Nursing Career Pathways Project
3. Discussion
3.1 Overview
The nursing workforce, is a service industry that is labour intensive and therefore costly. Consequently, the distribution and use of nurses, and indeed the health care work force (of which nurses are key players) is under continuous public and political scrutiny. The effectiveness of the work force is therefore a major factor in determining the delivery of appropriate, effective and coordinated health services.
The articulation of career pathways in Australian nursing has in the main been interpreted narrowly as meaning the development of nursing classifications existing in industrial awards and agreements. The relative absence of Australian literature on exploring and extending upon the concept of career pathways in nursing as is evidenced in the wider literature is perhaps a reflection of how nursing has been taken-for-granted as to not require promotion of career pathways other than through nursing classifications. The concern that was also expressed by many participants was that the lack of a national nursing infrastructure to facilitate the exchange of appropriate information and to maintain ongoing dialogue between the federal government and nurses, was also considered to contribute to this absence.
In relation to the questions asked in this study, the outcomes highlight that there are currently no articulations of career pathways for Australian nurses that:
- Address current and projected nursing workforce needs:
- Integrate nursing with other parts of the health work force:
- Demonstrate coherence / links between educational and industrial awards:
- Organize, link and show the need for, and importance of specific and ongoing education and training:
- Describe nursing as an attractive, diverse and skilled career and relevant career choice.
To ensure the applicability of nursing career pathways to nurses and potential nurses, key stakeholder participants concur that nursing career pathways need to incorporate choice, recognise skill development, and provide a framework to set out the goals and strategies to achieve them. Therefore, nursing career pathways need to be flexible to accommodate; individual life experiences, access to information, personal decision-making; and, emergent changes to health care systems. What is important is that nursing career pathways are responsive to the health care needs of society, and contribute to health outcomes for all Australians. Nursing career pathways need to incorporate Australia's cultural diversity.
The discussion that follows, has been framed by the questions:
How are nursing and health career pathways articulated in national and international literature and documents?
How are career pathways in nursing currently structured in Australian states and territories and how do they compare to each other?
What do career pathways offer / provide / promote / facilitate for:
- Prospective nurses?
- Current nurses?
- Emergent nursing roles e.g. Nurse Practitioners?
- Education providers - public and private (Secondary, Vocational and Tertiary)?
- 'other' Health professionals?
- Industrial, Professional and Regulatory authorities in the health industry?
- Employers (public and private)?
How do current career pathways in nursing link with health labor-force requirements?
To what extent is there a nexus between career pathways and education (Secondary Vocational and Tertiary)?
What relationship does a career pathway for nurses have with other parts of the health work force?
Whose core business is it to review, monitor and provide information regarding career pathways in Australian nursing?
How do career pathways in Australian nursing relate to international nursing issues and concerns?
3.2 What is a career?
Career issues are thus implicated in the current debate over the competitiveness of nations - their ability to grow in a global economy. The wealth of nations, after all, rests on how the efforts of people are channelled into jobs. And careers as well as jobs matter at the societal level because behaviour in today's work - and thus choices made, the decisions taken - is often a function of the expectations for tomorrow's work. (Kanter, 1989; 520)
As Kanter (1989) explains, a career (as distinct from the nature of career opportunity) is an event that is connected, in a dynamic relationship, with economic, social or political issues within a society and plays a role in outcomes for that, and other societies (Kanter, 1989; 506). Career opportunity is enlarged, limited or shaped by the economic and social performance of societies, the availability of investment capital or the rules governing industries and professions (Kanter, 1989; 506). Employment is only one of the ways in which organisations help form careers, others include: educating and credentialling; brokering or mediating between individuals and opportunities; protecting and enhancing; regulating; and funding (Kanter, 1989; 507). Any analysis of careers is more than simply how employers offer opportunities or how individuals select among work options and job sequences. As Kanter argues:
We also need to take into account the nature of decisions made in and by schools, employment agencies, communications media, unions, professional associations, and financial institutions - all connected, in turn, to institution-shaping or constraining decisions made by local and national governments. (Kanter, 1989;507)
Kanter's work is particularly relevant to the focus of this research and provides insight into much of what is under review by the National Review of Nursing Education in that a nursing career has macro-economic, macro-political, and macro-social consequences not just for Australia but worldwide.
At the societal level, there is concern about the nexus between the education of nurses and demands of the labour market. As stated by one key stakeholder:
We are not just training people to be monkeys. We are not just giving them a set of skills so they can be the hand maiden, we are actually giving them an awareness of social issues, political issues and being able to be leaders and resource people in the community. (Extract from interview with participant from key stakeholder group)
Concerns about nursing shortages and, - reduced interest in nursing as a career by school-leavers are discussed in terms of the aggregate well being of members of society. Nurses do not leave an organisation solely as a result of external forces and it should come as no surprise that there is a reduced interest in nursing as a career by school-leavers. When comparing the position of women twenty years ago with that today, as Halford, Savage and Witz (1997; 151) note, 'the lack of opportunities and explicit discrimination then as compared to now is breathtaking'. These same authors (Halford, Savage and Witz, 1997; 151, 153) also suggest that organisational processes, and dominant groups within organisations, continue to generate gendered (and we add ageist) career paths.
Gender inequity in nursing remains. While the number of men in nursing continues to be small, men none-the-less were the fastest growing segment between 1986-1996 (number of male nurses increased by 17.1% compared to a 6.7% increase in females over same period [AIHW, 1999] - it is noted however that the AIHW, 2000 report indicates that this increase was not sustained in 1997). The number of men entering nursing does not match attrition, therefore careers in nursing need to generate an increasing interest amongst females utilising different approaches than those that attract men. As well, different approaches are needed to attract females and males from different age groupings.
How nursing is promoted as a career and the way in which institutional and policy decisions are made to shape this career are significant attractors or detractors. The role of professional and industrial organisations is crucial in this regard. As identified in the New South Wales Nursing Workforce Research Project (2000; 45), nurses leave nursing because of the inflexibility of shift work, family responsibilities, and the physically demanding nature of the work. As participants indicated:
We don't value our people in the health work force. Maybe if we valued them a bit more we might not have the problems that we've got.... I became aware recently, one of our big hospitals who had no development program for their associate nurse unit managers or deputy unit managers, charge nurses. I thought this is ridiculous, these people, there is a huge investment in these people, why aren't they looking after them? (Extract from interview with participant from key stakeholder group)
There are a lot of nurses who really do not want to ever move out of the clinical area. That's their love and their passion. I think that the difficulty is the structure within the system within which they work, that's the problem. It's not the clinical work. If we could, through the various reviews and the safety and quality council and all these other avenues, if we can improve the system in which they work, I think that's got more to do with it than opening up the diversity of nursing and letting people see what else they could be doing. (Extract from interview with participant from key stakeholder group)
Nursing roles can take different shapes and assignments, thus there is not only one nursing career. As participants highlighted:
One of the beauties of nursing is you can be a clinician, you'll always get a job, but if you want to do something else, you've got the grounding in nursing to do almost any other job in the country. (Extract from interview key stakeholder participant)
I think that nursing is one of those occupations where you have a myriad of directions in which you can go because there are so many specialist areas of practice and so many different nursing contexts I think nursing is very fortunate in being able to have so much variety and flexibility. (Extract from interview key stakeholder participant)
The careers of nurses (registered or enrolled nurses or however titled) can be described as involving three principal career forms namely:
bureaucratic - defined by the logic of advancement,
professional - defined by skill, monopolisation of socially valued knowledge and reputation and
entrepreneurial - independent professionals (Kanter, 1989; 507).
Following Kanter, nurses who are clinicians, or nurses who are managers, or nurses who are involved in private businesses (including persons who are not nurses), will often misunderstand each other because their careers are driven by a different logic. As one participant highlighted:
Sometimes we see things so problematic as something you've got to guard against because for every question you ask someone, you are going to get a different answer but there are some commonalities. (Extract from interview with participant from key stakeholder group)
This difference in logic was evident in the collection of data from stakeholders and on reviewing published literature. Nurses have bureaucratic, professional and, entrepreneurial careers as well as, bureaucratic-professional and, professional-entrepreneurial careers. Indeed nurses are an occupational group that has shifted from the majority being bureaucratic careers as paid employees ('hospital-trained'), to emerging independent professional careers. This has created tensions for employers as nurses increasingly exert control over the shape and assignments their career will take. Thus the perspective from which any discussion of careers pathways is approached to address the recruitment and retention of nurses is significant.
3.3 Nursing careers pathways
Participants in this project agreed that there should not be a single definition for the term career pathway. A review of collated literature by nurses revealed that the term 'career pathway' generated many different meanings and usages. Likewise, career pathway material requested and received from nursing organisations included:
- Copies of career classification structures
- Industrial awards and agreements
- Educational pathways and programs
- Guidelines for the scope of nursing practice
- Specific sections of Nurses Acts that 'affect career pathways'
- Information about research grants.
There was general agreement amongst participants that the above materials are aspects of career pathways that need to be considered in developing nursing career pathways. Additionally, key stakeholder participants acknowledged that nursing career classifications were not the same as nursing career pathways and that in most instances nursing career classifications (sometimes referred to as nursing career structures) limited the focus of nurses to clinical roles.
Nursing career structure is narrowly defined as this clinical role. (extract from interview with participant from key stakeholder group)
I do not see it as being as prescriptive as a career structure, its something that much more individual. (Extract from interview with participant from key stakeholder group)
Nursing organisations in various states and territories are currently reviewing nursing classifications in industrial awards and agreements or nursing career structures as they are sometimes referred to. Indeed there is much review activity underway in some states and territories. Stakeholder participants strongly expressed the view that differences in the needs of populations and differences in opportunities in states and territories in Australia, translated to a need to maintain nursing classification structures linked to industrial awards and agreements at the level of state and territory jurisdiction. The decision of the research team with the support of key stakeholder participants was to leave the term nursing career structures to refer to nursing classifications in Industrial awards and agreements. In making this decision, the views of the International Council of Nurses [ICN] are noted.
Personal communication with the International Council of Nurses [ICN] highlights that in place of the term career pathway, ICN (1995; 5) utilises and defines career structure as:
A professional framework designed to facilitate the provision of improved health care, develop excellence in nursing and allow career advancement and remuneration for demonstrated competence, experience and education preparation at different levels within and across all fields of nursing: nursing management, nursing education, clinical practice and nursing research. ... The reason for a career structure is to maximise the profession's contributions to meeting human needs and to identify means from nursing's perspective. Career structures fulfil basic functions, such as:
Identify for all involved (i.e.. public, professionals, support workers) the qualifications needed to attain each career level.
Guarantee determined competencies at each level of the career structure
Foster interest in professional development.
Recognise and reward acquired competencies and excellence in practice
Provide options for career mobility.
Nursing career pathway material provided by Professor Joyce Kenkre (Professor of Primary Care, University of Glamorgan), had been developed by the Policy and Practice group, Research Society, Royal College of Nursing (2001). In this material, it is stated that:
Pathways map out the role, knowledge, skills and experience required by nurses operating at different levels within each setting. The pathways have been deliberately constructed in a uniform manner to illustrate the potential to develop and plan their career to enable nurses to transfer their knowledge, skills and expertise across roles and settings.
The United Kingdom document Making a Difference - Strengthening the nursing, midwifery and health visiting contribution to health and healthcare (1999), states that:
The creation of more flexible career pathways will improve and wide access into education and create an NHS workforce more representative of the people it serves. We tend to provide more career opportunities, from cadet to nurse consultant, valuing and building on the contribution of health care assistants, tailoring education and training to individual needs and lifestyles.
In the wider educational literature, the term career pathway in Prime Minister's Youth Pathways Action Plan Taskforce 2001 Footprints to the Future, was sourced from Young People's Participation in Post-compulsory Education and Training (1991), otherwise known as The Finn Review, where it is stated that career pathways are:
A concept that provides a useful mental image to explain the various combinations of education, training and employment activities which individuals may undertake over time to reach a destination.
The definition by the Ohio Department of Education (1999) builds on the above definition stating that
A career pathway is defined as a series of academic, technological and occupational coursework and other educational experiences leading to a career specialty. The career pathway concept supports development of a continuum of career-focussed programs providing multiple pathways to employment and post-secondary education.
One participant forwarded the following written statement in relation to defining nursing career pathways:
A career pathway concept [must] endorse nursing as a profession. ... What is sorely needed is a cohesive nursing pathway that allow for multiple entry points, multiple exit points with qualifications linked to levels of responsibility, and a range of specialty and expert endpoints, all of which service the nursing workforce needs of the entire health care system.
The research team and participant stakeholders proceeded from the position that nursing is a profession. This professional status was not challenged. Mindful of the need to ensure that language used in this report is familiar and relevant, the research team and stakeholders discussed in depth a variety of potential definitions and/or frameworks, for career pathways.
Maintaining an emphasis and focus on consequences for individuals, that is - career pathways that are people centred, was considered by participants as important though the question is from whose individual perspective? Career pathways can be focussed on the nurse as the individual or the person who receives nursing care. One way in which to influence the recruitment and retention of nurses is to ensure that career pathways are nurse centred. Though some participants cautioned being too focussed on nurses as is highlighted in the following quote:
I know we are pretty good at being martyrs us nurses. But too many times this is about what's in it for the nurse and yet sometimes we've just got to pinch ourselves and remember why we are here. We forget there's patients at the end of all of this. A really important thing about our career pathways is that they can, as a system, they can actually help improve what goes on clinically as much as what goes on for the individual nurse. (extract from interview with participant from key stakeholder group)
In agreement with Donner and Wheeler (2001), career pathways are about nurses taking responsibility for themselves and their careers, and as a process, involve scanning of the environment, completing a self-assessment and reality check, creating a career vision, developing a strategic plan, and marketing the self. In the context of this report, career pathways have been represented as a process (iterative rather than linear) integral to promoting nursing as a career and enabling nurses to develop as professionals.
Any comments or queries should be sent to: highered@dest.gov.au
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last updated on Tuesday, 04 December 2001
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