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National Review of Nursing Education

Discussion Paper

Chapter 5
Nursing in the healthcare system

• Healthcare and healthcare policy
• Australian healthcare trends
  • Changing demographics of health in Australia
  • Changes in models of care
  • Community expectations and the consumer
  • Developments in Science and Technology
  • Healthcare in the federal system
• The changing role of nursing in healthcare: trends and issues
  • Work organisation
  • Work organisation in healthcare institutions
  • Skills mix
  • Scope and standards
  • Advanced Practice nurse/nurse practitioner
  • Scope of nursing and its implications for education
  • Approaches to healthcare and education policy and funding: different directions?
• Exhibit

In this chapter the changing face of healthcare, models of healthcare and the role of nurses in this constantly evolving system are explored. Nurses offer a unique contribution to healthcare due to their numbers, flexibility and the work they do. In August 2000, 6.8 per cent of the Australian workforce were employed in the health industry and about 30 per cent were nurses who totalled over 200 000. The majority of nurses still worked in hospitals in 1997 and about 65 per cent were employed in acute care hospitals. Nurses’ contribution to healthcare is documented in an article by Moneyham and Scott (1997) discussed in Aitken et al. (2001, p. 20):

Nursing is broad in scope, adopts a holistic perspective to client care, has foundations in the biological and behavioural sciences and nurses themselves have considerable skills in providing holistic assessment including actual and potential risks relating to physical, psychological and social needs of individuals and families.

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Healthcare and healthcare policy

Common themes in healthcare policy are those of cost control, efficiency, equity and client focus. These drive debates about issues like skill mix, integrated teams, servicing within the community rather than in institutions, rationing of access to service, and who should provide those services. As a core group within the healthcare system, nurses feel the direct impact of changes in healthcare policy and systems.

A number of countries have carried out environmental scans to examine the changes that will impact on nursing and nursing education. These scans have identified very similar lists of issues as the two summaries below attest.

The US National League for Nursing (1999) identifies ten trends to watch in relation to the future of nursing education in the United States (Heller, Oros, & Durney-Crowley, 1999). These are:

• changing demographics and increasing diversity
• the technological explosion
• globalisation of the world’s economy and society
• the era of the educated consumer, alternative therapies and genomics, and palliative care
• shift to population-based care and the increasing complexity of patient care
• the cost of healthcare and the challenge of managed care
• impact of health policy and regulation
• the growing need for interdisciplinary education for collaborative practice
• the growing nursing shortage/opportunities for lifelong learning and workforce development
• significant advances in nursing science and research.

The Nursing Council of New Zealand Review produced an environmental scan as part its review of nursing education. This scan produced a similar if simpler list which it explored in terms of the implications of these factors for the healthcare system and nursing (2000, Discussion Paper 3, p. 6–8). The Council identified the following list of implications:

• technology and consumer driven healthcare would enable the consumer to require more informed and computer literate nurses;
• multi-disciplinary, multi-sector service provision will require communication and teamwork;
• high tech, short stay hospitals combined with more community care will demand medical technology and practice specialisation from nurses;
• a competitive, outcome focused service environment will require business and management skills in nurses;
• chronic care and increased screening and prevention will provide opportunities for enhanced primary health roles for nurses;
• job re-engineering, uptake of new roles and transfer of others will demand flexibility and adaptability, job re-engineering and loss of some traditional nursing work; and
• nursing services will need to be culturally safe and appropriate.

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Australian healthcare trends

The summaries of these environmental scans are relevant to the Australian setting and the trends identified have many and varied implications for nurse education and training. Though in no way comprehensive, the following list provides some information on a number of examples of these trends in the Australian context.

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Changing demographics of health in Australia

Ageing population

Australia’s population is ageing.⁹ In 1999, more than 2.3 million Australians, or 12.3 per cent of the population, were aged 65 years and over. Further, the growth rate of the older population is two to three times that of the rest of the population. The period from 1990 to 1999 saw the number of persons aged 65 years and over increase at an annual rate of 2.3 per cent, from 11.1 per cent of the population to 12.3 per cent. The number of people aged 65 years and over is projected to exceed three million by the year 2011. Those aged 80 years and over had an even greater growth rate of 4.1 per cent annually.

Gains in life expectancy since the 1960s have been high among the middle-aged and older populations, and death rates especially from diseases of the circulatory system, have fallen.

The effects of this for healthcare are that age, particularly advanced age, is a significant predictor of poor health and disability. Chronic diseases and conditions such as arthritis, heart disease, cancer and dementia are highly prevalent in the older population. In 1998, 11 per cent of the population aged 65 to 74 lived with a severe or profound core activity restriction. The proportion was 35 per cent among those aged 75 and over.

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Indigenous population

The story for the Indigenous population is different with life expectancy at age 65 significantly lower than for the non-Indigenous population. Only 68 per cent of Aboriginal and Torres Strait Islander males can expect to live beyond 65 years compared with a figure of 84 per cent for all Australian males. Among Aboriginal and Torres Strait Islander females, 80 per cent can expect to live beyond age 65, compared with 91 per cent of all Australian females.

According to estimates based on the 1996 Census and its projections, there were 410 615 persons of Indigenous origin in Australia in 1999, constituting 2.2 per cent of the population.¹⁰  Between 1991 and 1999, the Indigenous population increased at an annual rate of 2.2 per cent. This contrasts with the total Australian population, which grew by 1.1 per cent annually.

The Indigenous population is quite young in comparison with the rest of the Australian population. In 1999, 50 per cent were under 20 years of age and only 3 per cent were aged 65 years or over. In contrast, 28 per cent of the Australian population as a whole were under 20 years of age and 12 per cent were aged 65 years or over. The spatial distribution of the Indigenous population is also quite different from that of the rest of the population. Less than one-third of the Indigenous population live in capital cities with easy access to all mainstream health services. One in five Indigenous people resides in remote settings, away from centres with basic health facilities. About 29 per cent of the Australian population live in rural and remote Australia.

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Changes in models of care

Enhanced Primary Care

Enhanced primary healthcare in Australia is largely expressed as enhanced medical care. The average number of general practitioner and specialist consultations increased from 5.8 consultations per person in 1990–91 to 6.3 in 1999–00, an increase of 0.8 per cent per year. The increase in consultation rate may, in part, be due to increased numbers of doctors, as there was a 21 per cent increase in the number of primary care practitioners between 1986–87 and 1998–99. Increased promotion and awareness of steps which people can take to maintain their own health and that of their families, such as immunisation, Pap smears, blood pressure measurements and general health checkups, may have also contributed to the increased consultation rates.

While the increase in general practitioner services may be true for metropolitan Australian, rural and remote areas are particularly dependent on nurses for their healthcare services. Except for nurses, there is a much lower provision of health professionals in rural and remote areas. In 1998 only 16 per cent of the general medical practitioner workforce were located in rural and remote areas, despite 29 per cent of the population living in rural and remote areas.

Aitken and Bucknall (2001) also identify the emergence of population health. Populations may be geographically identified, or may consist of a cohort of clients sharing the same diagnostic related group. Importantly, the services for each identified population not only includes disease management, but also disease prevention and health promotion services.

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High tech short stays – acute hospitals

Both the number of beds and the time in hospitals has decreased. The number of beds¹¹  available in acute care hospitals¹² has declined from 5.2 beds per 1000 population in 1987–88 to 4.5 beds per 1000 population in 1991–92 and 4.0 beds in 1998–99. This change was not evenly distributed between the government and non-government sectors, with the number of private acute beds increasing by 14 per cent and the number of government acute beds decreasing by 11 per cent between 1991–92 and 1998–99.

The average length of stay in acute care hospitals in 1998–99 was 3.7 days. However, if same-day separations were excluded, the average stay was 6.2 days. Average length of stay has fallen from 4.6 days in 1993–94 to 3.7 days in 1998–99, representing an overall reduction of 19 per cent, or an annual fall of 4.2 per cent. The number of acute care hospital separations has grown from 257 per 1000 population in 1993–94 to 294 in 1998–99, representing an annual growth rate of 2.7 per cent.

The decline in average length of stay is due to several factors. These include the better use of anaesthetics, less invasive surgical techniques and the expansion of early discharge programmes enabling patients to return to their home to receive follow-up care. These advances have led to an increasing proportion of same-day patients, from 37 per cent in 1993–94 to 48 per cent in 1998–99. This rapid increase in the proportion of same-day separations has, in turn, led to rapid decreases in the overall average length of stay. Little change in average length of stay is noted if same-day separations are excluded from the data.

¹¹ The number of acute care hospital beds available per 1,000 population provides a measure of the capacity of institutional healthcare facilities. The indicator does not monitor total capacity, as hospital services comprise a mix of admitted patient, not-admitted patient and outreach services.

¹² Acute care hospitals are establishments that provide at least minimal medical, surgical and/or obstetrical services for admitted patient treatment and care, round-the-clock comprehensive qualified nursing services and other necessary professional services

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De-institutionalisation and community care

Combined with the scientific advances, some shifts in the philosophy underpinning healthcare policy have resulted in more emphasis on customer service through the integration of services within the community. In Australia this is reflected in a decrease in the percentage of recurrent health expenditure on hospitals¹³  and a decline in employment in hospitals of almost 8 per cent between 1986 and 1996 to 222 423 and an increase in employment in other health industry settings of 52 per cent to 306 366.

Aitken and Bucknall, (2001) describe this trend as a move away from institutionalised care and relocating care closer to the client in his/her home or local community. They indicate that the literature shows new ways of delivering care including case management/managed care, patient focused care, community nurse-led care, integrated hospital and community care, family provided care and care delivered by unlicensed personnel. They point out that these changes have affected all care modalities, but the literature also reveals specific considerations in the areas of mental health, acute care and midwifery.

Other Australian examples:

• Mental health was largely de-institutionalised throughout the 1980 and 1990s. Services supporting clients come from community mental health nurses and multi-disciplinary mental health teams.
• Integrated hospital and community such as hospital in the home, where hospital nurses give care in the home is a recent development.
• The changing face of rural health services in Australia with an increasing relationship between acute and community services, much of it driven by the implementation of case-mix/diagnostic related groups (DRG) related funding.

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Community expectations and the consumer

A number of surveys have identified nurses as highly regarded in the community and the most trusted of occupational groups. In its submission the Tasmanian Nurses Board raises the issue of nursing as a caring profession, and that

according to recent Morgan and Banks opinion polls, nursing, despite all the challenges, maintains its standing as amongst the most highly regarded professions by the community. Nursing portrays the face of healthcare in the community far more frequently than any other member of the healthcare team. For patients receiving community or hospital care, it is nurses who provide the majority of that care. Care rather than cure, distinguishes nursing from medicine, and it is care that patients come into our healthcare settings to receive.

Consumers are generally aware of the issues confronting nursing due to the changes in service delivery in recent years. With the reduced length of stay by patients in hospitals there is a corresponding need for more qualified nurses. Many believe that stresses within the healthcare system are leading to some loss of the human quality, the ‘caring’, of nursing. The Review heard from a consumer group that in aged care settings the nurses are so overloaded with the requirements of record keeping that they have little time to spend with those in their care, and that this has negative results for the elderly and their families.

However at the same time consumer involvement in healthcare has increased, with raised expectations of healthcare providers. The reviewers noted that a number of submissions addressed the issue of consumers, and the fact that consumers today want to be involved in decisions made about their healthcare. They are better informed and want to talk to healthcare providers on a range of issues that impact on their healthcare such as their treatment, care planning, recovery or prevention.

In its submission, the Australian Catholic University, for instance, stated that

consumers of healthcare services have become more aware. They have learned to expect and demand fast and immediate service, and satisfying outcomes. The consumer expectations apply to care in the public and private sectors, and thus to health and disability services in general. Many consumers are becoming more selective and they exercise their choice amongst many possible services including alternative or complimentary therapies. In a number of ways healthcare appears to have become regarded as a commodity and consumer rights for access to quality care are more widely recognized and acknowledged.

The Queensland Nursing Council also raised the issue of the accountability and liability of Registered Nurses to the care their patients receive.

With greater general access to information, higher educational standards and a move towards greater involvement of patients and families in decision-making and participation in care, there has been a move to increased external scrutiny and a developing litigiousness.

Aitken and team (2001) note that in the area of midwifery a number of studies demonstrate that the continuity of care model by a single care giver or groups of care givers is supported by consumers. Research also supports the Midwife in a lead role in continuity of care models. High levels of satisfaction are also reported from the care provided by teams of Midwives.

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Developments in Science and Technology

New technologies

Scientific developments in relation to disease management and control and technological changes as broad as those impacting on communication to those extending the scope of treatment, combined with the increasing costs of healthcare, have implications for the planning of the future education and training of nurses. They also have implications for shifts in the scope of practice for nurses, an issue well documented in Aitken et al. and in the summary submitted to the research forum (2001).

The emergence of the information age and the advent of the technology to support ‘remote’ care delivery in the community have also impacted on the way services are delivered. Information is a critical resource in the health system. It enables the integration across settings, reduces duplication and errors, and provides timely information. Professionals are increasingly reliant on information at the ‘point-of-care’ to make decisions crucial to patient outcomes.

This is well demonstrated in Telemedicine where the survey of the literature shows nurses leading consultations and/or being present to assist with examinations, providing patient education and manipulating/trouble shooting the telemedicine equipment.

The increasing specialisation resulting from developments in science and technology is well represented by Driscoll in her submission to the Review about critical care specialist nursing:

Workplaces and technology are constantly changing and impacting dramatically upon nursing practice. A prime example is Coronary Care nursing. The advent and explosion of Interventional Cardiology has necessitated an urgent need for Coronary Care nurses to revolutionize their nursing practice… There is a high demand for new technology nursing skill acquisition, yet, insufficient supply of nurse educators and clinical support nurses to train the nurses. In today’s highly technological healthcare system, nurses must demonstrate a high level of skills including humanistic and technological elements incorporating the knowledge and understanding underpinning the skill. (2001, p.2)

Another impact on healthcare is the rapid developments in pharmacology. This is evident in the increasing drain of pharmaceutical products on the heath services budget as a proportion of expenditure (See Exhibit 5.1). The proportional increase of pharmaceutical products to total health services expenditure has been similar to the proportional decrease in hospital expenditure. The representations in submissions regarding the development of a consistent core of knowledge about pharmacology in the nursing curriculum are also evidence of the impact of these developments.

Other implications of the increase of science and technology for nursing include the growing need for understanding of complex ethical and legal issues. Another challenge presented by the rapid changes in technology is the difficulty of returning to work in highly technologically-developed areas of nursing after a break away from this work. Nurses who become highly specialised to deal with developments in technology in their practice are also the most vulnerable to being overtaken by new technology. This results in loss of work in the area and difficulty for the nurse to transit to another area due to lack of recent general experience.

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Healthcare in the federal system

Healthcare expenditure

Healthcare expenditure is an area of real growth with an average increase of 4.0 per cent across the ten years to 1999–00 continuing to an estimated total of $53.7 billion, equivalent to $2817 per person and 8.5 per cent of GDP¹⁴. Labour is the largest item in healthcare expenditure. Available information does not enable the proportion of health expenditure spent on nurses to be calculated.

Changing patterns of health personnel employment show a decreases of approximately 8 per cent in total hospital employment between 1986 and 1996 to a total of 222 423. There was a 52 per cent increase in employment in other health setting to 306 366. During the period there was a decrease in full-time Registered Nurses.

Most non-government funding for health services in Australia comes from out-of-pocket expenditure by individuals. Expenditure by individuals accounts for 56.4 per cent of estimated non-government funding of health services during 1999–00. Private health insurance funds provided 24.7 per cent. The remaining 19.0 per cent came from other non-government sources (mainly compulsory motor vehicle third party and workers’ compensation insurers).

Non-government financing for total health expenditure, which averaged around 33 per cent each year between 1991–92 and 1996–97, fell to 28.8 per cent in 1999–00. This was largely due to the influence of the Commonwealth’s subsidy to private health insurance funds under the Private Health Insurance Incentives Act 1997.

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State and Commonwealth

Government policies, both Commonwealth and State, have marked impacts on the levels and distribution of funding for health services. For example, the Commonwealth Government’s subsidies to private health insurance members moved funding away from non-government sources after 1996–97. Both Commonwealth and non-government expenditure on private health insurance administration increased by an estimated $121 million to $717 million in 1999–00.

Table 5.1, based on information from the AIHW, shows that governments (Commonwealth, State and local) were the source of 71.2 per cent of all funds provided for Australian health services in 1999–00. This compares with 68.3 per cent in 1989–90. However, non-government sources provided 28.8 per cent of total health services expenditure in 1999–00.

In terms of the types of health services funded by the States and Territories and by local government authorities, spending on government hospitals dominates, accounting for 69.0 per cent of recurrent funding provided by those government sources in 1999–00. Table 5.1 compares State and Commonwealth expenditure from 1989–90 to 1999–00.

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Table 5.1 Total health services expenditure, current prices, by broad source of funds, as a proportion of total health services expenditure, 1989–90 to 1999–00 (%)

* Commonwealth and non-government expenditure has been adjusted for tax expenditures.
** Based on preliminary AIHW and ABS estimates.
Source: AIHW health expenditure database (2001a, Table 11).

There are also major differences in sources of funds for the different sectors of the healthcare system.

The dominant funding provider in each sector of healthcare varies. It is State and Territory government for public hospitals. For private hospitals funding is largely through private health insurance to which the Commonwealth Government makes a direct contribution, and for high care residential aged care by far the most significant source of funding is the Commonwealth Government. (See Exhibit 5.1)

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Aged Care

Changes in healthcare policy since October 1997 resulted in a major restructuring of residential aged care amalgamating nursing homes and hostels into one single system of residential care, with a single instrument classifying residents according to their care needs. Community aged care packages, which provide personal care services for people living at home, were also expanded. In 2000, there were 84 residential aged care places per 1000 population aged 70 years and over. There were a further 11 community aged care packages per 1000 population aged 70 years and over. In that same year, 7 per cent of persons aged 70 years and over lived in residential aged care facilities; this rose to 39 per cent of persons aged 90 years and over.

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The changing role of nursing in healthcare: trends and issues

Work organisation

One of the most striking features of any examination of the literature that covers the changing models of healthcare is the lack of Australian research. From the Australian workforce statistics it is evident that there has been a shift in the places nurses work, but there is no detail about these shifts that provides insight into changed patterns of work organisation. Research from the United States, Canada and the UK may give some insight into the new patterns of nursing work, but these developed in response to their respective healthcare systems with their individual underpinning philosophy and controls. In all cases these are different to the Australian healthcare system where the autonomous work of nurses is largely limited by the way Medicare works.

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Work organisation in healthcare institutions

Changing patterns of work organisation

The characteristics of flexibility and adaptability are identified as important in the evolving healthcare system (Department of Health, 2000; Pew Health Professions Commission, 1995 and 1998). Pressures of the escalating costs of providing healthcare have resulted in changes in work structure in hospitals which have made demands on the flexibility and adaptability of nurses. Many healthcare institutions have been downsizing, increasing the proportion of casual workers, reducing nurse management positions and introducing larger numbers of unskilled or semi-skilled workers.

The use of a multi-skill level workforce, while introduced in response to nursing shortages and to reduce costs, could decrease the ability of organisations to restructure work. Aitken and team (2001) report the work of Vincent (1996) in the United States who argues that to achieve restructuring, employees must be able to function autonomously, be self-directed, knowledgeable, flexible, empowered and require little supervision. She argues that the use of unregulated workers is likely to impact on nursing by increasing traditional supervision and has the potential to create a reductionist and mechanistic view of nursing.

Information on the Australian scene, discussed in the next Chapter, shows similar patterns of staffing in the aged care sector, though the pattern is different in the Australian healthcare system. As the literature demonstrates, these types of changes have increased demands on the flexibility and adaptability of nurses (Sochalski, Aiken and Fagin, 1997). Some overseas researchers are beginning to test the impact of these types of changes on the nursing work environment. Their findings suggest that some patterns of work structure and practice produce a reduction in the attractiveness of nursing as a career, impact negatively on patient outcomes and may not be cost effective (Aiken and Havens, 2000; Aiken, Clarke, Sloan, Sochalski, Busse, Clarke, Giovannetti, Hunt, Rafferty and Shamian, 2001; Fagin, 2001).

Work on Magnet Hospitals, a group of hospitals that were identified initially as being able to recruit and retain nurses in the United States in the shortages of the early 1980s, gives some evidence of the type of institutions in which nurses are happy to work. In these hospitals nurse leadership was visible and supportive of staff. The positive characteristics of clinical nursing in these hospitals were autonomy in practice, status within the organisation, and collaboration. Participative management and support of professional development were also traits of Magnet Hospitals (Gleeson Scott, Sochalski, and Aitken, 1999).

With the opening up of nursing work outside the institutional environment, the attraction of nurses to work in hospitals and other care institutions may well depend on ensuring hospitals meet the needs of nurses. This is particularly true as the work in these institutions is difficult and requires ‘unsociable’ working hours. Even the attempts to provide more flexibility and nurse control of hospital staffing rosters will be challenged by the unavoidable responses to changes in patient acuity or volume, and will lead to staff expectations not being met (Norrish and Randall, 2001). So the challenges to maintain a nursing workforce will require careful examination of issues of work organisation.

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Skills mix

Crisp (2001) summarised the literature on standards for nursing care and the relationship between skill mix and patient outcomes. Evidence from a broad range of literature and research suggested:

• Reductions in the number of RNs and the proportion of qualified nurses in the nursing skill mix were introduced initially to control the burgeoning cost of healthcare. The latest global shortage of qualified nurses increased interest in the development of models of care provision that maximise what is fast becoming a scarce resource: the RN.
• Changes to nursing skill mix proceeded initially with little evaluation of the various compositions of skill mixes and their impact on patient outcomes.
• There is now global acceptance that a broader range of potentially nurse-sensitive outcomes is required. Much of the recent work has concentrated on broad measures that are easily obtained and meaningful across settings. There is now an acknowledged need for measures that capture the specific contributions of nursing to patient care across the spectrum of setting in which nurses work.
• Administrative and clinical information systems are in their infancy with regard to capturing the work of nurses, and the standardised and valid data crucial for determining and comparing the impact of changed nursing skill mixes do not exist. Data are required that permit meaningful interpretations of the complex patient, staffing and organisational factors that impact on patient outcomes.
• Several large US studies were commissioned in the late nineties to examine the link between nursing skill mix and potentially nurse-sensitive patient outcomes. These studies are the first of a magnitude to permit clear interpretation of the contribution of nursing to broad patient outcomes, particularly adverse events. These studies are establishing clear links between the use of qualified nurses and reductions in adverse events such as mortality rate and nosocomial infections.
• Recent research suggests that changes to nursing skill mix may have adverse effects on qualified nursing staff and, somewhat paradoxically, have a clear potential contribution to the nursing shortage.
• The demands of modern healthcare on health professionals have increased radically, and continue to do so. In virtually all contexts in which nurses provide care there has been increased patient acuity, complexity of the care required, volume of patients/clients, diversity of casemix, expectations that practice is based on evidence and demands for accountability. Concurrently, there has been decreased length of stay and time available for meaningful professional /patient interactions. This situation has increased enormously the need for highly developed critical problem solving and organizational skills on the part of all health professionals, including nurses.

In Australia, we have witnessed a large decrease in the numbers of Enrolled Nurses as part of the nursing skill mix. An important factor in this decrease of the numbers of Enrolled Nurses has been the reduction of Enrolled Nurses working in government and non-government nursing homes where there has been an increase of the unregulated health worker. This is in part due to the lack of distinction between the type of work the two groups undertake in these settings. In 1996, 93 per cent of Enrolled Nurses worked in a clinical area with about one-third each working in gerontology/geriatric and medical surgical areas. Between 1989 and 1999 the Enrolled Nurses workforce dropped from 24 per cent to 20 per cent.

It appears that this decrease is at least in part due to factors related to changing employment conditions, but the research of McKenna and team (2001) suggests that while the use of Enrolled Nurses in aged care may have decreased, demand for Enrolled Nurses may be increasing in other areas. The research found that increasingly courses are introducing other clinical areas (mental health and community placements, including outpatient clinics and maternal child health). Some institutions expose students to maternity, paediatrics, operating theatre, and in one case, emergency. Employment has shifted from the traditional area of aged care to a range of clinical practice areas. Even employment in aged care is often not in nursing homes. In South Australia, more than 90 per cent of Enrolled Nurse graduates worked in acute care within three months of graduation. However, in rural areas, alternatives to work in aged care in nursing homes may be limited, suggesting the skill mix is context dependent, an issue identified in conversations with the Director of Nursing in Gove. Another factor limiting the use of Enrolled Nurses may be the different scope of practice due to differing regulations such as those covering the administration of medications. This factor may impact on the flexible use of Enrolled Nurses in some States.

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Scope and standards

Debates about the definition of the scope of practice for nurses are evident in the literature. Chiarella (2001) discusses this in the context of examining the regulation of nursing, and identifies the full range of responses from jurisdictions that do not define scope of practice to those that define it in detail. Two approaches are evident, one which is client/patient focused in which the needs of the client are identified as paramount and the other is an exercise in defining and protecting professional boundaries.

Another way of viewing the issue is that the scope of practice and definition is framed in a way that is either permissive or restrictive. To a degree the approaches taken in different jurisdictions appear to reflect nursing practice within the culture of individual healthcare systems. In Australia, Queensland has defined Scope of Practice and Western Australia is using this as a model for some developments in the area. Chiarella argues that while the Queensland approach is less permissive than the spirit of the United Kingdom Central Council for Nursing Midwifery and Health Visiting (UKCC) definition, it falls into a more permissive view as it defines scope of practice as ‘that which the nurses are educated, authorised and competent to perform’. Other Australian jurisdictions such as NSW use the ANCI competencies as the definition of standards, and do not define scope of practice.

Moving from the definition of scope of practice the study of McMillan, Conway, Little and Bujack (2001) discusses the influences on scope on nursing practice in Australia.

In relation to the changing scope of nursing practice in Australia they summarise their findings this way for the research forum:

Contextual factors identified as impacting on both scope of nursing practice and nursing education are increased diversity in practice contexts, increased patient acuity in all nursing contexts, financial constraints, the legal and industrial climate and consumer expectations. Data indicates that over the last two decades there has been a shift in the usual practice for all levels of nursing, particularly RNs and ENs. The practice of both is amplified: what was previously considered expanded practice is now the expected norm. There is recognition that inter and intra professional role boundaries in healthcare have blurred.

Comments regarding the skills and knowledge base for contemporary practice recognise that ENs perform an increased number of technical competencies. There is considerable feedback identifying a need for RNs to develop skills in management of units, finances and personnel; delegation and direction; education of patients, self and peers; and teamwork and collaborative practice. The impact of contemporary issues in healthcare has been evident in recommendations about curriculum content, for example conflict resolution training; management of aggression; knowledge of funding sources and government policies; and the ability to adapt to an ever-changing practice context are seen as increasingly significant.

Respondents have identified that education is a paramount concern for nurses and needs to be appropriate, ongoing and accessible.

The need for cross sectorial collaboration and support has been highlighted by a number of respondents as has the need to embed an expectation that nurses are lifelong learners in performance criteria. It is been suggested that there needs to be greater uniformity in operationalising existing competency standards to provide useful evidence of competence.

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Advanced Practice nurse/nurse practitioner

Services provided by specialist nurses including those services at the developing edge of specialisation occur in many models of healthcare. These changes in specialisation result from new or more technical nursing roles or substitution for other health workers when these are in shortage. Debate about concepts of extension, advanced nursing practice and expanded practice form part of the literature and definitions and role labels vary.¹⁵ For the purposes of this Review, we will note only that a range of developments have occurred in relation to this area. These include Queensland’s approach to practice based on education, authorisation and competency and the developments in the Nurse Practitioner role in NSW, and its exploration in other States.

Aitken and team (2001, p. 117–118) summarise the action in Australia in relation to Nurse Practitioners:

Australian States have approached Nurse Practitioners in a variety of ways. New South Wales, following an evaluation of the role in a variety of metropolitan and rural settings, amended the Nurses Act 1991 to provide for nurses to practise as Nurse Practitioners and the title has been protected since 1998. At least one emergency Nurse Practitioner and a community Nurse Practitioner have been appointed.

Victoria had pilot Nurse Practitioner projects in 1999 and currently has further pilots underway. The title, Nurse Practitioner, was recently protected in legislation and proclaimed in the Nurses Amendment Act 2000 in December.

In the Australian Capital Territory four Nurse Practitioner pilots are currently underway however the title is not currently protected. South Australia has had extensive consultation about the role through their Department of Human Services and the Nurses Board is currently seeking comment from key stakeholders on a draft standards statement for NP practice. These standards include protection of title. Similarly in Western Australia the Remote Area Nurse Practitioner report of April 2000 has recommended that the title Nurse Practitioner be protected.

Tasmania is also looking at the role but does not appear to have progressed as far as other States. In Queensland the title is not protected and there appears no move to do this however legislative changes have already been made to enable isolated practice nurses to administer specific medications, order x-rays and perform pap smears.

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Scope of nursing and its implications for education

Scope and education

Jones and Cheek (2001) in their study talked to 38 nurses including Registered and Enrolled Nurses across 17 areas of nursing practice within Australia. They summarised the views of these nurses about the impact of change and what it means for the education of nurses in the following way:

The most prevalent point made by nurses interviewed was the move towards a greater clinical component in nursing education. Essentially, a balance is required between the academic and practical elements of nursing education. There is a need for a national curriculum that is broad but allows for specialisation into particular areas of nursing practice. Furthermore there should be a more significant interface between the universities and the workplace; a greater contribution by the workplace in developing the nursing curriculum; guided contextual learning with appropriate resources to support; mentoring and preceptorship are key initiatives that would facilitate the growth, personal and professional development of nurses as lifelong learners; greater placement in the community—not just in pre-acute setting; and increased time for RN to be initiated into workplace before having full load responsibility (possibly a paid intern year).

Many Enrolled Nurses interviewed were frustrated with a lack of career direction and recognition of experience within the Enrolled Nurse position. The introduction of an Advanced Skills Enrolled Nurse position may overcome this.

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Consequences of these trends

For Australian nursing, the implications of the trends are also documented in the Jones and Cheek study (2001). These were summarised for the research forum as:

• Fast turnover from acute hospitals—forcing an increase into community care; increased recognition of the advantages of patients staying in the home, for example palliative care; increased focus on holistic care and rehabilitation; ageing population and the associated increase of chronic disease; increase in technology; and increase in need for independent decision-making.
• An increase in PCAs creates a need for their management and supervision. However, their role in supporting nurses should not detract from or replace nurses participating in certain interactions necessary for assessment, for example showering. While there is an increase in the need for greater collaboration between health professions, there is also a decrease in the ability to access resources because of budgeting constraints. Strategies need to be developed to facilitate mutual respect between doctors, nurses and other health professionals. On the whole, nurses tend to work within a team environment with other allied health professionals, although there is an emphasis that nurses are there 24 hours a day; and facilitate networking—knowing who to call for what.
• From the insights gained from the diverse range of nurse interviewees core skills include communication and people skills, life experience, problem solving, life long learning, IT and information literacy, negotiation and conflict resolution, health promotion, education and disease and injury prevention and a knowledge of people and their social context, local environments and networks, time management and working with and alongside others. Leadership and management skills are also required if nurses are to develop nursing where a balance between educating for autonomy and interdependence is achieved.

Another view on this is found in the work of Aitken and team (2001). New nursing roles have emerged in direct response to changes in service. As a consequence, roles have both expanded to become more generalist and extended to become more specialised. The development of roles continues to show distinct differences between the setting, locale and focus of practice. The literature reveals that both changes in service and changes in the role of nurses have impacted on the skills and knowledge required to provide optimal care in the current and future healthcare settings. The skills and knowledge identified as necessary for all service settings and roles in the literature in contrast to those identified by nurses above are:

• coordination of care
• patient/client assessment
• clinical decision making
• patient/client and family teaching
• research consumption and application and
• counselling

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Approaches to healthcare and education policy and funding: different directions?

Much of the current debate about the healthcare system assumes that the best way to develop delivery systems is to have an integrated approach focusing on the needs of the consumer. A typical example of this approach is found in the Western Australian Government document, Designing the Future, which describes that State’s goals for an integrated heath system (Health 2020). The expectations emerging from an integrated service model will define how ‘nursing’ will be expected to respond to new demands from the labour market. This debate, the assumptions underpinning it, and the evolving systems of work practice will influence decisions about the best approach to the future education and training of nurses.

Nurses form a key part of the health workforce, but one that in recent times has not been expanding at the same rate as the workforce of other health professionals.¹⁶

In the longer term, questions about how best to address the particular education and training needs of nurses will need to be addressed in a complex web of relationships with issues concerning the education and training of the whole spectrum of other health workers and professions. To achieve this synergy strong partnerships between the service sectors and the education and training sectors will be necessary.

While Australia has no infrastructure capable of providing this at present, recent moves to establish a national strategic health workforce body will, if successful, begin a more systematic integrated planning process across the different health professions.

In relation to the education of health professionals, of worth noting is the work being undertaken in the United Kingdom under the Quality Assurance Agency for Higher Education. As the result of benchmarking education standards for the different health professions, the Agency has now produced an emerging health professions framework which covers 11 different health professional groups including nursing and midwifery (The Quality Assurance Agency for Higher Education, 2001).

Exhibit

• Exhibit 5.1 Health expenditure

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