SUBMISSION TO THE REVIEW OF HIGHER EDUCATION
from the Australian Council of Deans of Nursing
Summary of key points:
Introducing the Council - represents all Nursing education in Australian universities
Theme 1 The purpose of universities - preparation for professions through high-level intellectual education. The place of nursing in universities - theoretical plus practical preparation for a complex, vital and rapidly changing profession
Theme 2 Trends to the future - growth in numbers, expertise, scope of practice, responsibility, levels of professional preparation, globalisation.
Theme 3 Accountability: regulatory framework
Themes 4,5 Financing higher education and research: Cost of nurse education - intrinsically high, not matched by remuneration. Cost-effectiveness of nurses: very high effectiveness compared to both higher-cost professionals and lower-cost, lower-effective health workers. Research in nursing: greatly increasing, not only from the academy but also from nurses generally.
Further theme Students: entrants to nursing: academic levels steadily rising
SUBMISSION
The Australian Council of Deans of Nursing represents all the Faculties or Schools of Nursing in Australian universities. It meets at least twice a year to consider matters important to nurse education in this country. It welcomes the opportunity to present a submission to the Review of Higher Education setting out its views on university education and the present position of nurse education and its likely future, for the Review Committee's consideration. The President and Secretary of ACDON would welcome an opportunity to meet the Committee for further discussion of these issues.
This submission follows the themes set out in the Guidelines for Submissions.
Major theme 1: The role of higher education
The purpose of universities has been, from their first beginnings, to prepare people for professional careers, initially in Law (Bologna), Medicine (Montpellier) and theology (Paris and its offshoot, Oxford). The education in liberal arts, in medieval times a study preparatory to theology, became from the sixteenth century onwards a preparation for careers in administration and teaching, exemplified since 1850 by such figures as Thomas Arnold, Lords Tweedsmuir and Curzon and a host of civil servants and teachers throughout the British Empire. The first Australian universities were established explicitly to provide such professional preparation (including preparation for teaching) as the debates leading to the establishment of the University of Sydney make clear.
With the growth of modern science and the increasing intellectual complexity of modern society and its professions, new fields of study and teaching were offered by universities. Many people enrol for the sheer delight of study, and universities welcome them; that does not alter the fact that universities began and continue as places to prepare for the professions (including the professions of teaching and scholarship), and are thus distinct from libraries and museums which are resources for study not leading to a professional qualification. They are also distinct from other educational institutions which focus principally on practical skills. The Council does not see this primary purpose changing in the foreseeable future.
The profession of nursing has come into Australian universities because of its increasing intellectual complexity. In the public’s view the image of ‘nursing’ may still be confined to that of meeting the sick and injured person’s needs for personal care. Modern nursing, however, is an intellectually very demanding occupation, constantly changing with advances in preventative health care as well as in the treatment of illness and injury. Teaching about health, promotion of healthy living and primary health care are fundamental to modern nursing practice and will be of increasing importance in the future. Nurses add value to all aspects of society in encouraging healthy education, healthy activity, healthy environments, healthy productivity and so on. The argument is one of investment in not only intellectual, but social capital.
From premature newborns to the frail aged, people who would once have quickly died are living longer and needing extremely sophisticated advice, care and treatment at critical times of their lives. As well as a knowledge of clinical treatments, often highly technological, the modern nurse must have skills in supervising other staff, relating to patients of many cultural backgrounds, counselling on health care, managing material resources and time, and observing the progress of the patient as a total person, not a mere clinical problem. The nurse often will have to practice far from advanced support facilities; nationally some 40% of nurses are employed in non-metropolitan areas.
The modern nurse needs intellectual preparation to degree standard; a preparation by apprenticeship which was adequate several decades ago (as it once was for Law or Architecture or Dentistry or other professions) can not provide the necessary foundations for safe practice in modern health care. Indeed, the health status of Australians is compromised if the public does not have readily available well educated professional registered nurses, with problem solving skills and a broad knowledge base, who are able to integrate the theory and practice of health care. This has been recognised in one country after another, and nursing education increasingly is offered in universities throughout the world. This level of education was reaffirmed in the recent national review of nurse education in Australia. There is evidence from other countries, notably the United Kingdom, that nurses who complete first degrees are more likely to remain in the nursing workforce and more likely to remain in clinical roles compared with nurses prepared in the hospital system.
Nursing draws from science, philosophy, medicine, arts, the law and an ever increasing body of knowledge that is unique to nursing. Nursing is in the universities because they provide the repository of this kind of knowledge. University based programs are designed to teach nursing students to be critical thinkers, to understand the difference between shooting from the hip and evidence-based practice, to learn to manage themselves and their patients in a rapidly changing health care context and to learn innovative ways of teaching patients and their families to look after their illnesses when they are discharged from hospital quicker and sicker. Nurses also learn at university that what they do is essentially political and always strategic. It is usually up to nurses to link their activities to national goals and strategies. University gives them a forum for discussion and strategic planning.
This is not to say that only university graduates are qualified to undertake the work of nursing. It has been long established in Australia that there are two levels of qualified nurses, the Registered Nurse (RN) and the Enrolled Nurse (EN), with ENs performing valuable tasks of patient care under the supervision of the more theoretically qualified RNs. ENs typically receive their vocational training through the TAFE/VET system. ACDON would see it as desirable to have a clear articulation between that preparation and the degree leading to RN status. This depends on the program of preparation for ENs in each State (they vary in length and intensity) and the general policies on credit in each university. ACDON would support a nationally consistent policy on this matter.
Major theme 2: Factors affecting future demand and provision
The contribution modern nursing makes to the nation’s health through health prevention and promotion activities is incalculable; and therefore equally incalculable is the contribution nursing makes to the national economy. A healthy population is obviously more economically productive than an unhealthy one, quite apart from the contribution that health makes to the happiness of individuals and society.
In workforce terms, all the evidence suggests that the growth areas of the Australian economy for the foreseeable future will be the service areas. It is in these areas that both economic value and employment will increase. Central among the service areas is health care, and central to health care is nursing by well-qualified professionals. They will not be the only people in the area; ACDON has noted with some concern an increasing use of unlicensed and untrained carers; but the professional nurse will lead and supervise the health care team, with the medical professional increasingly committed to the more specialised and medically and surgically complicated demands.
There are already many parts of Australia where the professional nurse is the foremost provider of health care, assisted by a visiting doctor or with doctors and full hospital facilities 100 or more kilometres away. There are health care teams in Australian cities, for instance in such fields as women's health, sexual health, children's health, occupational health and safety - where the professional nurse leads the team , makes care related decisions and refers patients to doctors only where medical treatment at that level is required. Given these responsibilities of nurses, and given the constant rapid change in the technologies of health care, it is essential that nurse education be provided at the most advanced levels.
Following a trend well established in the USA, there is now in Australia a small but growing cadre of Advanced Practitioners who have higher levels of qualifications and skills than the main body of nurses and who act in roles of greater autonomy and responsibility. It is likely that this cadre will grow, though of its nature it will always be a minority of the nursing workforce. The education of Advanced Practitioners is at the graduate level and linked to universities (usually in a collaborative arrangement with clinical agencies).
ACDON sees a need for continued and increasing provision of nurse education by universities for the indefinite future, given the community’s needs for nurses This education will become, like all professional education, both more generic and more specialised as time goes on: more generic to develop the knowledge base and intellectual habits that all nurses will need to enter and grow in the profession, more specialised as clinical and other nursing knowledge expands through research and international communication. ACDON would oppose the fragmentation of the profession into a series of isolated specialties, but prefers to see specialties develop from a common base of learning and values. ACDON is committed to the principle that nurses should be learning throughout their professional lives, both through formal courses and through reflective practice.
The professional preparation for specialties would best come at postgraduate level. There is no room within the limits of an undergraduate degree to provide also specialist education. Yet postgraduate qualifications in universities increasingly are provided only for fees, which can be quite high. The rationale for these charges is that higher qualifications commonly lead to higher incomes. That may be so in some fields of employment, but it is not so for nursing: the nurse with specialist qualifications in midwifery or geriatric nursing or intensive neonatal care is not going to increase her or his income through that qualification. When the Review Committee considers options for financing higher education, we ask it to bear this point particularly in mind . The education of nurses is far more a public than a private benefit, at postgraduate as well as undergraduate levels, and we urge that clinical specialisation courses at graduate level be liable for HECS rather than full cost fees.
The standard of Australian nursing education is well recognised internationally. Not only do Australian nurses have no difficulty gaining registration in any country where they choose to work, but many qualified nurses in overseas countries now enrol in distance mode in Australian courses designed to bring them to degree status. The demand for Australian nursing expertise for educational and clinical purposes by Asian countries now moving to upgrade their health care systems is rapidly increasing .
Major theme 3: regulatory and administrative framework
All university nursing graduates must meet the requirements of State/Territory registration bodies before they can practise as nurses. Having been first registered or enrolled, they must renew that status every year, with evidence that they have recent practice in their field They are therefore highly regulated and accountable. The registration bodies are bodies of the profession, as in all other professions; all State/Territory governments have seen this as appropriate. The registration bodies accredit the courses of all university nursing schools or faculties, as such bodies do for other professions, and can refuse accreditation to those which do not meet professional requirements.
However, Registration Boards or Councils can regulate only those who are claiming to be nurses. They have no control over those other workers, variously named, who are actually performing nursing activities (whether trained or untrained). Certain activities of nursing may appear deceptively simple (eg. bathing, walking, dressing wounds); however, there is often required a higher level of assessment and monitoring associated with the skill, to ensure safety of care. For such higher level skills, a considerable body of knowledge is required and higher order skills. The ACDON considers that the performing of nursing activities, no matter how apparently simple, should be performed only by nurses. Although the persons employed to undertake such activities are caring and responsible people, nursing should be performed only by those with sufficient educational preparation and who are under the regulation of the Nurses Boards, to ensure protection of the public. Thus, nursing should only be performed by those registered or enrolled as nurses. The public has a right to expect that those providing nursing care are not only well prepared, but also regulated by the profession itself.
ACDON considers that there should be no more than two levels of nurse. It recognises that there is now a plethora of unregulated workers and raises the question: why such a movement has occurred. The arguments for a third level of nurse are largely economic and although seductive, do not address quality issues. The activities performed by this level of worker will continue to require supervision by the registered nurse. In terms of quality, therefore, it is necessary to have only two levels of nurse.
Nursing was the first of all the professions to set out a statement of necessary competencies and to move to competency-based preparation and assessment. It is now amongst the first - possibly the very first - to move from a statement of the competencies expected of the beginning practitioner to a statement of those expected of the experienced and advanced practitioner. In short, the Council would suggest that Nursing is at the forefront of professional accountability and regulation in the interests of the safety of the public.
Major themes 4, 5: Financing higher education and research.
Within the university nursing is a relatively high-cost course because of the nature of the preparation required. It is not possible to provide the professional preparation of people for health care simply by lectures to large classes and the prescription of written assignments. Leaving aside the question of whether that is a good university education for anyone - the education of nurses requires that they be skilled in the use of elaborate equipment and in procedures that can be taught only to small groups. In that and other respects it is much closer to education in Medicine than it is, say, to Law. It also requires that student nurses spend time in clinical placements in hospitals and other health care facilities; this is an expensive requirement, since each student has to be supervised and the cost of that supervision has to be met by the universities.
The education of nurses is a major public benefit, yet nurses are not highly remunerated and provide relatively low-cost health care. In many parts of Australia where doctors simply refuse to go, or where it would be too expensive to provide a full medical service, nurses are the first source of health care. As noted above, some 40 per cent of nurses work outside metropolitan areas. Even within highly populated areas, nurses are more and more commonly found in community settings advising on healthy habits, treating less complex ailments, continuing care of early discharge hospital patients and generally performing many of the services of the village doctor a century ago - at a fraction of the cost. As their education prepares them for more demanding and responsible roles, nurses can extend health care without increasing costs, and relieve the demand on expensive facilities.
In short, nursing as a field of study and practice is one where the cost of professional preparation and education is not at all matched by pecuniary rewards. ACDON would wish to impress upon the Review Committee that public financing of nurse education is an investment in public rather than private good to a far greater extent than perhaps any other field of higher education.
The various approaches to the financing of higher education listed in the Guidelines seem inappropriate to Nursing:
More broadly in professional practice, with the general contemporary pressure to reduce public expenditure in all fields, and specifically the field of health, employing authorities are increasingly using unlicensed health carers, especially in institutional settings such as nursing homes. This trend suggests a second level of care for "second class citizens "
which the elderly are frequently thought of as being; this would be in contravention of the Nurses’ Code of Ethics. ACDON’s opposition to the use of unlicensed carers is stated above.
One of the remarkable features of the last fifteen years or so has been the increase in research amongst Australian nurses, not only those in universities. They have produced a large number of books and journal articles, established new journals, and publish regularly in the leading international journals. Their topics range from technical clinically oriented articles to writings on psychology, sociology and economics with a nursing focus. They have also been active in experiments with different types of nursing and different approaches to various client groups - in short, they are pursuing the range of activities of any vibrant profession. This research has no less need of funding than research in all other fields. There is in modern nursing an emphasis on evidence-based practice, which is entirely commendable; but this depends on continued research into best practice and outcomes of nursing. Thus university education for nurses and research into nursing are both fundamental to best patient outcomes.
Entrants to nursing
A surprising feature of the Review Committee's guidelines is the absence of any mention of the student body, its qualifications, ambitions, social composition or any aspect of its interests. Nursing has historically enabled many women to obtain a university education, in particular women from lower socio-economic groups and rural areas; it has been a major avenue of social mobility and equity. ACDON hopes that it will continue to be so, and not become a profession open only to the more privileged class.
As far as Nursing students are concerned, recent years have seen a rise in the university admission scores of entrants to nurse education, and some nursing faculties now are recruiting students in the top 30-35 per cent of the school leaver population, which places them on a par with schools of engineering. There are signs also that the pressure from hospital-trained registered nurses, to enrol in conversion courses leading to a degree, is now slackening. This would suggest that the profile of the nursing student body will come to be the same as that of the student body in general.
Conclusion
This submission argues that Australian nurses are well prepared through university education for the demands of modern nursing and for the health care of all people in Australia. This preparation grows more complex as the demands of modern health care become more complex. The profession has a sound structure of accountability and registration which should cover all who claim to practise nursing. The expertise of the profession derives from a combination of theory and practice which in turn rests on university-level education and research. To maintain this requires the maintenance of funding at least at current levels, which should be seen as an investment in public health and economic benefit rather than any private good to the nurse.
If the Review Committee would like any further information or clarification of matters concerning the education of nurses and the development of the profession ACDON will be happy to supply it.