally, hours worked, number of years since practising midwifery and since working as a nurse.

The two most positive factors were FTE length of experience as a midwife and the number of years since midwifery had been practised.

Applying the standard derived from the panel, about 2 500 of the 7 500 midwives in the ‘reserve pool’ could be employed as midwives without additional refresher training. Of these, about 1 600 are estimated to be interested in returning to midwifery at some stage in the future.

5. The final paper, Future training numbers for Queensland’s midwifery workforce – some options for the next five years, considers four options that differ according to the number of midwives trained and the consequent reliance on the ‘reserve pool’. Drawing from the analysis of the second paper, an underlying assumption of each option is the need to recruit 360 midwives each year through some combination of training and re-entry. It is noted that the number of midwives being trained annually in Queensland has dropped from 215 in 1994–1995 to fewer than 120 —‘all indications are that this decrease in training numbers is a result of the transition in the provision of midwifery training from hospitals to tertiary institutions’ (p. 60).

• The first option is to continue to train 120 midwives a year, and thus place heavy reliance on the reserve pool to provide re-entry midwives, providing a source for 240 re-entrants a year. The paper notes that ‘all indications suggest that the likelihood of successfully encouraging 240 midwives from the reserve pool to return. each year is low’ (p. 61);
• The second option is to train 360 midwives a year, and place no reliance on the reserve pool. Not surprisingly this option is expected to result in substantial oversupply as those in the reserve pool who wish to re-enter are unable to (or graduates of midwifery programmes are unable to gain positions). It is suggested that so many midwives unable to obtain a midwifery position may cause community concern and discourage potential midwifery students (p. 62);
• The third option is to train about 220 new midwives a year, drawing from the reserve pool at a sustainable rate. This assumes that around 140 will re-enter from the reserve pool annually, ‘although it is estimated that about 250 midwives from the reserve pool are interested in re-entering the midwifery workforce annually’ (p. 62).; and
• The fourth option is seen as a ‘managed reduction of the reserve pool’, involving the training of about 180 new midwives each year, and drawing the same number from the reserve pool. Like option three, this is expected to create over the coming five years neither a critical over supply or a critical under supply, and to be manageable by universities.

The paper ends with a recommendation to increase training numbers to 180 and implement promotion of re-entry. It is commented that the recommendation indicates only the number of midwives to be trained, and does not deal with ‘important issues such as the types of training and the models of education required’ (p. 63).

The options are based in the assumption that around 250 midwives from the reserve pool are interested in re-entering the midwifery workforce annually, though practically 140 is considered sustainable without special promotion (option three). Much of the work in the previous papers has led to this conclusion. Yet there is no indication in any of the papers of current or historical rates of re-entry. As Census data indicates a declining rate through the age ranges of practising as a midwife by those with midwifery qualifications, an annual re-entry rate that is greater than the total annual number of newly trained midwives some years earlier is clearly unsustainable. The reductions in midwifery graduate numbers since 1995, and changes in the age of those completing, needs to be taken into account when estimating the size of future reserve pools and making realistic estimates of the annual number of re-entrants from the pool. It is noted in the paper that the current number of vacant midwife positions (125), spread over a large number of facilities, ‘does confirm that the total number of midwives currently entering the workforce (either as new entrants or re-entrants) is not sufficient to meet demand under normal working conditions’ (p. 61). Thus current levels of re-entry, combined with newly trained entrants, is insufficient. This indicates that the pool has not been artificially dammed by a lack of available positions for re-entrants, and puts to question the comment that:

The reserve pool is an asset whose value degrades over time. The strategy therefore is to reduce the waste of this asset by utilising the reserve pool heavily over the next three to five years’ (p. 63).

The level of vacancies indicates that the flows into and out of the pool have been broadly in equilibrium, and that higher rates of re-entry (heavy utilisation of the pool) should not be expected without substantial extra incentives. Perhaps a third to a half of those in the pool at any one time (mostly those who left for family reasons, redundancy or relocation –see p. 36) are highly likely to re-enter as a matter of course, while others (those who gained promotion or chose alternative employment, or retired — including those who ceased being registered) would be unlikely to return without very substantial incentives, if at all. The former group in the reserve pool would turnover at a high rate, and be the majority of new entrants to the pool each year. Those unlikely to return to midwifery make up fewer of the new entrants to the pool each year, but as they stay in the pool for a substantial period (up to 54 years – see p. 37) they are a large component of it at any one time. Over a period of time the annual number entering the pool cannot exceed the number who completed midwifery training some years earlier – over recent years fewer than 130 (p. 60). To estimate a sustainable number of re-entrants, from that absolute maximum, the number of midwives who remain working as midwives, as well as those who leave and are unlikely to ever return must be deducted.

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4.3 South Australia

4.3.1 SA health system nursing and pre-registration student nurse intake requirements: 1998–2002

Prepared for the Office of the Chief Nurse, South Australia Department of Human Services by Edward Rawinski, Judi Brown and David White, 9 September 1997, 7 pp. www.health.sa.gov.au/nurselabour/student-nurse-intake.htm (accessed 28 February 2001).

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4.3.2 SA aged care nursing requirements: 1999-2001

Prepared for the Office of the Chief Nurse, South Australia Department of Human Services by Edward Rawinski, Judi Brown and David White, September 1998, 8 pp. 
www.health.sa.gov.au/nurselabour/student-nurse-intake.htm (accessed 28 February 2001).

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4.3.3 SA enrolled nurse training requirements 1999–2003

Prepared for the Office of the Chief Nurse, South Australia Department of Human Services by Edward Rawinski, Judi Brown and David White, April 1999, 7 pp. 
www.health.sa.gov.au/nurselabour/student-nurse-intake.htm (accessed 28 February 2001).

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4.3.4 SA midwifery student intake requirements 2000-2020

Prepared for the Office of the Chief Nurse, South Australia Department of Human Services by Edward Rawinski, Judi Brown and David White, September 1999, 11 pp.
www.health.sa.gov.au/nurselabour/midwife-paper.htm (accessed 10 May 2001)

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4.3.5 SA critical care student intake requirements 2000- 2004

Prepared for the Office of the Chief Nurse, South Australia Department of Human Services by Edward Rawinski, Judi Brown and David White, March 2000, 9 pp. 
www.health.sa.gov.au/nurselabour/student-nurse-intake.htm (accessed 28 February 2001).

The South Australian Department of Human Services publishes on its website nurse labour market projections (listed above), statistics on the nurse workforce, and quarterly Nurse Labourforce Bulletins, which include some labour force projections and related data and commentary. The various documents are inter-related, and will be outlined together. Other reports were in preparation at the time this report was written on the requirements for graduates of pre-registration nurse education programmes in South Australia, and on requirements for peri-operative specialist nurses. Note that the recent report is concerned with requirements for graduates of pre-registration programmes, not intakes. This is in recognition of the difficulties of estimating attrition and transfers in and out during the duration of courses, and, perhaps, indicating a boundary to the respective responsibilities of the Department of Human Services and universities.

The reports are based on an appropriately simple and transparent methodology. Public and private sector nursing requirements (headcounts) are estimated in consultation with the relevant authorities, taking account of FTE requirements and estimates of the ratio of FTE to headcount. Net attrition from the registered nurse workforce is estimated within a broad range. The method used for estimating attrition is based on an assumption of the average period in the workforce of a graduating student nurse.

This method is appropriate for a workforce in equilibrium (where recruitment rates have been more of less constant for decades, and the average length of period in the workforce has similarly been constant for decades and is expected to remain so). However the nurse workforce has not been in such a state of equilibrium, and is entering a period of dynamic change related to the changing age profile. That said, the range of net attrition rates assumed in most of the studies appear broadly reasonable for the periods under consideration. Some of the studies listed are concerned with intake requirements, and thus the projections include estimates of attrition rates between intake and graduation that were developed in consultation with the universities.

In several of the reports it is pointed out that ‘from a health system perspective, under supply is more difficult to manage than oversupply’, and the ‘labourforce system is very sensitive to changes in patterns of workforce attrition and participation’, thus intakes in the higher, rather than lower, recommended range are recommended.

The recommendations and conclusions are:

• SA pre-registration student nurse intake requirements: 1998–2002 (1997): The report recommends that intakes be in the range 600-800 over the period 1998 to 2002 (according to DETYA Selected Higher Education Student Statistics data on commencing basic nursing students, actual commencements have largely been within this range: 733 in 1998, 873 in 1999, and 713 in 2000.) It is pointed out in the report that ‘intakes of 1 162 would be required to maintain the South Australian RN workforce at its current estimated headcount of 13 553 with a net RN attrition rate of 6 per cent. It is only due to the continued decline in public sector requirements that lower intakes are acceptable’ (p. 6); and

• SA aged care nursing requirements 1999–2001 (1998): There are twelve recommendations covering quantitative and qualitative matters related to higher education and other training for aged care nurses, funding (especially to facilitate participation by country nurses in continuing education), work organisation and conditions, careers, and promotion of nursing in aged care and education for aged care nurses.

Some specific recommendations relevant to nurse education in universities include:

• Universities provide between 20 and 76 aged care postgraduate places per year;

• Universities continue working with the aged care industry and the community in the development of aged care programmes and curricula;

• Prior learning and experienced within aged care and gerontic nursing be recognised and appropriate credit given within approved programmes; and

• South Australia Midwifery student intake requirements 2000–20 (1999). It is recommended that midwifery training numbers should be about 132 per annum over the period 2000–04 (p. 4).

However, this is based on separation rates from the midwifery profession of between 6.35 per cent and 8.60 percent (p. 3) which is derived from a survey of the midwifery workforce from which the mean length of midwifery experience is estimated to be just under 16 years. However, 1996 ABS Census data on the occupation of South Australians with midwifery qualifications indicates that a net separation rate of a little over 5 per cent may be more appropriate — assuming, as the Midwifery report does, that all graduates of midwifery programmes ‘enter the midwifery workforce’ (p. 3). The Census indicates that 32 percent of South Australians with midwifery qualifications were working as midwives — 62 per cent of those aged 25 to 29, decreasing at a broadly even rate to 24 per cent of those aged 45 to 49. A separation rate assumption of a little over 5 per cent is consistent with the report’s ‘low training requirements’ scenario attrition rate of 5.16 per cent, indicating a need for 74 graduates each year. The difference in these conclusions (one a need for about 132 graduates a year, the other for about 74 graduates a year) indicates the impact of different assumptions about net separation rates. Even so, the number of graduates of midwifery courses in South Australia, at fewer than fifty, is well below the lowest estimate of demand for graduates. The utilisation of midwifery qualifications within nursing as a whole appears to be a significant issue for labour force projections. According to the Census data, many South Australians with midwifery qualifications are working in nursing occupations other than ‘midwifery’, almost all as RNs, less than 3 per cent as nurse managers, educators or researchers. The proportion with midwifery qualifications and working in nursing occupations, who are working as ‘midwives’, drops from over three-quarters of those aged under 35, to less than one quarter of those aged over 50. The Census data cannot tell us the degree to which those classified as working as RNs are utilising their midwifery skills. The Midwifery report only explicitly takes account of those with midwifery qualifications working in other nursing occupations in terms of the very small additional number who may take up clinical educator positions with the introduction in 2002 of the new direct entry midwifery course at Flinders University.

SA critical care student intake requirements 2000–02 (2000): It is recommended that the intake numbers for critical care courses be maintained in the range 124 to 209 over the period 2000–04 (p. 4). This is above the current level of around 100.

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4.4 Tasmania

4.4.1 Nurse labour force requirements and supply projections: Tasmania 1991-2002

By Ron van Konkelenberg for the Nursing Advisory Unit, Department of Health Services, Tasmania, December 1992 (20 pp.).

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4.4.2 Specialist nurse labour force requirements and supply projections for the Tasmanian Department of Community and Health Services

By Ron van Konkelenberg for the Department of Community and Health Services, Tasmania, June 1994 (26 pp.).

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4.4.3 Review of registered/enrolled nurse and midwife labourforce projections

By Ron van Konkelenberg for the Nursing Advisory Unit, Department of Community and Health Services, Tasmania, July 1996 (16 pp.).

These three reports were prepared by Dr Ron van Konkelenberg, who has also prepared projections for Victoria.

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4.4.4 Nurse workforce planning project

Project Plan (February 2001).

Supply and Demand Projections sub-project.

These projects are being carried out by the Tasmanian Department of Health and Human Services (Strategic Development).

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4.5 General RN workforce

4.5.1 Nurse supply and demand to 2006: projections and issues

A project currently being carried out for the Australian Council of Deans of Nursing by Barbara Preston.

The project involves the development of broad supply and demand projections for Australian resident graduates of pre-registration nurse education courses. The primary objective is to inform policy on intake numbers, but the outcomes of the project may also inform health authority recruitment and staffing policies.

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5. Data sources

5.1 National data sources

5.1.1 Nursing labour force 1993 and 1994, national health labour force series number 9, March 1997

The Australian Institute of Health and Welfare (AIHW), Canberra.

5.1.2 Nursing labour force 1995, national health labour force series

Number 11, 1998. The Australian Institute of Health and Welfare (AIHW), Canberra.

5.1.3 Nursing labour force 1998, national health labour force series, 1999

The Australian Institute of Health and Welfare (AIHW), Canberra.

5.1.4 Nursing labour force 1999: preliminary report. 2000

The Australian Institute of Health and Welfare (AIHW), Canberra.

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5.1.5 Health and community services labour force 1996

The Australian Institute of Health and Welfare, Canberra.

The Australian Institute of Health and Welfare (AIHW) prepares periodic reports that present statistics on nurses registered with the nurses board or nursing council in each State and Territory of Australia, and data from the ‘national nursing labour force survey’, a survey of individuals conducted in association with renewal of registration or enrolment with the board or council. The reports also include other statistics from the Commonwealth Department of Education, Training and Youth Affairs (DETYA), the Australian Bureau of Statistics, the Department of Employment, Workplace Relations and Small Business (DEWRSB), the Department of Immigration, and other sources. Data is provided on enrolled nurses as well as registered nurses, and some key tables do not disaggregate enrolled and registered nurses.

Many labour force studies reviewed in this report make heavy use of the AIHW data. There are some difficulties with the data in terms of timeliness, data quality, and appropriateness or completeness for the purposes. These matters are discussed in the main text of this report.

The nurse labour force reports are available at:

http://www.aihw.gov.au/labourforce/nurses.html

The Health and community services labour force 1996 report is available at:

http://www.aihw.gov.au/inet/publications/hwl/hcslf96/index.html

Major findings from the recent reports include:

• The number of registered nurses in 1999 was 212 878, an increase from 207 038 in 1996, and just surpassing the 1993 figure of 212 630. (Nursing labour force 1999: Preliminary report, Table 1);

• The number of employed registered nurses per 100,000 population has declined between 1989 and 1999 from 890 to 883 nationally. The pattern. varies from State to State. For example, in Tasmania there has been a decline of 29 per cent from 1 441 to 1 021 per 100 000, while in Western Australia there has been an increase of 10 per cent, from 752 to 828 per 100 000. (Nursing labour force 1999: Preliminary report, Table 3);

• In 1997, 87 per cent of registered nurses were employed in nursing. The proportion was just over 90 per cent in all States except New South Wales, where it was close to 80 per cent, with a similar proportion in the two territories. (Nursing labour force 1999: Preliminary report, Table 5);

• Between 1989 and 1999 the number of employed registered nurses increased by 12 per cent to 167 400, while the number of employed enrolled nurses fell by 40 per cent to 28 500. (Nursing labour force 1999: Preliminary report, Table 3);

• Basic nursing course commencements (Australian citizens and permanent resident students) fell from a high of 9  325 in 1991 to 6 821 in 1996, and then increased to 7 388 in 1999. (Nursing labour force 1999: Preliminary report , Table 10) (More recent DETYA data indicates a fall in commencements in basic nursing courses between 1999 and 2000 of 5.2 per cent - http://www.dest.gov.au/highered/statpubs.htm);

• Basic nursing course completions have fallen by 27 percent from a high of 6 397 in 1993 to 4 661 in 1998 (Nursing labour force 1999: Preliminary report, Table 11);

• Temporary migration of nurses from Australia increased through the 1990s from 720 in 1993-94 to 851 in 1989-99; permanent migration of nurses from Australia changed little overall though the period, from 666 in 1993-94 to 661 in 1998-99. That is, a total of 1 512 nurses migrated from Australia in 1998-99. (Nursing labour force 1999: Preliminary report, Tables 14 and 15);

• Temporary migration of nurses into Australia almost quadrupled over the period – but from a small base of 118 in 1993-94, to 450 in 1998-99; permanent migration of nurses into Australia fluctuated from 847 in 1993-94, to 1 166 in 1995-96, dropping back to 955 in 1996-97, before reaching 1 080 in 1998-99. That is, a total of 1 530 nurses migrated to Australia in 1998-99 —a net gain to Australia of 18. (Nursing labour force 1999: Preliminary report, Tables 12 and 13); and

• Of the sixteen nursing specialisations listed, all but five were in shortage nationally in December 1999, and each of those five were in shortage in at least one major State (Queensland in each case, New South Wales in two, Victoria in one). (Nursing labour force 1999: Preliminary report, Table 16).

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5.1.6 Department of Employment, Workplace Relations and Small Business (DEWRSB) ‘job outlook’

The Commonwealth Department of Employment, Workplace Relations and Small Business (DEWRSB) provides broad estimates of job prospects over the coming five years for occupations according to the Australian Standard Classification of Occupations Second Edition (ASCO2). Information is provided from various sources (mostly ABS) on patterns of employment, main employing industries, the proportions of openings resulting from turnover and from overall employment growth, occupation size, weekly earnings, hours of work, age profile.

The front webpage for nursing and related occupations is at: 

http://jobsearch.gov.au/joboutlook/SpecOccCat.asp?CatCode=82

Individual nursing occupations can be found as follows:

Registered nurses: http://jobsearch.gov.au/joboutlook/ASCODesc.asp?ASCOCode=2323

Nurse educators and Researchers: http://jobsearch.gov.au/joboutlook/ASCODesc.asp?ASCOCode=2322

Nurse Managers: http://jobsearch.gov.au/joboutlook/ASCODesc.asp?ASCOCode=2321

Registered Mental Health Nurses: http://jobsearch.gov.au/joboutlook/ASCODesc.asp?ASCOCode=2325

Registered Midwives: http://jobsearch.gov.au/joboutlook/ASCODesc.asp?ASCOCode=2324

Technical information is available at: http://jobsearch.gov.au/joboutlook/Information.asp

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5.1.7 The Commonwealth Department of Employment, Workplace Relations and Small Business (DEWRSB)

Provides broad estimates of job prospects over the coming five years for occupations according to the Australian Standard Classification of Occupations Second Edition (ASCO2). Information is provided from various sources (mostly ABS) on patterns of employment, main employing industries, the proportions of openings resulting from turn over and from overall employment growth, occupation size, weekly earnings, hours of work, age profile.

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5.1.8 Skilled labour: gains and losses

By Bob Birrell, Ian R Dobson, Virginia Rapson and T. Fred Smith, Centre for Population and Urban Research, Monash University, July 2001 (36 pp. plus appendix).

http://www.dima.gov.au/research/publications/skilledlab/index.htm

This report provides detailed information on movements of professionals and other skilled workers (including professional nurses) to and from Australia between 1995 and 2000. Information is also provided on country of last and next residence over the three years to 2000. Those moving into or out of Australia are subdivided into ‘settlers’, ‘residents’, and ‘visitors’. The report provides evidence of increasing net movements of residents out of Australia since 1995.

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5.2 State/Territory data sources

5.2.1 Workforce characteristics: nurses re-registered in Queensland 1996; 1997 and 1999

Queensland Health and Queensland Nursing Council, 2001 (20 pp):

http://www.health.qld.gov.au/hic/nurses/nurses.htm

Includes statistical information on re-registered enrolled and registered nurses by gender; age; employment type, location, and setting; work nature and area of nursing activity; hours of employment. Detailed tables are preceded by a one page methodological introduction to the survey (the survey form accompanies re-registration forms) and summary of findings.

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5.2.2 Workforce planning information paper series. ‘The changing profile of persons enrolled in pre-registration nursing courses in Queensland (1994–1998)

Queensland Health, December 1999 (5 pp.).

The paper covers changes to OP (tertiary entrance scores) cut offs, numbers of applicants and places, first preferences for nursing by year 12 and late-entry applicants, and the age distributions of applicants and newly enrolled students. Conclusions and findings include:

• ‘Changes to OP cut-offs need to be viewed with caution’ and typical (median) OP scores of the cohorts are a better indicator of demand and student quality, and these have remained fairly stable over the period;

• The number of applicants has outstripped the number of places by at least 1.5:1 through the period; in 1998 there were 59 596 applicants for 39 447 places;

• Consistently through the period more than three per cent of applicants gave pre-registration nursing as first preference; however, the proportion of year 12 applicants giving pre-registration nursing first preference has fallen, and the proportion of late-entry applicants giving pre-registration nursing first preference has increased between 1994 and 1998; and

• The age of applicants and newly enrolled students has increased, in 1994 about 80 per cent were under 25, in 1998 about 60 per cent were under 25, another 30 per cent between 25 and 39.

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5.2.3 Workforce planning information paper series. ‘The cohort of students commencing study in nursing pre-registration courses in 1996 in Queensland universities’

Queensland Health, February 2000 (9 pp.)

The project followed up students who had enrolled in pre-registration courses as at 31 March 1996, sending them a questionnaire and investigating their registration with the Queensland Nursing Council. Data is provided on: university of enrolment; age of the cohort in 1996; OP and TE rank distribution of the cohort; and registration rate by age group, OP and TE rank and university attended. The questionnaire was sent to those who had not registered, with a 20 per cent response rate. Some conclusions and findings are:

• Half the cohort had registered by June 1999;

• Older students were more likely to have completed the course and registered, with a registration rate of over 60 per cent by those aged 35 to 44;

• Students with low or very high OP (or TE rank) are less likely to have registered;

• Of those surveyed, 60 percent were planning to complete the course and work as a registered nurse, or had already done so (it was noted that the respondent group probably over-represented those planning to become an R.N., or who had already done so);

• Almost all of those not intending to complete a BN had transferred to another course in the first year of study, generally courses with similar OP/TE cut-offs to nursing (this finding does not support the notion that students use nursing as a route to courses with higher entry standards); and

• In response to a question on what would encourage then to return to the nursing course, the students who had transferred indicated ‘the course needs more direct nursing practice rather than theory’ (8 out of 26 respondents) or a change in personal financial situation (4 out of 26).

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5.2.4 Nursing recruitment and retention taskforce: data analysis and benchmarking report

Workforce Relations and Planning, Territory Health Services, Northern Territory Government, December 2000 (35 pp).

This report presents statistics on nurses working within Territory Health Services in 2000, covering matters including:

• Total number;

• Commencements and exits;

• Classification levels and distribution;

• Age/sex cohorts;

• Geographical distribution;

• Service setting distributions; and

• Staff utilisation and workload activity data.

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6. Conclusion

This paper is to convey information, not to make judgements or recommendations. Neither of the authors is a nurse, and we are not qualified - nor were we commissioned - to make such judgements and recommendations. We have looked at this fairly large number of recent reports and we have summarised their contents. It is clear that a few topics predominate in the inquiries and reviews of the last few years. It is clear that there are quite a number of issues (which nurses brought to our attention) which do not appear to have been the subject of inquiries and reports although they bear, to some extent, on nurse education. It may be that the matters which have received reports have been the most urgent - a judgement of priorities. We simply present the picture and leave it to our sponsors - the Australian Council of Deans of Nursing, the Department of Education, Training and Youth Affairs and the Department of Health and Aged Care - to decide what further actions they wish to take.

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7. Appendices

Appendix A

The Reid review (1994)

Nursing Education in Australian Universities Report of the National Review of Nurse Education in the Higher Education Sector - 1994 and beyond. AGPS 1994.

Overview

A committee chaired by Professor Janice Reid (then Pro-Vice-Chancellor of Queensland University of Technology) was established in 1993 to review nursing education at the point at which the transfer into the higher education sector was just complete. The review was to assess the extent to which the objectives of the transfer were being achieved and to recommend any measures which might be thought necessary to improve the effectiveness of nurse education. The review was extensive and took twelve months to complete. It was asked to address the changing needs of the nursing workplace and the roles of the different categories of nurse: Registered Nurses, Assistants in Nursing, Enrolled Nurses, nurse practitioners and nurse specialists, and their implications for nurse education; the balance between undergraduate and postgraduate courses; funding arrangements for clinical placements; articulation, credit transfer and career paths for Assistants in Nursing and Enrolled Nurses; workforce information for educational planning; the role of the industry in such planning; the practicality of core curricula; and the concept of an intern year following graduation from basic nurse education.

The recommendations are very detailed and run to 14 pages. They follow the Terms of Reference closely. The discussion leading to the recommendations addresses certain issues which surface, not surprisingly, in many of the other reports: the problems of transition from university to the workplace; the need for collaboration between the academy and the health care agencies; the arrangements, including financial arrangements, for the practicum; the need for labour force planning to take account of the many cultures now within Australian society; the need for articulation of training programmes and a career structure for health workers aiming to become registered nurses.

The review also discusses the length of the basic course leading to registration, and ‘was not able to support an extension of funding [for such courses] beyond three years at this time’ (Executive Summary, p.9). When the other major recommendations had been implemented and evaluated it would be time to look again at the duration of public funding for a nursing course. At the postgraduate level, it notes that ‘Australia has the opportunity to become a world leader in the postgraduate field’ (p.10) through the development of postgraduate courses and research in nursing.

This review is much cited in later, more limited studies and has had an effect on nurse education regardless of whether recommendations have been implemented by governments or other agencies. DETYA has in other areas initiated evaluations of the impact of reviews some years after the completion of the reviews; it may be time now to evaluate the impact of this one.

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Review of Implementation

The report contains over 100 recommendations. The paragraphs which follow attempt to indicate, through information supplied by senior deans, which of these were implemented, either substantially or partially, and which appear to have been ignored. The recommendations begin at Chapter 8 of the report, and are therefore numbered 8.1, 8.2 - 9.1, 9.2 - and so on to 16.4.

8.1 and 8.2 deal with mechanisms for labour force planning.

These recommendations have been largely implemented, if not necessarily in the form in which the report recommended.

8.3 and 8.4 deal with shifts in university student load, and with DEET’s (now DETYA’s) definitions and categories of students and fields of study.

No evidence of implementation.

9.1 refers to an Australian Vice Chancellors Committee (AVCC), reference group on nursing in higher education and recommends support for its proposals on articulation and a pilot project on credit transfer between university schools of nursing.

No evidence of implementation.

9.2 recommends course lengths to bachelor degree, for hospital-certificated Registered Nurses (RNs), of two semesters (FTE) and, for diplomates, of one semester (FTE).

There was informal agreement among the Deans in NSW that there would be acceptance of the first year of the B N programmes for mutual recognition. This was never formalized. There were two AVCC reference groups on credit transfer across nursing, health sciences and other degrees. One was undertaken by Betty Andersen and the other by Roy Killen. Pamphlets were published but it is hard to find any trace of the documents.

9.3 recommends provision of migrant bridging programmes for overseas-educated nurses with resident status in Australia.

The Australian Nursing Council Incorporated (ANCI), has done some work on this. Most states offer a programme for such nurses. People who complete the course proceed to registration with the Nurses Registration Board.

9.4 deals with enrolled nurses (ENs): that their education be in the Vocational Education Training (VET), sector, at a nationally consistent level; that universities be consulted on the curriculum for ENs, and that there be specified block credit for ENs at the point of entry to RN bachelor courses.

Implementation has been patchy; there is no consistency across States. Three universities in NSW have bridging programmes for ENs.

9.5 recommends ‘a demonstration project in the form of a fully articulated pre-registration undergraduate course in which the first year is conducted in the VET sector and consists of EN education. All students completing the first year successfully would be eligible to graduate as EN s. The final part of the programme, for students to graduate as RNs, would be conducted at university’.

One of the bridging programmes mentioned at 9.4 resembles this but none probably exists in this form.

9.6.1 recommends establishment of an articulated system of nursing education for Assistant in Nursing (AIN), - however termed, ENs. and RNs.

There is variable recognition of the TAFE Certificate Level 111 for AINS; there is no consistent system.

9.6.2 endorses activity on the review of (ANCI) competencies, the AVCC pilot project on credit transfer and national guidelines on course accreditation.

These have been largely implemented.

9.7 recommends that universities publicise the availability of courses, credit transfer arrangements and so on.

This is being done.

• Chapter 10 deals with the undergraduate programme.

10.1 recommends that universities take into account the changing needs of the community and the profession.

This is being done.

10.2 recommends ‘that all university schools of nursing develop and maintain course advisory committees’ for curriculum development and quality assurance.

This is being done.

10.3 suggests that schools of nursing "develop and publicise best practice models of health service consumer involvement" and seek funding support from various public service programmes.

Diana Keatinge and a team from the University of Newcastle worked on a project jointly managed by the Australian Nurses Federation and the Royal College of Nursing, Australia; it focussed on strategies for nurses to involve consumers in health care. (Title: Project to Support Nurses to Involve Consumers in their Health Care).

10.4 recommends that the Committee for the Advancement of University Teaching (CAUT) nominate nursing as a priority area and fund projects on ten named aspects of nurse education.

That committee was disbanded in 1996. Its successor, the Australian Universities Teaching Committee, has funded one major tripartite project in nurse education.

10.5 recommends a national workshop on curriculum development, teaching quality and innovation in nursing, to be funded by DEET.

This was not implemented.

10.6 contains a strong endorsement of comprehensive bachelor of nursing programmes as the level of entry to professional practice as a registered nurse. Such programmes should all include ‘basic strands’ in medical/surgical, community health and mental health nursing.

This has been implemented.

It recommends against direct entry undergraduate mental health and midwifery programmes; some direct entry midwifery programmes are now being developed.

10.7 recommends funding for demonstration or pilot projects in core curricula across the health sciences, coming from the National Priority Reserve Fund.

No evidence of implementation.

10.8 ‘That at this stage in the development of the undergraduate programme, the duration of public funding not be extended to four years’ — this decision to be reviewed after implementation and evaluation of the Review’s proposals on clinical education, transition to work, the undergraduate degree and teaching quality.

The proposed National Review of Nursing Education will presumably consider this.

• Chapter 11 deals with pre-registration clinical education.

11.1 recommends evaluation of clinical education by assessment of the outcomes, not by time spent.

Implemented in a limited fashion. Course experience questionnaire feedback suggests that students say that the clinical is the most critical aspect of their course and that they could have done with more. Work on transition to the workforce shows that amount of time does not translate into a high level of satisfaction with the field experience.

11.2 recommends funding for testing and evaluating different models of clinical education.

Many universities are implementing and evaluation different models of clinical education.

However, the availability of clinical places remains a challenge given the high patient turn over, the unwillingness of some nurses to work with students given their workloads and the sheer complexity of the workplace.

11.3 recommends a set of principles to apply in staffing clinical education programmes.

These are now generally accepted.

11.4 recommends principles governing cooperation between universities and health facilities in provision of clinical education.

These are now generally accepted.

11.5 sets out procedures for coordination of clinical placements ‘to avoid inter-institutional competition for or loss of clinical placement opportunities’.

The procedures are generally followed, but have not obviated competition and loss of placements.

11.6 recommends that higher education nursing courses be funded ‘appropriately’ and that the funding of clinical education be further considered in the light of a DEET– Department of Human Services and Health, (DHSH), study of the costs of clinical education in the health sciences.

This has been attempted but was derailed. At least one university costed its field experiences and found that those subjects are subsidised by other nursing subjects.

• Chapter 12 deals with transition to work.

12.1 recommends that the ANCI entry-level RN competency statements meet employers’ expectations of a beginning practitioner as well as registering authorities’ requirements for registration.

This has been implemented in so far as employers’ expectations are realistic.

12.2 recommends a period of at least four weeks continuous clinical practice in the final semester of the undergraduate course, with associated recommendations about assessment.

This is fairly common if not the universal practice.

12.3 recommends that new graduates should be provided with employer-funded assistance and programmes for transition to employment.

This has been partially implemented, not always on an adequate scale. Funding ranges from $900 per new graduate in one state to $11 000 per new graduate in another.

12.4 rejects the use of year long graduate nurse programmes and recommends that the resources thus saved be used for shorter programmes available to a greater number of nurses beginning employment.

Implemented in various patterns.

12.5 rejects the use of a system of internship.

This appears to be the present situation.

• Chapter 13 deals with postgraduate nurse education.

13.1 recommends Higher Education Contribution Scheme, (HECS), exemptions for postgraduate coursework enrolments in specialist nursing.

Not generally implemented; perhaps in some universities.

13.2 recommends collaboration between universities and health agencies in development, provision and evaluation of courses leading to clinical specialist qualifications.

This has been implemented at least to some extent.

13.3 recommends articulation arrangements for specialist and postgraduate courses provided outside the higher education sector, with credit transfer; and universities should regard hospital-educated RNs as eligible to enter postgraduate courses and proceed to higher degrees if they are judged likely to be successful.

Generally implemented.

13.4 Employers and nursing organisations should develop national competency standards for specialist nursing, consistent with the ANCI entry level competencies.

Many specialties have now adopted/adapted the Australian Nursing Federation (ANF), competencies.

13.5 There should be HECS exemptions and other scholarships for postgraduate nursing, funded by universities, by employers and by the Commonwealth.

Implemented in a limited manner.

• Chapter 14 deals with aspects of Australian society.

14.1 on mental health recommends that all undergraduate nursing programmes have a significant mental health component; that post-registration courses be provided to prepare nurses for specialist mental health practice; and that the number and distribution of these courses be determined by labour force needs.

Generally implemented.

14.2 recommends funding by Australian Health Ministers Advisory Committee (AHMAC), for one or two centres for rural and remote area nursing and recommends criteria for selection of these centres.

No evidence of implementation.

14.3 recommends rural clinical placements, support for rural students, course components on rural nursing, specialist courses on remote-area nursing, and monitoring of the proportion of nursing students from rural backgrounds.

Implemented in some universities.

14.4 recommends support for distance education, use of technology, mixed mode and innovative approaches to provision of remote area education of nurses.

Much is being done in this, and will continue.

14.5 recommends measures to recruit and support Aboriginal and Torres Strait Islander, (ATSI), nursing students, funding for demonstration projects, and research into health care and nursing in these communities.

Implemented in some universities.

14.6 recommends articulation of courses for Aboriginal Health Workers (AHWs) with courses preparing Enrolled Nurses (ENs), and RNs.

No evidence of implementation.

14.7 similarly recommends measures to recruit and support nursing students from non English speaking background (NESB).

No evidence of implementation.

• Chapter 15 deals with academic staff and research.

15.1 recommends a programme of staff development specifically for nursing academics, with targets of 70 per cent having higher degrees and 30 per cent having doctorates (no time frame is set for these targets).

No evidence of implementation.

15.2 recommends access to National Health and Medical Research Committee (NHMRC), funds for research in nursing.

No evidence of implementation.

15.3 recommends NHMRC funding for scholarships to encourage and develop researchers in nursing.

No evidence of implementation.

15.4 recommends special support from the Australian Research Council (ARC), for research in nursing.

No evidence of implementation.

15.5 recommends joint NHMC– ARC support for nursing research, especially in public health and health services.

No evidence of implementation.

15.6 recommends universities to provide support, seed funding and research advice to advance nursing research.

This has been implemented in most universities as part of their general support for research.

• Chapter 16 deals with the arrangements transferring nurse education into higher education.

16.1 recommends ‘a common national standard for Commonwealth funding of nursing in higher education’.

This has probably been implemented by DETYA.

16.2 recommends DETYA funding to support studies of efficiency, effectiveness and costs in nurse education.

DETYA has supported several such studies, as the present report illustrates.

16.3 recommends formal links between schools of nursing and hospitals and other health agencies, through clinical chairs, joint appointments and other measures.

Many of these have been established.

16.4 recommends that nursing education be designated a priority area under the National Priority (Reserve) Fund.

Implemented.

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Appendix B

List of reports, by category

Educational programmes

1995 CSU Improving the Education and Career Options for Enrolled Nurses in Rural and Remote Areas through a Distance Education Bridging programme.

A flexible approach to the delivery of an undergraduate nursing degree to rural and remote area students, 1997 by Anita Lange, Ian Blue, Pauline Hill, Helen Bradley, Jill Barclay.

A multi-centre comparative investigation of the impact of undergraduate mental health nursing curricula and clinical experience on attitudes, skills and clinical confidence, June 1997 by Alison Bell, Jan Horsfall, Bill Goodin (University of Sydney), NPRF/DETYA.

An exploration: Clinical learning programmes in undergraduate pre-registration Bachelor of Nursing Courses, 1999 by Elizabeth Bethune, Sally Wellard, Allison Williams, Dallas Mischkulnig and Carole Rushton, School of Nursing, Deakin University.

An integrated support programme for Nursing students from non-English speaking backgrounds, 1997 by Martijntje Kulski and Vickey Brown, Curtin University of Technology.

Best practice and clinical placements: quality, cost effective, clinical education for undergraduate nursing students, 1997 by Patricia Mills, Julianne Cheek, Bronny Modra, Meryl Williams, University of South Australia.

Credentialling and Accreditation Feasibility Project - a national approach to the credentialling of advanced practice nurses and the accreditation of related programmes. Royal College of Nursing, Australia. (Funded by Health and Aged Care).

Dedicated Education Units: 1 - A new concept for clinical teaching and learning, 1999 by Kay Edgecombe, Karen Wotton, Judith Gonda and Peter Mason. Flinders University (published in Contemporary Nurse 1999, 166–171).

Dedicated Education Units: 2 - An evaluation, 1999 by Judith Gonda, Karen Wotton, Kay Edgecombe and Peter Mason. Flinders University (published in Contemporary Nurse 1999, 172–176).

DETYA (NPRF) Evaluating the quality and effectiveness of selected models of pre-registration clinical education, by Nash, Fentiman, Mannion, Theobald, Lemcke and Walsh.

Evaluation of Enrolled Nurses' bridging programme, 1998 by Professor Pamela Bell, Charles Sturt University.

Final Report on the Implementation of the Partnerships in Clinical Practice Project, 1997 by Elizabeth Davies, Australian Catholic University.

For AUTC by Flinders, UTS & QUT:

• QUT – Clinical education models.
• UTS – Curriculum development and review.
• Flinders – Recruitment, transition, retention.

Learning Outcomes and Curriculum Development in Major Disciplines in Nursing, for completion November 2001.

National Review of Specialist Nurse Education, 1997 by Lynette Russell, Lindsay Gething, Paula Convery, Faculty of Nursing, University of Sydney.

Nurse Practitioner Project Stage 3 - Final Report of the Steering Committee (NSW Health, 1995).

Nurse Practitioner Services in NSW (NSW Health, 1998).

Nurses’ experiences of work during their undergraduate education, by Libby Denmead, Ralph Forbes and Andrew Fleming, UWS.

Registered nurses’ experiences of educational transition programmes, by Mary Lambell and Andrew Fleming, UWS.

The Development of Teaching and Learning Partnerships in Nursing: Academics, Clinicians and Students, 1997 by Judith Clare, Karen Wotton, Eileen Ingham, Lee Gassner, Didy Button, School of Nursing, Flinders University.

Transition from Education to Employment: from University Student to Registered Nurse, 1997 by Judith Clare, Pauline Glover, Dianne Longson, School of Nursing, Flinders University.

Undergraduate nursing clinical education in acquired disability settings, by Laynie Hall, Julie Pryor, Lyn Chenoweth, Ralph Forbes and Aine Higgins, UWS.

State and national reviews:

A Strategic Review of Undergraduate Nurse Education in New Zealand.

New Vision, New Direction: a study for the future of Nursing and Midwifery in Western Australia (in progress). Nursing Council of New Zealand.

Nursing Education in Australian Universities Report of the National Review of Nurse Education in the Higher Education Sector - 1994 and beyond. AGPS 1994.

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Appendix C

Summaries – educational programmes

1. A flexible approach to the delivery of an undergraduate nursing degree to rural and remote area students, 1997 by Anita Lange, Ian Blue, Pauline Hill, Helen Bradley, Jill Barclay.

This reports on the University of South Australia's development and delivery of external course materials for the first year of an undergraduate nursing course. The rationale for the development is the number of people in rural and remote areas of South Australia wanting to become registered nurses but who for various reasons are not able or willing to move to Adelaide for the period of study required. These include a number of Indigenous Australians who want culturally appropriate nurses educated in culturally appropriate ways.

The University has long and successful experience in the practice of distance education and has professional course developers who were able to assist in the modification of on-campus courses to distance mode materials. A full first year course was developed, delivered to some 58 students, and evaluated. It was successful in that participation rates of rural and remote students, including Aboriginal and Torres Strait Islander students, in undergraduate nursing increased; teaching and learning strategies which best suit such students were further developed; collaboration between universities, health service providers, professional health and community organisations, and the VET sector improved; rural graduates were more likely to continue to work in rural and remote health service delivery; and at the end of the first semester 53 of the 58 students who had enrolled remained in the course. Eight of the original ten ATSI students remained; but only three remained enrolled in the unit Human Anatomy and Physiology 1, so there was clearly a problem with the content and presentation of this unit to this group.

The report regards this project as a success and concludes that ‘offering other nursing, science and social science subjects in the external mode in both the second and third year of the course is essential if rural and remote student enrolments are to continue’ (p.22).

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2. A Multi-centre comparative investigation of the impact of undergraduate mental health nursing curricula and clinical experience on attitudes, skills and clinical confidence, June 1997 by Alison Bell, Jan Horsfall, Bill Goodin (University of Sydney). NPRF./DETYA.

‘This study aims to document the attitudes, skills and knowledge required for undergraduate comprehensive nursing courses to clinically prepare beginning practitioners for general health-care settings as well as community-based mental health services, acute care and long-term rehabilitation psychiatric services. In particular, the project examines the effect of supervised clinical experience in a mental health setting on undergraduate nurses' attitudes and clinical confidence’ (p.3).

It starts with the question: ‘What are the core mental health nursing abilities required for graduates to be effective beginning practitioners?’ Thus it is not about preparing specialist mental health nurses, but about equipping general registered nurses with the skills and attitudes required in mental health settings. An essential component of such preparation is experience in such settings, but ‘students face the mental health clinical placement with fear or disinterest’ (p.4). This project measured student nurses' attitudes and clinical confidence before and after such a placement and identified factors leading to positive outcomes from the placement. Since registered nurses are very likely to have contact with people with mental illness at one time or another, the study assesses the contribution of mental health nursing theory and practice to nursing generally.

It found that about ten per cent of undergraduate nursing students would choose to practise in mental health, while with support and encouragement a further 52 per cent would consider the possibility. Practically all the students felt that an experience of mental health nursing would contribute to their nursing practice in general. The study developed a scale, the Mental Health Nursing Clinical Confidence Scale (MHNCCS), to measure the clinical confidence of nurses and students in this field of nursing. ‘There was no relationship between age and confidence scores. This finding is important as registered nurses and others have claimed at times that young registered nurses are not ready for the challenges of mental health nursing. There were also no differences in the self-reported confidence levels between males and females, nor those for whom English was a second language’ (p.11). This scale will be of continuing use, and can be modified to apply to other clinical areas.

The outcomes of the project were clearly positive in dispelling many fears and preconceived ideas about mental illness and mental health nursing. ‘The results clearly support the inclusion of mental health nursing in the undergraduate nursing programme. Despite the reality that the majority of graduating nurses will not choose to work in a specific mental health setting, the majority of students valued the contribution of mental health theory and clinical experience in their total preparation for practice as a registered nurse’ (p.13). The recommendations from the project mostly address issues of curriculum.

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3. An Exploration: Clinical Learning programmes in Undergraduate pre-registration Bachelor of Nursing Courses, 1999 by Elizabeth Bethune, Sally Wellard, Allison Williams, Dallas Mischkulnig and Carole Rushton, School of Nursing, Deakin University.

‘This study explored the organisation and implementation of clinical learning programmes in undergraduate pre-registration Bachelor of Nursing courses currently being offered in Australian universities’. It evaluated the effectiveness of the programmes and the factors enhancing or inhibiting their effectiveness. Nursing is a practice-based discipline, and such programmes are essential if nurses on graduation are to achieve the levels of competence required for registration and successful practice.

The report quotes an earlier study (Battersby and Hemmings, 1991) arguing that the quality of clinical experience, rather than the number of hours spent in clinical placements, that develops the required competence. This is important because the cost of clinical placements is closely related to the number of hours. Yet little time is spent in the preparation of supervisors to give better quality clinical supervision (pp.4, 14) and five universities ‘reported that clinical learning facilitators were expected to be responsible for their own preparation’ for that role.

A number of barriers to the provision of satisfactory clinical experience are identified in the report, amongst the more important of them: competition between universities for placements; cost of provision; geographic location; differing expectations between nursing academics and agencies offering clinical practice; and the academic calendar, which imposes clusters of demand for placements at certain times of the year.

Quality of supervisors is of critical importance, and cannot be guaranteed (pp.29–31). Assessment of the student nurses is an area of difficulty, with supervisors generally having less experience than academics in this activity, and with differing expectations between the two groups. Pages 35–45 are a good discussion of the whole range of issues in the practicum, and conclude with the finding that ‘innovative models of clinical supervision have been adopted but there is little research to support their introduction. This raises the question as to why research is not penetrating clinical learning programmes’ (p.45). There are no agreed criteria on what constitutes good practice or what a best-practice model would look like. Intelligence, dedication and hard work are to some extent being dissipated for lack of such direction.

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4. An Integrated Support programme for Nursing Students from non-English Speaking Backgrounds 1997, by Martijntje Kulski and Vickey Brown Curtin University of Technology.

This reports on yet another initiative arising from the National Review of Nurse Education in 1994: a project to develop and implement an integrated support programme for NESB nursing students at Curtin.

A key word is ‘integrated’. There have been measures of support for NESB students implemented in probably every Australian university at the institutional level, especially by provision of bridging and preparatory courses. However ‘there are few reports of developments at the curriculum level in Schools and Departments, which aim to produce a curriculum that is both adaptive and responsive to NESB students. NESB students enrol in various courses of study still requiring additional support with discipline-specific communication skills’ (p.8).

‘Areas of identified difficulty included: cultural and gender barriers to communication with clients, clinical teachers and other health care workers; academic writing in a nursing context; health care terminology; and nursing documentation’ (p.9).

This project highlighted helpful teaching strategies: ‘specific components of the curriculum could be adapted to include teaching strategies which focus on oral communication, academic writing skills, laboratory based learning or clinical communication skills’ (p.9). In this way NESB students could cover the same curriculum content towards the same objectives as their ESB peers, under different teaching and studying strategies in particular components. Thus students of both backgrounds would attend the same lectures, but would be separated for some of their tutorial, laboratory or clinical work, which would be taught with the emphasis outlined above. Since the change is to an educational approach, not to the quantum of classes, once the components have been developed and the staff trained to teach them there is no additional cost to the School and no overload for the student. Indeed there is some saving, in that staff and NESB students need not put in so much extracurricular time coping with special language problems.

The rest of this report describes the detailed steps taken to implement the project and the educational materials found useful for it.

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5. Best practice and clinical placements: quality, cost effective, clinical education for undergraduate nursing students, 1997 by Patricia Mills, Julianne Cheek, Bronny Modra, Meryl Williams. University of South Australia.

In a context of competing needs and declining resources available for teaching in hospitals, this study attempted to identify guiding principles for the development of models of clinical placement. It proceeded by literature review; a Delphi survey; focus group discussion; and development, implementation and evaluation of pilot clinical placement models. The authors point out a number of limitations of the study which ‘make it inappropriate to generalise’ (p.10). Nevertheless they make 25 recommendations based on their findings.

One of the most interesting aspects of the report is, that if one takes into account all the factors (not only financial outlays) involved in costs, it is not possible to determine absolute costs of clinical placement.

Chapter 4 is a report of the discussions of clinicians and students in focus groups. It will strike chords with every reader who is at all familiar with the practice of nursing in hospitals. What comes out of it is the need for better communication between the university staff and the clinicians, better preparation of the students for the clinical experience, and a greater degree of helpfulness and patience on the part of some (by no means all) of the clinicians.

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6. Credentialling and Accreditation Feasibility Project –

Royal College of Nursing, Australia (Funded by Health and Aged Care).

The project aim is to examine the feasibility of implementing a national approach to the credentialling of advanced practice nurses and the accreditation of nursing education programmes.

The report will comprise:

• An examination of key concepts and mechanisms for the establishment of a national approach to the credentialling of advanced practice nurses and the accreditation of related education programmes;
• The development of options for a national approach to the credentialling of advanced practice nurses and the accreditation of related education programmes in Australia; and
• The development of strategies to enable the exploration, testing and promotion of the proposed options for the credentialling of advanced practice nurses and the accreditation of related education programmes.

While this report is interesting to read, other reports on the improvement of clinical placement appear to be more useful in practice.

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7. Dedicated Education Units: 1 A New Concept for Clinical Teaching and Learning, 1999 by Kay Edgecombe, Karen Wotton, Judith Gonda and Peter Mason. Flinders University (published in Contemporary Nurse 1999, 166-171).

and

8. Dedicated Education Units: 2 An Evaluation, 1999 by Judith Gonda, Karen Wotton, Kay Edgecombe and Peter Mason. Flinders University (published in Contemporary Nurse 1999, p.172–176).

These two papers describe an innovation by Flinders University’s School of Nursing in the provision of clinical practice to nursing students. ‘Traditionally clinical placements consisted of short, condensed blocks of time’ (p.166); the weaknesses of the traditional model are well known and documented. In this new venture, ‘third year students were placed in each DEU for three days per week for fifteen weeks from week one of the semester; second year students were placed in week six and attached to the third year students; and first year students were placed in week ten and attached to either a second or third year student’ (p.173). DEU.s are existing health care units in which clinical nurses and academics collaborate to optimise the learning experiences of the students, and students cooperate in teaching each other. ‘There was an overwhelming positive response [to the evaluative questionnaire] from students about the advantages of peer teaching and learning, with use of words such as brilliant, excellent, rewarding and enjoyable. Students indicated that teaching other students reinforced their own learning’ (p.175). Similarly, clinicians found that the DEU ‘enabled them to assist students to apply theory to practice. Some stated the DEU enhanced their own practice by stimulating them to question and critique; others said the breaking down of barriers between the clinicians and academics was a positive and rewarding outcome’ (p.175). Key features are the length of time students spend in the one health-care environment, getting to know the clinicians and the tasks; and the close collaboration between clinicians and academics, so that both understand the aims and tasks of the others. The evaluation is highly positive.

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9. EIP project, by Deakin University. Awarded December 2000, for completion May 2001. Mapping Nurse Education programmes: all that offer general and specialist nursing qualifications, reporting these by institution.

Survey to find numbers of graduates who completed or will complete a specialist nursing qualification in 1999, 2000 and 2001 - by individual specialty, reported by institution and a State profile in each specialty. Also the number of graduates who will meet general nursing registration requirements for the first time in 1999, 2000, 2001.

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10. Evaluation of Enrolled Nurses' Bridging programme, 1998 by Professor Pamela Bell, Charles Sturt University.

This report describes and evaluates a bridging programme to bring Enrolled Nurses into the degree course at CSU leading to registration. The programme, which was funded by the National Priority (Reserve) Fund, had several aims, including: to extend the career options for ENs; to further progress towards the articulation of nursing courses; and, through distance education, to assist people in rural and remote areas to qualify as registered nurses. The programme was based at Dubbo and bounded by Dubbo, Broken Hill and Wellington in NSW, and involved cooperation between Charles Sturt University, the New South Wales TAFE Commission and Orana Community College, Dubbo. The evaluation pronounced the pilot venture successful, although in subsequent offerings some things would be done differently.

Apart from being a report of one successful programme, this evaluation makes a number of points about the position of the EN ‘The salary differential between an experienced EN and a first year RN is minimal. Economic sense therefore dictates employment of the RN who has a lengthier and more intensive academic preparation than the less qualified EN. The latter has only restricted work opportunities by comparison and legally may only practice under the supervision of an RN or a medical practitioner....Unless ENs retrain to become RNs they will have very few future employment opportunities....An Australian study revealed that, while no differences existed in the quality of care received by patients, an all RN staff was more cost effective on a surgical ward. Due to financial restraints and the restricted scope of practice of the EN, very few health care managers [in New Zealand] would consider increasing their numbers in future employment patterns’ (p.1).

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11. Final Report on the Implementation of the Partnerships in Clinical Practice Project, 1997 by Elizabeth Davies, Australian Catholic University.

The Macauley Campus of ACU had experienced frustration and dissatisfaction with the clinical component of its Bachelor of Nursing (Pre-Registration) course, and in 1996 implemented a new way of organising it. The number of agencies was rationalised across five clinical fields: domiciliary, acute care, maternity, aged care and mental health. It devised a sustainable three-year plan for placements, determining the number of students in each year to go to each field of placement. It eliminated the use of part-time, intermittent clinical nurse teachers and used only staff seconded full-time from the providing health care agency and full-time university staff. Selection criteria were agreed between the university and the agencies, and a short preparatory course was provided for the seconded staff. These staff were awarded a certificate of achievement and were identified as Clinical Affiliates of the School of Nursing. Liaison and administrative arrangements were simplified, and the agencies were remunerated for their seconded staff at the award rate for casual clinical nurse teachers.

As a result, the students found in the Clinical Affiliates nurses who were familiar with the operations and staff of the agency in which the students were placed, and the staff in the agencies were dealing with people (Affiliates) whom they knew and in whom they had confidence. This led to increased learning opportunities for the students. There were occasional tensions when clinical nurses in the agencies expected the Affiliates to be simply extra practising nurses, but these dissipated when roles were clarified. For the Affiliates the experience provided professional growth, while ‘there were a number of benefits and no disadvantages identified in relation to clinical staff’ in the agencies (p.13). The evaluation of the project was overwhelmingly positive.

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12. Learning Outcomes and Curriculum Development in Major Disciplines in Nursing. For completion November 2001.

This project is being carried out for the Australian Universities Teaching Committee by a consortium of three universities. ‘The study will focus on the impact on national competencies and other issues such as the scope of nursing practice, the changing nature of employment, health care and technology in terms of undergraduate Nursing course aims and objectives, teaching strategies and assessment practices. Little has been done to ensure that good planning and management will retain an appropriate nursing workforce in Australia’. The team has identified three critical issues:

• Recruitment of students, transition of graduates and retention of nurses - to be undertaken by a team from Flinders University;
• Curriculum development and review - to be undertaken by a team from the University of Technology, Sydney; and
• Clinical education models in nursing - to be undertaken by a team from the Queensland University of Technology.

The study will lead to the production of a comprehensive report on the subject of nursing recruitment, educational preparation, transition of undergraduate students to practice, and the retention of new graduate nurses. It is anticipated the report will provide insights into;

• Current nursing recruitment, transition and retention;
• Strategies, contemporary nursing curriculum content and assessment;
• Processes and their impact on student learning;
• Present models of clinical education; and
• How these models affect opportunities to demonstrate clinical competence for nursing students.

The project will:

1. Develop a framework to evaluate competencies in curriculum design, teaching and assessment.
2. Describe current curricular and clinical education models.
3. Describe current student recruitment and transition-to-employment strategies.
4. Explore key stakeholders' perceptions in relation to models (process, outcomes, efficacy, and strategies).
5. Derive ‘best practice’ principles for Australian undergraduate nursing education, emphasising clinical education and transition support.

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13. National Review of Specialist Nurse Education, 1997 by R.Lynette Russell, Lindsay Gething, Paula Convery Faculty of Nursing, University of Sydney.

‘Currently there are no clear criteria for defining a speciality, specifying the role of a nurse specialist or for use in credentialling of specialists. ....The project reported in this document had as its major purpose the development of recommendations for the current and future pattern. of specialist post registration nurse education in Australia’ (p.7). A literature review ‘produced a picture of confusion and inconsistency in regard to definition of terms, criteria for defining a specialty and for defining the role of a clinical nursing specialist. It also revealed a complexity of issues....’(p.8).

This report recommends adoption of the following definition of nursing specialist developed by the International Council of Nurses: ‘The nursing specialist is a nurse prepared beyond the level of a nurse generalist and authorised to practise as a specialist with advanced expertise in a branch of the nursing field. Speciality practice includes clinical, teaching, administration, research and consultant roles. Post-basic nursing education for speciality practice is a formally recognised programme of study built upon the general education for the nurse and providing the content and experience to ensure competency in speciality practice’ (p.10). Then follow (p.11) nine criteria developed by the ICN with some modifications by the Australian group of National Nursing Organisations.

The report explains the growth of specialties and the pressures to develop a further career structure for more advanced nurses. It regards it as urgent to achieve a nationally agreed nomenclature for the specialties and proposes seven broad bands of speciality each with seven to eleven sub-specialties. It proposes a system of credentialling and accreditation, recommending a graduate diploma as the minimum qualification for recognition as a specialist nurse in 1998, and a masters degree by 2003.

Pages 21 to 32 summarise the current offerings in Australia and illustrate the range and confusion in the field. The remaining pages of text (to p.37) discuss the demand and needs for such courses, their nature, and the need for collaboration between health care agencies and higher education in their provision.

• 14. New Vision, New Direction: a study for the future of nursing and midwifery in Western Australia.
• The study will not look at nurses and midwives in isolation but will identify their optimal use in the interdisciplinary team. The study will also consider the working environment of nursing and midwifery staff with the intention of increasing job satisfaction and making nursing and midwifery more attractive career choices.
• Issues to be addressed:
• Professional practice - including how to improve the quality of patient care through the development of a nursing and midwifery decision-making framework. The framework will incorporate the areas of delegation of care and the collaboration required with other health care professionals. This includes the scope of nursing and midwifery practice and the expanded and advanced role of the nurse and midwife;
• Workforce issues - including the management of the nursing and midwifery workforce, recruitment and retention strategies, skill mix, career development and the utilisation of other health care workers (etc);
• Professional standards - including clinical specialisation and expansion of roles that may require credentialling and accreditation to be examined. (Also, competencies);
• Education - including the area of professional development and clinical specialisation. The transition from university education into the health industry needs to be examined. (including graduate programmes); and
• Nursing and midwifery strategic leadership - how encouraged and achieved?

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15. Nurses’ experiences of work during their undergraduate education, by Libby Denmead, Ralph Forbes and Andrew Fleming, UWS.

Experiences of student nurses working in a variety of roles will be explored in this interpretive study. The three work areas are: nurses working as third year undergraduates in a special role commensurate with their level of education; and undergraduate students working in nursing related roles, e.g. assistants-in-nursing, or non-nursing related, e.g. McDonalds. Understandings will be developed that disclose what it is like for students working during their undergraduate education and the relevance of this work to their education. The research questions to be explored include:

1. What are the experiences of students working as third year undergraduates?
2. What are the experiences of students working as assistants-in-nursing?
3. What are the experiences of students working in a non-nursing role?
4. What is the perceived contribution of this work to their educational preparation for the role of a registered nurse?

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16. Nurse Practitioner Project Stage 3 – Final Report of the Steering Committee (New South Wales Health, 1995).

This report is the culmination of seven years of discussions, pilot projects and negotiations under the aegis of the NSW Minister for Health concluding in recommendations that Nurse Practitioners be recognised as legitimate providers of health services in NSW that the title ‘Nurse Practitioner’ be protected, that guidelines and limits of practice be established and that many other consequential issues be addressed. It neatly defines the different focuses of the nurse and the doctor: ‘The focus of the role of the nurse can be seen as making the experience of the consumer/patient as acceptable as possible at that moment in time... . This nursing focus is in contrast to the focus of the role of the doctor, whose main concern. is to make a diagnosis, and affect [sic] a cure which might involve (eg. in chemotherapy or surgery) a temporary deterioration in the patient’s experience’ (p.5). ‘The nurse practitioner role is a further development of advanced practice which... necessitated the introduction of new activities to meet the focus of the nursing role for nurses working in particular practice settings’ (p.8). Clearly the doctor and the nurse practitioner have different roles, but complementary and with some overlap of activities.

This report describes ten pilot projects covering a range of settings from major metropolitan hospitals to a hostel for homeless men (frequently alcoholics) and outback NSW. Within the pilots a total of 2 706 interludes of care were provided by experienced and advanced level registered nurses, the type who were likely to become nurse practitioners. All these instances of practice were assessed and evaluated by medical and nursing clinicians against a number of criteria. Against every criterion the nurse’s action was assessed as justified in over 95 per cent of cases.

Against this background the report concluded with a recommendation ‘that nurse practitioners be recognised as legitimate providers of health services in NSW, as defined in this Report’ where a local agreed need could be established by a local interdisciplinary group of stakeholders. The NSW Government accepted the Report and almost all the recommendations, and has now (2001) accredited its first nurse practitioners. One of the recommendations was for a five-year ‘grandparent provision’ to allow for the immediate accreditation of nurses currently operating in roles similar to those of nurse practitioners (Rec.13-iii); the Government declined to make any such provision.

Although it had two nominees on the Steering Committee for the project, the NSW Branch of the Australian Medical Association notified the Government that it dissented from the recommendations and the Report.

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17. Nurse Practitioner Services in NSW (NSW Health 1998).

‘A nurse practitioner is a registered nurse working at an advanced practice level leading into practice as an expert nurse, the characteristics of which would be determined by the context in which they have been accredited to practice. The scope of practice of the nurse practitioner will be defined by the clinical context of practice in which accreditation has been sought and by clinical guidelines developed and endorsed by the local multi-disciplinary team’ [Nurse Practitioner Services in NSW, NSW Health 1998].

This booklet (eight pages of text) sets out the process for accreditation of nurse practitioners in NSW, the principles for the development of clinical guidelines for nurse practitioner practice by Health Services, and the required legislative amendments and recommendations to enable nurse practitioners to practise in NSW. Amendments were required to the Poisons and Therapeutic Goods Act (to enable nurse practitioners to prescribe certain medications), the Nurses Act (concerning accreditation of nurse practitioners) and the Pharmacy Act (to authorise pharmacists to dispense medications on the prescription of a nurse practitioner).

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18. Registered nurses’ experiences of educational transition programmes, by Mary Lambell and Andrew Fleming, UWS.

‘The period of two to three years beyond the initial graduate year of registered nurses has not been studied in any depth. Also there is little known concerning the experiences of recent graduates embarking upon a career in specialty nursing. This study will explore the lived experiences of ten recent graduate registered nurses undertaking a 12 month clinical specialty development programme. Through multiple in-depth conversations the participants will describe and interpret their experiences of being-in-the-world as a recent graduate and reflect on this in relation to previous graduate experiences. Findings from the study will provide knowledge and understanding of the recent graduate nurse experience particularly in relation to the transition to clinical specialisation’.

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19. The Development of Teaching and Learning Partnerships in Nursing: Academics, Clinicians and Students, 1997 by Judith Clare, Karen Wotton, Eileen Ingham, Lee Gassner, Didy Button. School of Nursing, Flinders University.

This project brought together four academics, six clinicians and 104 undergraduate nursing students ‘to refine, further develop and implement an integrated teaching and learning strategy which was congruent with clinical reasoning processes used in the clinical environment’ (p.2) in the third year of an undergraduate course. It begins with a discussion of the differing emphases of the university - integration of theoretical concepts with practice - and the clinical environment, focussing on task and time development with less attention to promoting students' clinical reasoning.

These differences, if left unaddressed, mean that ‘students often experience difficulty in firstly transferring learning to the clinical setting and secondly making the transition from the university to the clinical context’ (p.4). The project aimed to develop working partnerships between the academics and the clinicians so that each understood the expectations of the others and the contexts in which each operated — thus ensuring that an integrated developmental experience was provided for the students in their practicum.

The outcomes of the project included: enhanced preparation of the student nurse for nursing practice, with a higher level of clinical reasoning skills, a more holistic orientation to patient care, and increased confidence in the use of professional language; development of teaching and learning methods in the university and the clinical settings; development of a bank of case notes for use as a teaching resource; improved techniques for evaluating clinical reasoning; and better liaison between academics and clinicians.

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20. Transition from Education to Employment: from University Student to Registered Nurse, 1997 by Judith Clare, Pauline Glover, Dianne Longson School of Nursing, Flinders University.

This study addresses a well-known problem: that of graduate nurses' performance in their first employment. It followed a cohort of 85 graduates into the paid workforce, gathering data from the graduates, their clinical coordinators and employers. It was clear that graduates had expectations of cooperation and support which often were not met, while employers had expectations of levels of skills and competence which also were often not met. The report says, with emphasis: ‘No other employer of a discipline or profession would expect a university graduate in their first position to take on the most complex cases with so little support’ (p.6). At the same time, ‘the employer, in many instances, is providing expensive and often inappropriate year long de facto 'internships' (graduate nurse programmes) ‘... These programmes for new graduate employment have developed over the years based on little if any research and have never been evaluated’ (p.2). The frustrations engendered in the new graduate contribute to the wastage rate from the profession.

This study identifies factors which enhance and which inhibit the transition of the university student to the beginning registered nurse. Positive factors included ‘adequate support, open communication, fair appraisals, resolution of conflicts, a conducive culture to learning and the gaining of clinical experience’ and the nature of support offered in the first graduate placement (p.5).

Factors inhibiting a smooth transition to employment included the time-wasteful process of multiple applications for positions which are, after all, mostly positions within the same State's health care system — ‘Many students applied to up to eight clinical agencies, most of whom had different and specific application forms and processes’ (p.5). It could take up to eight months to get into a graduate nurse programme, in which time it can be difficult to find interim employment. Preceptorship and mentoring were often inadequate because of pressures on the preceptor or the graduate nurse; other staff could be impatient with the new graduate's lack of experience or with new ideas that the graduate brought from her or his university course; in these situations ‘an almost complete lack of conflict resolution’ (p.6) fostered the graduates' doubts about the choice of nursing as a career.

The study includes a set of recommendations to improve the process of transition, limit the waste of time and money, and improve the experiences of employing agencies and new graduate nurses with each other.

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21. Undergraduate nursing clinical education in acquired disability settings, by Laynie Hall, Julie Pryor, Lyn Chenoweth, Ralph Forbes and Aine Higgins UWS.

Second and third year undergraduate nursing students from the University of Western Sydney Hawkesbury who undertake clinical placements at the Royal Rehabilitation Centre Sydney (RRCS) are being studied. The study seeks to explore whether there is any change in students’ attitudes to people with disability following clinical placement in a rehabilitation setting. It is also tracking the development of clinical assessment skills in these students across time. This project commenced early 2000 and data collection will continue through 2001.

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