The Australian Nursing Council Inc. (ANCI) is a national body
which was established in 1992 with the purpose to establish and
maintain national standards and processes for the regulation of
nursing within Australia. One of the objects of the Council
is to coordinate all matters relating to the regulation of nursing
in Australia which includes education. The nurse regulatory
authorities in Australia constitute the primary membership of
the Council.
The core business of the Council is competent quality nursing
care for the Australian community. Education of nurses and the
standard of that education is of considerable significance in
this business. It is from this background that the comments
in this submission are made.
Summary of Key Points
Theme 1 Professional education for nurses should continue to be conducted in universities at bachelor degree level because of the complexity of their role and the need for a strong intellectual underpinning.
Theme 2 A range of factors impact on nursing labour-force patterns and there is a need for cooperative planning.
Barriers to demand include individual costs and inflexible structures.
Theme 3 Nursing is a regulated profession. Ensuring that nursing care is provided by nurses who are competent and accountable includes the profession setting standards for nursing education.
Theme 4 Public funding should continue to be provided for nursing education.
The cost of nursing education is not fully acknowledged.
Theme 5 Support is essential to the continued development of nursing research which is critical to the provision of a nursing service which will meet the future health care requirements of the Australian population.
Theme One: The role of higher education in Australia's
society and economy.
This review comes at a time when nurse education in universities
is still relatively new compared to other professions and disciplines.
The transfer of education for registered nurses to the higher
education sector was completed in 1993. While the future of
nurse education in the universities is now established, as was
noted by the Committee of the National Review of Nurse Education
in the Higher Education Sector - 1994 and Beyond, the effects
of the transfer will take at least a decade to be completely realised
and understood.
There is no doubt that one of the reasons for the transfer of
nurse education to the higher education sector was to ensure that
nurses would be prepared adequately for practice at all levels
and in all areas where nursing takes place. Professional nurses
must continue to be prepared in universities because of the complexity
of their role, the higher intellectual skills of critical thinking
and critical analysis required for this role, and the need to
develop new knowledge about nursing in particular and the health
care industry in general.
It is also necessary that consumers can be assured that graduates
of nursing programs meet the profession's required competency
standards. Not only have Australian society's health care needs
been changing, but there have also been changes to health care
delivery influenced by economic reform and health care policies.
In addition, nurses are increasingly providing primary health
care services in a variety of areas in metropolitan, rural, and
remote Australia. The education of nurses is a major public
benefit
Contemporary health care practice requires that health professionals
be responsive to society's needs and that they are adequately
prepared through their education. As stated in the executive
summary of the National Review of Nurse Education in the Higher
Education Sector - 1994 and Beyond: Australia needs a nurse
who will leave university with a comprehensive grounding in the
theory and practice of nursing including the basic strands of
medical/surgical nursing, community based nursing, and mental
health nursing - and a nurse who goes on learning throughout her
or his professional career. Australia therefore needs nursing
education which facilitates and encourages such professional development,
consistent with the system of health care that is needed (p.1.).
The scope of practice of nurses is constantly being challenged
with the advances in technology, preventative health care, treatment
of illness and the restructuring of health care provision. Universities
have the scope to ensure that nurses, in preparation for their
increasingly complex roles, receive a broader education which
is not limited to the purely service needs of specific organisations
and institutions, and which promotes the development of nursing
professionals who are able to commit themselves to life long learning.
It is submitted also that in providing a service that meets society's
needs and is going to contribute in a beneficial way to the economy,
that provision must also be made for the development of the discipline
of nursing through both research and scholarship, resulting in
the generation of knowledge which would enhance both the practice
and knowledge base of the profession.
There is concern that the six semester nursing undergraduate degree
program is already under funded, and the ability of universities
to ensure that an adequate comprehensive undergraduate curriculum
is able to be implemented is at risk. In order to prepare graduates
with the required level of competence, an expanded program in
the future should not be discounted. According to the Australian
Bureau of Statistics, nursing is now categorised under the major
group, Professionals, the same as medicine. The current program
of three years would appear to be inadequate in comparison to
other health professional courses.
Importantly, in accordance with the Code of Ethics for Nurses
in Australia (ANCI 1993), nurses aspire to promote and uphold
the provision of quality nursing care for all people……
Quality nursing care includes competent care by appropriately
qualified individuals…….and includes valuing continuing
education…Additionally, the Code of Professional Conduct
for Nurses in Australia (ANCI 1995) is a set of national minimum
standards for accountable professional nursing conduct. The
first statement of this Code refers to nurses being responsible
for providing safe and competent nursing care. Professional
nurses are looking to the universities for the appropriate programs
of education that will prepare them as critical thinkers who base
their practice on research, and who are able to provide competent
nursing care in roles of increasing responsibility and autonomy.
Theme Two: Factors affecting the demand for and
provision of higher education over the next ten to twenty years.
As already indicated, a range of factors such as population growth,
population location and diversity, shifts in disease patterns,
global health care initiatives and the trends in social and economic
reform bring changes to health care policy and delivery. The
many factors impact on the providers of health care including
nurses. Labour- force patterns change accordingly with demands
on not only the numbers of graduates required, but also the specific
requirements for specialist areas and advanced practice.
The Australian Institute of Health and Welfare identified in the
publication Health in Australia (1995), a number of health labour
- force issues that were important including appropriate numbers
of health professionals, requirements for personnel and specialties
within the professions, quotas for students undertaking tertiary
education to meet future labour - force needs, and requirements
for the maintenance or upgrading of skills (p.78). It was also
noted that the occupation of registered nurses was identified
as having a low growth which was rationalised as being due to
the transfer of nurse education to the universities. By contrast
the number of medical practitioners has risen giving rise to oversupply
concerns.
Any changes to higher education policy and planning has the potential
to impact upon the nursing labour-force. Reducing the numbers
of nursing students in order to reduce funding or re- distribute
available funding amongst a smaller number of students can negatively
impact on the supply of qualified nurses to meet health care demands.
Labour- force needs should not be left to the mercy of education
policies alone. As stated in Nursing Education in Australian
Universities - 1994 and Beyond, labour-force planning for university
educated professions is not easy, even those which are dominated
by government employment. Cooperative planning which involves
representation from the nursing profession and from the health
and education arenas is needed and must be supported by resources
that provide for the necessary strategies to be put in place.
As stated earlier the complexity of the nursing role requires
an education for nurses in a system which can facilitate a commitment
to life long learning, a strong intellectual underpinning for
the nursing role, and the essential generation of new knowledge.
A nursing workforce which meets the requirements of the health
service of the 21st century can only be produced through universities
providing appropriate education.
It is also submitted that the current structure of an academic
year does not allow for the flexibility that is required in alternative
structuring of courses at the undergraduate and post graduate
levels. Provision of nursing care occurs generally on a continuous
basis over a 24 hour period every day of the year. An academic
year is generally limited to two semesters of 13 weeks' duration
during which time provision has to be made for the clinical teaching
component of the nursing program as well as periods of time for
examinations. Flexibility in the structure of the academic year
could provide optimal access for potential students.
Another factor, apart from labour market trends, globalisation,
and changes to industry, which will influence demand for higher
education places will be the cost of an individual's education.
It is most important that a percentage of HECS funded places
remain available for undergraduate nursing courses. The earnings
of most nurses are not commensurate with those of other health
professionals. For full fee paying students, there would be
no real prospect of repaying a debt for their education in a relatively
short period of time. This could be a barrier to demand.
Theme Three: Regulatory and administrative framework
for higher education.
Nursing is a regulated profession, and the primary purpose of
such regulation is to protect the public. As stated in the ANCI
Guidelines for the Accreditation of Nursing Courses (1996), nursing
regulatory authorities, authorised by their respective legislation,
are responsible for assuring the public that nurses licensed
to practise nursing are able to provide safe and competent nursing
care. Setting standards for nursing education and practice is
one of the ways the nursing regulatory authorities exercise their
responsibility to achieve this purpose. Standards for nursing
education are designed to facilitate the nursing competence of
course graduates and therefore support standards for nursing practice……This
is not inconsistent with universities which are accountable to
the community for the quality of graduates produced.
The recognition of nursing courses by nursing regulatory authorities
through accreditation indicates that courses are developed in
accordance with the standards for nursing education. This form
of accreditation is complementary to the process for award purposes
and both are necessary for nursing courses, as nursing is a practice
based discipline which must meet the demands of changing practice
as well as academic standards. The continuance of the relationship
between the profession and the universities is paramount in promoting
the pursuit of excellence and meeting the responsibility to protect
the public, discover new nursing knowledge, and enhance nursing
practice.
The ANCI established the Guidelines for the Accreditation of Nursing
Courses as an important contribution to establishing and maintaining
national standards and processes for the regulation of nursing
within Australia. While the Council is not seeking uniformity,
it is concerned to ensure that each course meets the standards
which can be difficult when pressure to reduce costs is brought
to bear differently in each university, and market forces dictate.
Consistent standards are also important in terms of the mutual
recognition of nurses between states and territories in Australia,
and between Australia and other nations.
Theme Four: Financing higher education teaching
and research training.
Since the Commonwealth assumed responsibility for full public
funding of nursing education in the higher education sector, there
have been various cuts in funding to the sector. This has placed
considerable pressure on resources that may have been available
for appropriate and adequate education for nurses and the development
of professional nursing in this sector.
Undergraduate nursing courses are expensive due to the necessary
provision of a clinical component. There is no way of producing
a nurse whom the nurse regulatory authorities can accredit as
competent to practise without having an adequate and appropriate
clinical component in the course. Unless nurses are adequately
prepared there is a likelihood that the funds allocated are being
wasted, therefore the true cost of undergraduate nursing courses
must be acknowledged and must be funded accordingly.
As already stated, nursing is a practice based discipline. While
studies have recently been completed on the costing of clinical
education in the health sciences, the reports were of little benefit
except to highlight the differences in funding provided for clinical
teaching between different health professions. There was little
recognition of the nature of nursing and the aims of nursing education.
While on-campus clinical teaching serves a useful and a necessary
purpose, it is not a substitute for clinical experience in nursing
settings.
Funding cuts to universities have already impacted negatively
on the provision of the clinical component of clinical education.
Health care agencies are charging fees for service in providing
clinical placements and the provision of instructors. Changes
to the health care system such as early discharge, day surgery,
closure of hospitals, de-institutionalisation of psychiatric patients,
rural health, and competition with other health professionals,
have also impacted on the nature of the experience available.
The clinical component of nursing programs must be further enhanced and not reduced.
Costing should include factors such as quality, time, the development
of a range of models of clinical education, the provision of appropriate
staff and education for that staff, and health - education collaboration.
Flexibility of academic year structures would enable better
access to clinical experiences.
Therefore, deliberation on policy in the area of clinical teaching
of health professionals should take into consideration the true
cost of a nursing program, the already inadequate distribution
of funds in the area of clinical teaching, and the relative contributions
of the education system and the health system in this process.
While consideration, in the interests of effective use of funds,
may be given to the potential for the development of core curriculum
modules with other health professional groups, such a development
within a three year nursing program could further limit the ability
to provide an integrated and comprehensive nursing curriculum.
Therefore, consideration should be given to the development
of a funding model which provides for an expanded program of more
than three years where there are moves to develop a core curriculum.
It is pertinent to submit at this point that the ANCI does not
support the development of a program for entry into the profession
which has as its basis a common core curriculum followed by specialty
education. A full three or four year university undergraduate
program of nursing education at bachelor degree level which is
comprehensive in nature is required for the development of practitioners
who are adequately prepared to deliver a socially relevant service
in the 21st century. This foundation is also essential for further
postgraduate studies to prepare nurses to practise at the advanced
level required in an ever changing care system which demands innovation
and development of service delivery.
Nurses providing services within the specialist and advanced practice
arenas generally acquire further education and experience in order
to provide the necessary service. Since the transfer of nursing
education to the higher education sector, developments in postgraduate
education have been improving. However there still remains a
shortage of nurses in a range of specialist areas without the
necessary postgraduate education in the specific areas. If full
fees were to be introduced for this group it would have an enormous
impact on the ability of the Australian health system to be able
to continue to provide the highly skilled workforce required to
meet the challenges of the needs of the community and health service
delivery over the next 20 years. Within the context of a limited
earning capacity, full fees for postgraduate qualifications are
a considerable barrier to a further enhancement of quality nursing
practice and, ultimately, patient outcomes. It has already been
stated that nursing is a public benefit, but if no public funds
are available to provide for nursing education, this will negatively
impact on the health system.
Theme Five: Funding of Higher Education Research
Nursing research assists nurses to define and extend the body
of nursing knowledge to support the delivery of high quality nursing
services in multiple contexts. The type of research and scholarly
work necessary to do this involves the elements of discovery,
integration, application and teaching. Nurses have found it
difficult to attract the attention of the key programs of academic
research funding such as the National Health and Medical Research
Council (NHMRC) and Australian Research Council (ARC). Nurses
are continuing to seek and obtain research funding from a variety
of other resources, but these resources are limited.
The enhancement of the quantity and quality of nursing research
is a key to the provision of high quality appropriate and socially
relevant nursing care as Australian nurses move into the 21st
century,..(Nursing Research Targets into the Twenty-first Century,
A National Statement. Royal College of Nursing, Australia, 1992).
It is critical to the provision of a nursing service which
will meet the future health care requirements of the Australian
population. Increasing links between nurse academics and nurse
clinicians initiate and support clinical nursing research to develop
theory from practice. Examples of initiatives to co-sponsor
such a role are already available but are limited. Therefore
resources for research must be expanded and developed, and include
the provision of nursing positions which facilitate research activities
such as joint clinical and academic positions.
Support must be given to the continued development of nursing
research, including post doctoral research, in order for the full
potential of the research to be realised in patient outcomes.
It is also not in the best interests of the health care of the
community to limit significant research funds to a small number
of universities which may exclude smaller universities where nursing
education is conducted.
Research training is focused in universities. While nursing
research and scholarship may be relatively young compared to
other disciplines, there is already a growing body of evidence
of its proliferation and intellectual rigor through books, journals
and other scholarly publications. The transfer of nursing education
to the universities has facilitated this growth. Any reduction
in the availability of research training through reduction of
nursing programs and nursing researchers will negatively impact
on the quality of future health service delivery.