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National Review of Nursing Education 

Discussion Paper

Chapter 7 
Nurse Education and Training Today

• Education and healthcare funding and policy
  • The Australian contexts of healthcare and education
  • Health policy and funding related to education
  • Education and training funding policy
  • Contributions of the States and Territories/private sector
  • Nursing Students?
• Current models of education and training
  • Training for unregulated care worker/assistant in nursing/personal care worker
  • Enrolled Nurses
  • Registered Nurses
  • Midwives
  • Post-initial Education and training
• Strengths and limitations of current models
  • Articulation between nursing levels
  • Specialisation and beyond
  • General learning outcomes achieved by current models
  • Specific Outcomes Current models
  • Partnerships
  • Field/Clinical education and clinical placements
  • Transition to practice
  • Costs and funding
  • Specialists and postgraduates
  • Funding implications of changes to current models of education and training
  • Other challenges
• Exhibits

It is a challenge to educate a nurse to work competently in the highly technical, litigious, rapidly changing environment identified earlier in the paper and yet maintain the focus of care on the individual patient. The education of Registered Nurses in universities aims to provide them with the skills and knowledge to work from an evidence-base in a professional manner. There appears to be a growing frustration with a purely scientific approach to nursing in some places. The university preparation of nurses has been blamed for a perceived lack of clinical skills in new graduates, and a perception that the new nurse lacks the ‘caring’ attitude expected by the community. There has been overwhelming support for the initial preparation of Registered Nurses to remain in universities.

A range of policy and funding organisations impact on the ways nursing education and training are developing. This chapter examines these and the current models of education and training for unregulated care workers, Enrolled Nurses, Registered Nurses and specialist nurses. It also explores the strengths and limitations of the current models.

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Education and healthcare funding and policy

The Australian contexts of healthcare and education

Much of Australian nurse education occurs at the intersection between healthcare and education systems and settings. This is a highly complex space in which a variety of players contest and collide: different professions, professional bodies, workers, government and non-government employer agencies. It involves multiple levels of authority, different regulatory regimes and frameworks, different funding sources and complex relationships. These arrangements are often the result of the separation between funding sources and responsibilities under the Australian Constitution in a federated system of government. For example, Commonwealth funding is important in higher education, but the regulation of nursing is under State and Territory legislation.

The Commonwealth and State governments are key policy and funding players in both education and health. The non-government sector is also a key player in healthcare22  and to a lesser extent in the education system. Further, the role of the volunteer or family carer in unpaid support in healthcare in Australia is difficult to quantify, but is an important contribution to healthcare.

The different responsibilities for funding, the supply of different levels of nurses, and the delivery of nursing services has led to dysfunction between these processes. While the States ask for additional graduates, due to shortages, retention of experience and expertise in health services are essential to the education and support of these graduates. These issues are rarely treated within the same debate.

This policy infrastructure sets the boundaries, constraints and freedoms within which models of education and training for nurses can be designed. Some of the implications of these broad policies will be of more immediate consequence than others, particularly those related to funding.

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Health policy and funding related to education

Commonwealth Government health policy tends to focus on the supply of doctors, costs associated with Medicare, and aspects of the healthcare system for which the portfolio has direct responsibility. Nursing practice is controlled by State legislation and the Commonwealth has little direct involvement with nurse employment. Its interests in nursing relate to the national interest, that is, providing access to an adequate quality heathcare system for all Australians. Further, the Commonwealth makes a considerable contribution to aged care²³  and sets standards for the management of aged care facilities. When the Review met with State Health Departments they appeared to regard workforce planning for the aged care sector as a Commonwealth issue. Much of the State and Territory workforce planning overlooks the aged care and private healthcare sectors.

These various roles and responsibilities create policy silos resulting in circular debates.

The Commonwealth has also responded to nursing concerns by developing programmes to address areas of disadvantage²⁴ . The Commonwealth Health portfolio also funds university departments of rural health. Nurses should have access to these departments but there was limited evidence to the Review that the majority of these currently provide any substantial support to nurses in rural centres.

²⁴The 2001/2 Budget for the Commonwealth Health and Aged Care portfolio included announcements of funding for nursing – predominantly for programmes addressing regional and rural shortages of nurses. The announced programmes are intended: to encourage nurses not currently active to return to the workforce; to provide scholarships that assist rural students with the costs of becoming a nurse; and to provide funding for doctors to employ practice nurses in rural, remote, provincial and outer metropolitan areas where doctors are in short supply and hard pressed to cope with the demand for services

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Education and training funding policy

Educational funding arrangements for universities and the Vocational Education and Training (VET) sector are different. The following material outlines some features of funding and policy in each sector.

Higher education funding and policy

While the universities themselves are autonomous bodies created by separate Acts of (usually) State and Territory governments, the Commonwealth has the primary responsibility for funding and policy in the higher education sector. It provides block grants to universities to meet a given target in terms of university load. Universities can distribute the funded load in response to demand or other priorities (see Exhibit 7.1) While the trend is to a market driven response model, universities are encouraged to respond to the needs of the nursing labour market as well as student demand.

Not all of the funding for nurse education comes from government. Students also contribute to the costs of their education, with the size of their contributions depending on the type of course. The Higher Education Contribution Scheme (HECS) applies to undergraduate nursing courses. The HECS payments go to consolidated revenue, not to the universities. Universities are able to charge fees for undergraduate nursing courses to both domestic and overseas students within certain guidelines, but the majority of undergraduate nursing students pay HECS.

Higher Education policy and innovation have the potential to impact on nursing education directly and indirectly. Universities are encouraged to broaden their sources of funding and to develop more commercial operations and many are responding by broadening their student base with overseas students and other partnership arrangements. Systems of quality assurance are being developed with the establishment of the Australian Universities Quality Agency (AUQA), which will assist in the promotion of Australian education overseas, and the recognition of Australian credentials internationally.

Some commercial initiatives have particular issues for nursing. One issue raised with the Review Panel was that while overseas students provide extra funding for the university, healthcare services are questioning why they should offer clinical placements to these students when there is such competition and it is costly on their resources.

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Vocational education and training funding and policy

The responsibility for the management and funding of the VET system lies with State and Territory Governments. Although Commonwealth funds support the training sector, its contribution is through the Australian National Training Authority (ANTA) or through targeted programmes administered directly by the Commonwealth. New Apprenticeships is one such programme. This programme provides employer incentives to take on a trainee, personal benefits and support services for the trainee. Some Enrolled Nurse preparation is undertaken through traineeships (see Exhibit 7.2).

Under the VET arrangements industry training advisory boards (ITABs) are responsible for the national training packages that describe the skills and knowledge required to work in particular occupations. Currently, Enrolled Nurse preparation is not covered by a training package, although there are packages for some Certificates II and III developed by the Community Services and Heath Industry Training Board which articulate into Enrolled Nurses training.

The arrangements for funding Enrolled Nurse training are more complex than those for undergraduate students since they involve both government and non-government training organisations and different models of preparation. They also vary in the different States and Territories. It is therefore impossible to provide any detail on funding in this paper, other than that relating to costs to students, which are discussed later in this Chapter.

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The Australian education and training system

Australian Higher Education and VET qualifications are brought together under the Australian Qualifications Framework (AQF). The AQF encompasses the whole range of qualifications from school, vocational education and training, and university and other higher education institutions. The Australian Government endorses this framework. While the issuing of some qualifications is the preserve of a discrete sector, other qualifications are issued in more than one sector. Examples of this are: both the VET sector and the schools sector, or the Higher Education sector and the VET sector. At the current time, Enrolled Nurses usually complete Certificate IV or a Diploma in the VET sector and Registered Nurses gain Bachelor Degrees, Graduate Certificates, Graduate Diplomas, Masters Degrees and Doctoral Degrees in universities.

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Contributions of the States and Territories/private sector

Support for nursing and nurse education and training via healthcare budgets

There is a great variety of support and a significant contribution to nursing education from the States and Territories through central structures and their healthcare institutions. The following list exemplifies some of these contributions:

• employment of Student Registered Nurses and Student Enrolled Nurses;
• support for continuing professional development of staff via hospitals and healthcare budgets (including continuing professional education for all staff, and scholarships and other support for postgraduate education of Registered Nurses);
• support for Colleges (such as the NSW College of Nursing) to offer professional development;
• scholarships for rural and indigenous students and nurses;
• student clinical education;
• contracting for particular courses with universities.

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Nursing Students?

Students may choose to study nursing for any of a numbers of reasons. It is fair to assume most are planning on a career in nursing, but this may not be true for all students. A university education aims to provide all students with an opportunity to develop higher order thinking and communication skills.

Educational institutions respond to different agendas to those of industry. One particularly challenging issue for nursing education is the way to deal with students who for reasons of disability and/or medical conditions will not be able to find employment as nurses. Nurses’ registration boards deal with issues from the perspective of the safety of the public, whereas the education institutions are not able to discriminate in relation to access to education on the basis of disabilities or medical conditions. The rights to access are enshrined in State and Federal legislation, such as the Disability Services Act 1992 (WA) and Disability Discrimination Act 1992 (Cwlth).

These difficulties are examined in Guides and Procedures to Assist Universities to Examine the Inherent Requirements of their Courses (when accommodating students with disabilities and/or medical conditions), Report Book (Vol 1, 2000).

Further, difficulties can arise when the university courses prepare students for qualifications that enable entry or membership to particular trades or professions, and the relevant registration boards and associations impose conditions on the university courses and therefore the students, that are related to practice rather than qualification. One example of this is in schools/areas/departments which have field practice requirements in their courses and the student’s disability and/or medical condition has the potential to conflict with professional or trade requirements.

An interpretation of the DDA makes it clear that

‘.. it is unlawful for education authorities to refuse to admit a person with a disability to a professional or a skill-based training course on the basis that the person with a disability is unlikely to be able to work in the profession or trade because of his or her disability. Qualifying and vocational bodies may refuse to authorise or to qualify a person with a disability, if because of the person’s disability, the person is unable to carry out the inherent requirements of the trade or profession (s 19). Educational authorities are not able to pre-empt the decisions of the qualifying body.’
Acting Against Disability Discrimination, manual 1994.

Judgements about whether a university can provide reasonable accommodations for the students with disabilities or medical conditions are determined by the essential requirements of university units/subjects. Guidelines for this can be found in the associated Work Book (Watts, Stickels, Fraser, Carroll, Stewart, and Radloff, 2001).

Several nurse registration boards raised with the Review the issue of difficulties associated with students graduating who can only be registered with restrictions on practice or not at all. This issue will only be addressed by ensuring students are provided with information on the requirements of their regulatory bodies in relation to safe practice, and universities must work on the assumption that not all graduates from nursing courses will work in a clinical capacity as a nurse.

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Current models of education and training

While the focus of consideration for the Review is on Registered and Enrolled Nurses, the growing number of unregulated care workers who are directly supervised by nurses means the preparation of this group needs to be given consideration, due to its direct impact on nursing work. The Review examined the importance of this group of workers who are covered by some of the VET training packages. Table 7.1 provides a summary of the arrangements for these groups and links them to the AQF. The inclusion of unregulated care workers gives recognition to the relationship with nursing and to the pathways already being used to gain nursing qualifications.

The following sections provide commentary on both the roles and models of education and training of the unregulated care worker, the Enrolled Nurse, the Registered Nurse, the midwife, and the specialist nurse.

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Training for unregulated care worker/assistant in nursing/personal care worker

Level II and III Certificates

Industry training packages provide the framework for competencies for the Level II and III Certificates. The Community Services and Health Industry Training Advisory Body, has developed two training packages that accommodate occupations and skills in related fields of health (see Exhibit 7.2). While this level of qualification does not encompass nurses, it does prepare a range of workers whose work involves care and is often done under the supervision of a nurse. This is particularly true in aged care. There is also a used and recognised pathway from this level of care worker to Enrolled Nurse.

A range of models is shown in Table 7.1. One approach is to introduce school students through VET programmes. The Enterprise and Careers Education Foundation supplied information on the involvement of schools in this area in their submission:

The Community Services (Aged Care Work) Certificate II and III is currently being offered in high schools in a number of States and Territories. It is a VET subject that provides an introduction to the health/nursing field and offers students an opportunity to learn on-the-job in health settings in aged care facilities, working with residents who have low to high care needs.

Aged-care facilities host the work placements, and staff act as workplace trainers and supervisors through a ‘buddy’ system. Students, therefore, get the chance to train with Enrolled or Registered Nurses and are usually ‘buddied’ with senior personal carers/assistant-in-nursing staff.

At Launceston College in Tasmania, twelve 16–19-year-old students completed either Certificate II or III courses in 2000. Of these, seven found employment directly in aged care facilities and seven are pursuing further studies, with a number planning to enter tertiary courses in registered nursing or diversional therapy.

While these programmes are not available to high school students in every State, particularly in NSW and Queensland, there is work being done to encourage schools to provide exposure to nursing within the senior school curriculum in some States.

The linkage between different roles and training arrangements is of interest. McKenna and team (2001) found that between 25 per cent and 75 per cent of students in Enrolled Nurse courses undertake employment in related areas (especially in aged care in hostels or nursing homes as AINs or PCAs) while they are studying.

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Enrolled Nurses

Certificate IV/ Diploma

Information on Enrolled Nurse education and training comes mostly from the work undertaken by McKenna and colleagues for the Review. In most cases, course offerings are determined through the agreements of TAFE institutes and nurse registering authorities. The development of courses within the various States and Territories has resulted in considerable variation in the educational programmes. Courses are offered through 22 capital city and 32 regional providers.

Table 7.2 shows the inconsistency that exists across the States and Territories in regards to the courses offered for Enrolled Nurses. Although most courses are offered at AQF level four, Queensland is a precedent for Enrolled nursing leading to higher levels of qualification. The level four courses are predominantly offered over 12 months or equivalent full-time study, except in Western Australia.

The flexibility of courses varies considerably around Australia. In New South Wales all students undertake a full-time employment model. Currently, there is no option available for part-time studies in that State. Western Australia also offers only full-time programmes. In a hospital-based programme to be offered in South Australia in 2002, students will undertake an employment-based programme, available by full-time mode only. Within the other States and Territories, there is greater flexibility for students to study either full-time or part-time.

Many TAFE institutes are considering means for improving flexibility of programme delivery. As highlighted by a number of rural institutes, many students travel large distances to and from scheduled classes. Some institutes in South Australia and Queensland offer many modules by distance education. Teaching and learning is supported through the use of videoconferencing facilities in outlying areas reducing the need for students to travel long distances. Spencer Institute in South Australia also offers a Certificate IV programme across State borders for students in other States including Tasmania and Queensland. Some Queensland students travel to South Australia to undertake clinical experience. TAFE Tasmania organises clinical placement experience for students in that State.

Hours of course contact are determined within the curricula set at State and Territory levels. Some variation in contact hours exists between States and Territories. Enrolled nurse students usually undertake block placements in health and community settings throughout their courses. Focuses for clinical practice experiences vary from State and Territory. All courses expose students to significant amounts of aged care and rehabilitation as has been traditional for these courses. Furthermore, all the courses included in our study provide students with exposure to acute care areas, mainly medical surgical nursing. From the interviews it appears that more attention is being placed on acute care nationally than was previously the case (see Exhibit 7.3 for more information).

Increasingly, courses are reducing their emphasis on aged care and rehabilitation. Many courses have introduced placements within mental health and community placements, including such areas as outpatient clinics and maternal child health. Within a smaller number of institutions, students are also being exposed to clinical areas such as maternity, paediatrics, operating theatre, and in one case interviewed, even emergency. This exposure is opening up new practice possibilities for Enrolled Nurses on completion of their courses.

Currently the ANCI is reviewing the competencies for Enrolled Nurses.

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Registered Nurses

In Australia, nurses work in a wide range of environments. This diversity formed the basis for the development of the comprehensive model of initial education. Nurses work in areas as diverse as: the community, prisons, acute hospitals, mental health, childcare, doctors’ practices, and midwifery to name a few. Despite this, hospitals continue to employ most of the nursing workforce. Changes in this area of service mean that graduates need higher order skills due to the levels of acuity, combined with mental health conditions, the effects of ageing and very short length of patient stay in hospital. Building on this comprehensive base, additional education and training are needed to work in some specialty areas.

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Bachelor degrees

Ogle and colleagues (2001, p. 12) separate the Bachelor Degree programmes into two groups: undergraduate nursing programmes were categorised as pre-registration or post-registration. These groupings differentiate students completing undergraduate nursing courses who would be eligible for registration for the first time (pre-registration) from students completing undergraduate nursing courses who were already Registered Nurses (post-registration).

Pre-registration programmes mainly comprised the following undergraduate nursing courses, noted in full-time years of study:

• Three-year Bachelor degrees in nursing.
• Four to five-year combined degrees, which either consisted of a Bachelor degree in Nursing with a Bachelor degree in another field of study such as Psychology, Commerce or Arts, or a Bachelor degree in Nursing with a Bachelor degree in another nursing discipline, such as Midwifery or Rural Health.
• Two-year Bachelor degrees in Nursing for graduates from another discipline or students with previous nursing studies, such as Division 2 nurses. (These students are usually admitted into the three-year pre-registration Bachelor of Nursing programme and are given credit equivalent to one year's full-time study).
• One-year re-entry programmes (Bachelor degree or Certificate in Nursing) for nurses whose registration had lapsed.
• One-year conversion programmes (Bachelor degree or Certificate in Nursing) for overseas-qualified nurses seeking registration in Australia.

Post-registration nursing programmes mainly consisted of the following undergraduate courses, noted in full-time years of study:

• One-year conversion programmes for hospital educated Registered Nurses, seeking to upgrade their qualifications to a Bachelors degree in Nursing.
• One-year honours programmes (undertaking a research thesis) for students who have completed an undergraduate pre-registration Bachelor degree in Nursing. (These students are eligible for registration as a nurse before they commence their honours programme).

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Modes of delivery

Undergraduate nursing programmes are offered at 28 universities as well as Avondale College. In total, full or part nursing programmes are delivered at 58 campuses across Australia, including places such as Geraldton and Whyalla. Relative to their populations New South Wales and Victoria have a proportionally higher number of domestic pre-registration students (55 per cent collectively). Both Western Australia and the Northern Territory indicated at consultation meetings that they rely on graduates from these States for their workforce.

Ogle and colleagues (2001, p. 85) report that although institutions had difficulty providing accurate data on part-time versus full-time study, due to students moving randomly between the two modes of study, about 82 per cent of undergraduate pre-registration students were full-time, while post-registration students utilised a mixture of full-time and part-time study.

The involvement of hospitals and other facilities in the clinical education of undergraduate student is examined is a survey commissioned for the Review. Duffield, Donoghue, Uyeda, Forbes, Mitten-Lewis and Proude designed and analysed a questionnaire seeking the experience and views of health and aged care institutions of clinical placements for student enrolled, registered and specialist nurses as well as new graduates. The material used in this paper comes from an early draft of the report so no page numbers are included in references. A total of 432 questionnaires were returned with approximately half each from metropolitan and non-metropolitan areas. While responses were received from all States, none were received from the Territories.

The sample analysed represented four sectors, public, private for profit and not for profit and charitable and included acute care (38 per cent), community (4 per cent), day facility (11 per cent), hostel (9 per cent), maternity (6 per cent), mental health (4 per cent), paediatrics (1 per cent), nursing home (26 per cent), and rehabilitation (2 per cent). Sixty four percent of the organisations offer clinical placements to undergraduates. Most public institutions and between 40–60 per cent in the other categories accept undergraduate students. If day facilities, hostels and community care are removed from the sample, over 80 per cent of health and aged care institutions accept students. The researchers comment on the small number of day facilities (9 per cent) that take students for placements:

These facilities are expected to provide a large proportion of care in the future, but relatively less students are exposed to these facility types. Just under half the nursing homes sampled did not have undergraduate nursing students.

Some institutions also employ students as Assistants in Nursing. Public institutions are less likely to employ students. The remaining three sectors utilise student as AINs at fairly similar levels (46 to 51 per cent) compared to the 24 per cent of public institutions.

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Midwives

Bachelor and postgraduate

Midwifery is the only regulated area of ‘nursing’ specialisation in all States and Territories. Under present arrangements midwifery registration usually follows registration as a nurse and study at the postgraduate level is the most common route. A new four year double degree programme integrates preparation to become a nurse and undergraduate Midwife as part of an undergraduate programme. A further development, direct entry midwifery courses will be offered in 2002 in at least one State. Tasmania had no midwifery courses in 2001.

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Post-initial Education and training

Specialist nurses

Despite the recommendation of the National Review of Specialist Nursing (Russell et al. 1997) that the International Congress of Nurses (ICN) definition of specialist nursing be adopted in Australia for use in labour force planning, there is still no universal definition of nursing specialist or specialist nurse in use in Australia. The ICN definition is:

The nursing specialist is a nurse prepared beyond the level of a nurse generalist and authorised to practise as a specialist with advanced expertise in a branch of the nursing field. Speciality practice includes clinical, teaching, administration, research and consultant roles (1992, p. 12).

The ICN also adopted four essential requirements to ensure the orderly development of specialisations in nursing. These elements are:

• the adoption of a systematic means of determining and designating nursing specialities combined with minimum standards in regard to education, experience, performance and the maintenance of competence;
• the establishment of a regulatory mechanism for nursing specialists to ensure a certain level for competence; and
• nursing resource planning with coordination of nursing education and workforce planning as an integral part of healthcare system development.

The Council also recognised the importance of the links between labour market needs, career planning and the relationship with other generalist nurses working in the specialist area.

Lack of planning around the development of nursing specialisations in Australia has not only resulted in a lack of clarity about the definition of ‘specialty’ but also created difficulties in dealing with particular areas of specialty, and the design and accreditation of postgraduate courses and their recognition for endorsement to practise across State boundaries. The evolution of areas of specialty has also resulted in critical care gaining a higher profile than primary healthcare and chronic care. This lack of profile is of particular concern in the aged care sector, and in mental health.

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Postgraduate programmes

Specialist nursing courses may range from Graduate Certificates through to Masters Degrees in any given specialisation. Courses preparing for specialisation can attract the same level of qualification but show considerable variation in length, the mix of clinical and theory and the level of involvement of the health sector in their delivery.

While postgraduate programmes are studied at a range of levels, for labour market purposes the interest is more in the way the qualification provides skills for particular specialty nursing areas. Ogle and colleagues (2001) provided a profile of university courses by speciality and the number of graduates expected in 2001. This profile includes Postgraduate Certificate, Diplomas and Master Degrees by coursework. The graduate numbers in Table 7.3 include any of the three levels of qualification above.

One issue complicated the usefulness of the data collected for workforce planning. The advent of and trend towards generic courses (where nursing specialisations were unable to be identified) complicated the process of trying to accurately quantify the number of enrolled and completing domestic postgraduate nursing students in specialty courses. To overcome this problem, an attempt was made to tease out specialities within generic courses and recode the student data into nursing course specialties based on the percentages of domestic students enrolled in the various specialty courses in Australia in 2001 (excluding the midwifery and research specialties).²⁵  A proportion of generic courses could not be matched to specialties, and as such 10 per cent were left as generic. The remaining 90 per cent of generic courses were apportioned to nursing specialties. Table 7.3 shows identified speciality groups, the expected graduates in 2001 and in some cases an estimate with the generic component recoded and apportioned to the specialities. This number is found in brackets in Table 7.3.

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Note 1: Does not include non-university sector (NSW College of Nursing) Ogle and colleagues (2001, p. xvi) summarise the postgraduate trends:

Postgraduate courses were predominantly offered part-time, used flexible modes of delivery and were both up-front fee-paying and HECS funded. Postgraduate nursing data displays a trend toward courses within the specialties of midwifery and high dependency. States varied in the number of specialties that they offered, and the number of students projected to complete these courses in 2001. For example, the projections for the New South Wales 2001 university midwifery completions were larger than any of the other States (17.8 per cent) whilst Victoria projected higher 2001 high dependency completions (39.5 per cent) than any other State. Whilst there appears to be a trend toward an overall increase in postgraduate student enrolments into specialty courses, this trend may reflect the tail end of the transfer of postgraduate nurse education into the tertiary sector. The advent of and trend towards postgraduate generic courses complicated the process of attempting to tease out and quantify accurately the number of enrolled and completing students in postgraduate speciality courses. Approximately (26 per cent) of postgraduate domestic student enrolment data was reported utilising a generic nursing category.

Duffield and colleagues (2001) from their survey of healthcare institutions document some interesting findings about specialist clinical arrangements. The number of facilities with agreement/s with a university to provide clinical experience for postgraduate students was 116 out of 432 who responded to the survey. Half of those organisations with agreements were in the public sector and slightly more than a quarter from the private for profit sector, with most of the rest in the private not for profit sector. Few Charitable institutions offered postgraduate clinical placements. All four categories are less likely to have postgraduate students than undergraduate students.

There appears to be high variation in the number of affiliations within different sectors with the average number of affiliations ranging from 1.4 to 1.9 with a maximum for any one institution being seven. The most commonly offered specialty is midwifery, followed by operating theatre. The public sector offers the greatest variety of specialty placements.

Health and aged care institutions report few supports from the universities for taking postgraduate students, but among the most noted supports were email and internet access, and in second place student supervisory staff. Involvement of healthcare organisations with postgraduate programmes took a range of forms. The researchers note:

Respondent identified having sitting members on a/some university course committees (N=53, 45.7 per cent) as the most frequent activity in which organisations are involved. Interestingly, 33 (28.4 per cent) respondents indicated they have no role in specialised postgraduate nursing education, while 47 (40.5 per cent) respondents would welcome an invitation to contribute to postgraduate nursing course design.

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Strengths and limitations of current models

The New Zealand Council of Nursing (2001) made an important point about the issue of ‘nursing identity’ and confusion about the purpose of initial nursing preparation. The Council expressed the view that: ‘the nursing profession needs to decide if nurses are to be educated as beginning practitioners with a wide range of nursing skills such as critical thinking skills and a professional identity or as practitioners clinically competent in pre-registration nursing skills as well as particular more specific skills’ (p. 38).

In Australia, this is also a serious issue that is at the heart of much of the debate about best practice models of nursing education and training. While a number of studies identify the need for better links between industry and education in the development of curriculum, they also argued for better consistency in standards with the retention of local variation. In this regard there have been interesting developments in the way local arrangements have enabled partnerships to develop between education and healthcare. While not suggesting these are the only examples a number that were drawn to the Review’s attention are summarised in Exhibit 7.4.

There are a range of challenges and successes in the areas of articulation, education for specialisation, field/clinical education, particular and general learning outcomes, research and transition to practice. These are explored in the following section.

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Articulation between nursing levels

Credit for experience and previous study is a developing feature of the training arrangements in Australia. There are increasing numbers of universities that give some credit to Enrolled Nurses who enrol to undertake pre-registration nursing courses. This pathway may increase the opportunities for some groups and individuals to access a career in nursing. For example, lower sociol-economic and Indigenous Australians may be better able to access a career as a Registered Nurse through a pathway beginning as an Enrolled Nurse or one which starts as an unregulated care worker with articulation into Enrolled Nurse preparation.

Members of the Review met a number of people who had already made their own path through different parts of the system or who were planning to do so. The Panel met one nurse who in 1990 started as an AIN and in 2001 is undertaking a Master of Midwifery Degree. Others had completed Certificate III, had been working as Assistants in Nursing and were training to become Enrolled Nurses. Many Enrolled Nurses were undertaking courses to become Registered Nurses. During discussions with Student Enrolled Nurses, the students identified the importance of mentors who assisted individuals to negotiate their pathways.

While the pathways already exist and are used, issues raised with the Review concerned the standardisation of credit and the type of infrastructure that supports movement for the individual who wishes to progress through the system. The types of articulation pathways in place and likely to be in place as of 2002 are displayed in Figure 7.1.

Different approaches to credit and transition are evident in the credit arrangements for Enrolled Nurses seeking a place in a university. The difficulties of establishing a system that gives standard credit for education and experience arise from a number of factors.

• Standards and qualification requirements for Enrolled Nurses vary across Australia and standards even vary within States and Territories. Without a common standard it is not possible to identify an appropriate level of credit.
• University courses also vary in approach and the order in which materials are covered, so topics an Enrolled Nurse has previously completed may be distributed anywhere in the six semesters of the standard university course.
• There is no framework that demonstrates that Enrolled Nurse competencies are an identifiable subset of those for Registered Nurses, or that the theoretical foundations required for the university course are established as part of the Enrolled Nurse programme. Without this overlap, there can be little justification of credit for Enrolled Nurses at university, or for the proposal that at some point during the university course Student Registered Nurses should be able to be enrolled and gain employment as Enrolled Nurses. To do so the Student Registered Nurses would need to meet the ANCI competencies for Enrolled Nurses.

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The current situation means that in States like NSW which has a centralised enrolled nursing curriculum, the development of conversion and bridging courses at TAFE allows students to gain credit at university as well as overcome some of the challenges automatic credit arrangements might cause.

Universities use different approaches to credit and the organisation of support for students entering the degree course with credit. Some rely on the student to identify and cover any missing skills or understandings. Others provide either different units especially designed to address these students’ needs, or entirely different programmes designed for Enrolled Nurses, or summer schools before beginning courses.

What is possible and who could run bridging or transition programmes depends on the education/training infrastructure in the State or Territory. Where the VET system may be in an excellent position to develop and deliver these courses in partnership with universities in one State, this may not be true for all jurisdictions.

Graduate programmes which give up to a year's credit also exist. Since 1996 5–6 per cent of commencing bachelor of nursing students have already completed a bachelor degree or postgraduate qualification in some other discipline.

Another issue which links to articulation is the question of different exit points during the bachelor degree course. There is some support for a model of Registered Nurse preparation which allows Student Registered Nurses to be ‘enrolled’ part way through their degree so they can be employed as Enrolled Nurses. This would provide an exit prior to completion of the degree or simply to allow part-time employment in the healthcare system.

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Specialisation and beyond

As indicated elsewhere in this discussion paper, a substantial body of professional opinion acknowledges the need for levels of specialist preparation going beyond initial preparation for practice in specialist areas of nursing. Some of this is to allow transition into specialty practice and is largely conducted at the postgraduate diploma and certificate level, though there is some support for the view that it should be education at Master degree level. The lack of clarity and agreement across the profession regarding the desired outcomes of various educational programmes, especially at the postgraduate level, is a difficulty for the profession and for education. For example, is a graduate of a Graduate Diploma in critical care meant to produce an entry-level practitioner to the specialty, or an expert in the specialty, or somewhere in between—there is currently no agreement about this.

How this debate relates to credentialling is discussed in Chapter 2. Some levels of practice require a broader knowledge and skill base than others, particularly in terms of research training. For the purpose of simplicity we will use the terms ‘advanced clinical practice’ and ‘Nurse Practitioner’ to incorporate this level of practice. Overseas trends have been to require Master level qualifications for these lead roles in nursing.

Masters courses have developed in a range of areas in the universities (see Ogle et al. 2001), but it is clear that the approach to length of course and nomenclature varies. Some Masters Degrees are of two semesters duration while others are as long as four. This range may be due to different entry requirements but once again the diversity suggests a lack of consistent standards. The profusion of different approaches causes problems for employers in assessing whether the competency they require is met through the course. Divergence in these models of specialist preparation and the growing number of providers suggests that this situation will only be exacerbated if some standardisation does not occur.

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General learning outcomes achieved by current models

A number of areas of nursing require more than one specialisation. Questions need to be asked as to whether multiple certificate/diplomas rather than Master Degrees are more appropriate categorisations of the level of study for each specialty. For example, nursing educators need both nursing and education skills and knowledge. It does not follow that the two areas build on a common knowledge base. Similarly a number of areas of nursing require some specialist skills in more than one area, such as community nursing with oncology for programmes like nursing in the home.

Van Loon (2001) provided to the Review a summary of the findings of a project currently underway under the auspices of the Australian Universities Teaching Committee. Three universities are involved in the project and its component parts: Flinders University, Adelaide—recruitment, transition and retention strategies; University of Technology, Sydney (UTS)—‘Best Practice’ models of curriculum; Queensland University of Technology (QUT)—‘Best Practice’ models of clinical education.

Models: There are a variety of curriculum models, all a high standard, integrating theoretical and practical knowledge, and providing opportunity for competency development. Gaps identified: theory/practice, some inadequacy in partnerships between tertiary/clinical sectors, lack of flexibility and choice, and extent of clinical practice in courses. Key elements identified include longer quality clinical experience, improved coordination of clinical supervision, clinical ‘buddying’ during placements, and development of quality clinical learning environments and learning cultures.

Skills and Knowledge: Graduates satisfactory in terms of ANCI competencies. Areas for improvement include coordination of tasks/activities in set timeframe, applied pharmacology and medication management, and clinical experience in acute care and high dependency. Notably, graduate performance improves markedly in the second six months of employment.

Life Long Learning: Issues limiting postgraduate learning are complex and include lack of; remuneration for qualifications, career paths and professional autonomy. Requests for increased flexibility, reduced cost of education and incentives to maintain intellectual stimulation.

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Learning outcomes achieved by different approaches to teaching and learning

A systematic review of the literature on models of nurse education and training by McKinley and team (2001) found the following information, largely from overseas literature. The combination of choice of course and higher levels of education (Bachelors or Higher Degrees) is associated with higher order knowledge and performance, that is, better grades and nursing performance, and higher levels of critical thinking and clinical decision making. Accelerated bachelor programmes for holders of other degrees are associated with at least as good learning and performance outcomes. Bachelor conversion programmes are also associated with good outcomes. The team argue that the observed outcomes in this research may well have been influenced by personal and sociodemographic characteristics that are also associated with choice of course. They conclude that there is no evidence to recommend particular models, nor is there evidence to recommend against the models of nursing education currently in place in Australia.

The only strong evidence for models of educational practice concerns the use of clinical practice as a learning environment, and computer assisted learning in combination with traditional approaches to teaching and learning.

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Specific Outcomes Current models

Rural nursing

According to Francis, Bowman and Redgrave (2001), rural nurses want greater access to educational opportunities in a range of clinical areas, both as generalist nurses required to operate over an expanded range of areas, and to extend their expertise in particular fields of clinical practice. Some of these needs can and are being met by short courses offered (often by healthcare providers in cooperation with universities) in the workplace, and by Postgraduate Diploma courses. But, beyond the initial levels of advanced practice, the tension between expanded and extended approaches to practice is more acute in rural nursing. In some settings, individual nurses, healthcare provider agencies and communities require the knowledge and expertise of the clinical specialist (for example, in acute care). In other settings—for example, more remote settings where nurses are the only locally available health professionals—there is a need for nurses with the knowledge and clinical practice skills of the Nurse Practitioner.

Rural nurses report that access to continuing professional education is difficult, partly because there are fewer education providers locally. Backfilling their position while they undertake the course is also difficult. Access is improved where there are local university campuses, but smaller numbers of students mean that it is difficult for schools of nursing to offer appropriate courses at appropriate times and with appropriate frequencies that potential students desire. To some extent, this situation is eased through workplace learning and flexible learning approaches. Rural nurses report, however, that they prefer online education and other forms of flexible learning to be supplemented by face-to-face teaching and learning.

The core skills required by nurses for initial rural practice pre and post-registration are identified as interpersonal skills, management, legal and ethical issues, practice skills, education and research.

As in other areas, the researchers are uncertain of the extent to which students can be adequately prepared for practice by the three-year general undergraduate nursing degree. Some specialist units and electives are currently offered in undergraduate programmes, but they may be little more than introductions to the kinds of skills and knowledge required for clinical practice in rural and remote settings. The researchers note the emergence of some four-year double degree programmes. These programmes may prove more effective in meeting generalist requirements while also preparing students more adequately for clinical practice in rural and remote settings (for example a Bachelor of Nursing/Bachelor of Rural Health Practice programme).

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Australian Aged Care Nursing

As in other specialised areas of practice, Pearson and team (2001) argue that undergraduate nursing programmes currently offer too little specialised theoretical work and clinical practice in aged care. As a consequence, newly Registered Nurses are often inadequately prepared for work in the area. When students are offered placements in exemplary clinical settings, when they are well-supervised, and when they have excellent preceptors, they are more enthusiastic about the prospect of work in aged care settings.

Developing specialised knowledge and clinical skill in aged care meets similar problems to those in other specialised fields including problems of tuition fees, quality and availability of placements and preceptors. There is also feedback which points to lack of good quality placements to provide these services and the lack of a culture of continuing professional development.

The researchers suggest that undergraduate nursing preparation be extended from three to four years. The current three years, they argue, does not allow sufficient time for the development of general knowledge and clinical competencies and for the development of specific knowledge and skills adequate and appropriate for clinical practice in a particular area of specialisation—whether in aged care or other settings. If a fourth year became mandatory for registration, the additional time would allow students to develop the particular knowledge and clinical skills appropriate for work in different specialised settings. The researchers also argue for further development of training programmes for Enrolled Nurses, and for the training of the currently unqualified and unregulated nursing assistants whose work is increasingly significant in aged care and other fields of nursing.

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Mental Health

The Clinton, du Boulay, Hazelton and Horner (2001) research commissioned for this Review indicates that there are some good models of programmes in Australia. It identifies and lists many key competencies required of the specialist mental health nurse. While some or many of these competencies are developed in various existing mental health nursing programmes, it is argued that they need to be more widely adopted as the basis for programmes.

The authors take the view that a return to separate pre-registration nurse education programmes for mental health nurses is unwarranted. On the other hand, they argue, there is good reason to believe that current programmes preparing general nurses contain too little, and inadequate, preparation for mental health nursing practice. Specialist preparation, of higher quality, and of greater intensity in both theory and clinical practice, is therefore needed to meet workforce demands of quality and quantity of the mental health nursing workforce. As in other specialisations, post-registration courses are expensive for students, often too short to guarantee clinical excellence, and of variable quality. There is a need for evaluation of courses and of outcomes for consumers of mental health nursing programmes.

The report canvasses a variety of possible models for mental health nursing education. These focus on undergraduate programmes including generalist programmes which provide initial exposure to metal health nursing, and programmes offering an initial period of specialist preparation within a three or four year degree. On the basis of the models reviewed in the report, it might be concluded that there would be advantages in adopting a four-year model, based on generalist preparation in the first two years, followed by specialist theoretical and clinical placement components in at least the last year. Initial registration as a nurse might be possible after the third year, but specialist registration as a mental health nurse not until after the fourth.

The report also discusses possibilities for the development of both clinical specialists and Nurse Practitioners in mental health nursing. It touches, too, on the lifelong learning needs of mental health nurses.

Questions arising from this literature review are: What should be the mental health competencies required of graduates from UG (undergraduate) courses in nursing? What should be the relationship between these competencies and those from PG courses in mental health nursing? What should be the relationship between competencies in mental health nursing achieved in courses in the tertiary education sector and those facilitated by in-service and similar professional development programmes? What should be the length and content of UG and PG (postgraduate) courses in mental health nursing? How should they articulate? What modes of delivery are appropriate to ensure clinical relevance and what can be done to advance the development of clinical skills and to recognise prior learning? What strategies can be used to ensure a strong consumer focus and involvement in mental health nursing education? How can universities best build their capacity to advance teaching, learning and research in the field of mental health nursing? How can universities and mental health service providers work more closely together to ensure that the supply of graduates in mental health nursing meets demand?

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Midwifery

As already indicated, there is a long-standing debate about the place of Midwives and midwifery in the Australian healthcare system and in nurse education. In former times, when nurses were hospital-trained, many nurses proceeded from their initial qualification to a certificate course in midwifery. While recognising that there are some strong programmes of postgraduate midwifery education following initial comprehensive nurse education, the Australian College of Midwives Incorporated (ACMI) advocates separate, direct-entry undergraduate programmes for the preparation of Midwives, as a complementary mode of entry. On the basis of a cooperative effort between midwifery educators in a number of States, a three-year Bachelor of Midwifery has been developed for implementation in 2002 and 2003.

The researchers commissioned to investigate midwifery and midwifery education for this Review (Leap and Barclay, 2001) reported that there are:

(S)erious inconsistencies across States and Territories in [both] the education and regulation of Australian midwifery. There has been lack of national leadership and absence of high quality accountability leading to the current situation… and serious concerns about the standard of midwifery education in Australia, particularly when comparisons are made with midwifery education in other western countries (p. 6).

The researchers argue that hospital-based programmes of former years, though they had problems (including some inadequacies in theoretical preparation), at least prepared nurses with the competencies needed to practice in the workplace. In their view the shift to university training meant that general nursing training compromised midwifery education. This was exacerbated by the lack of a strong national professional body of Midwives, and strong regulatory and accountability arrangements, capable of assuring the preparedness to practice of new graduates entering midwifery practice. Indeed, limited midwifery education within the comprehensive nursing undergraduate degree is insufficient to prepare new graduates for practice in the field.

Under current arrangements, the preparation of Midwives for clinical practice must therefore occur through postgraduate programmes—usually at Graduate Diploma level. These courses attract fees under present arrangements for the funding of education beyond an initial degree, unlike the postgraduate Diploma of Education needed before science or arts graduates can enter secondary school teaching (which does not attract fees). These postgraduate qualifications in midwifery are required for general nursing graduates to practice as Midwives. The researchers commissioned by this Review therefore argue that initial postgraduate education for practice in midwifery should be funded through the Higher Education Contribution Scheme (HECS) arrangements, rather than entirely through student fees whether these are met by students or their employers.

The problem of paying for midwifery education is exacerbated under present arrangements for clinical placement. Where students are both studying and working part-time, their income could help to meet the costs of their education. This is not the case for many students. However, the finances provided by the part-time nursing work many graduates undertake is absorbed during their clinical placements where they are supernumerary and therefore unpaid. Many cannot afford to proceed under these circumstances. A prominent reason given for the high rates of attrition of midwifery postgraduate students is the issue of supernumerary work in clinical placements (rather than paid work—for example, at initial rates for Registered Nurses). In rural and remote situations many Student Midwives have to save up leave over a number of years to be able to undertake a block clinical placement in a hospital at some distance from their work place.

The researchers suggest that the perspectives and institutional arrangements for general nurse education have exercised too great an influence in the development and implementation of midwifery education. Professional associations, accreditation and registration arrangements and regulatory boards concerned with midwifery practice have been relatively weak (by comparison for those for nursing more generally) and fragmented (with different regimes and arrangements in different States and Territories). In the absence of strong guidance from such sources, the researchers argue, schools of nursing have been insufficiently responsive to the demands of midwifery practice.

According to this research, the results of the current arrangements for midwifery education include:

• lack of preparedness of new nursing graduates for midwifery practice, and inadequate preparedness of some graduates of some postgraduate midwifery programmes;
• financial disincentives to postgraduate midwifery education for students, and high attrition rates in midwifery education programmes;
• abdication of, or withdrawal from, responsibility for the education of Midwives by health service providers (including support for clinical placements for midwifery students, provision of skilled and committed clinical supervisors and preceptors, and support for the continuing education of Midwives in and outside the workplace);
• lack of agreed national standards for and consistent regulatory regimes governing midwifery practice; and
• in consequence, a national shortage of qualified Midwives prepared for work in the various settings of contemporary midwifery practice.

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Partnerships

A range of different models of partnership support different purposes. The Review found a variety of approaches and developments which offer greater potential to consolidate the relationship between education and practice. This consolidation is more likely to develop educational programmes that integrate theory and practice. Examples of some leadership and research partnerships are:

• Joint appointments to clinical chairs between universities and health services, for example Aged Care in Victoria
• Chairs situated in clinical settings and funded by that setting but appointed to a university, for example University of Technology Sydney.
• Fellowships

In the educational enterprise there are other arrangements such as:

• Health services contracts for the delivery of courses both postgraduate and undergraduate
• Clinicians on curriculum committees
• Part-time appointments of clinicians to university positions
• Short term secondments of clinicians to university positions
• Joint curriculum development and delivery of course
• New models of undergraduate clinical experience.

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Field/Clinical education and clinical placements

In the preparation of the new health professional the integration of theory and practice is a recurring theme (Pew Health Professions Commission, 1995 and 1998). This theme has been very evident in the discussions about clinical education and the concerns that the present system is not delivering the outcomes desired in this area. McKinnon and colleagues (2001) found evidence to support potentially valuable approaches to the learning of clinical skills, such as the value of learning in actual clinical practice.

One of the constantly surfacing issues is that of the adequacy of clinical education of Registered Nurses under the university model of nursing preparation. There is a strong perception that newly graduating nurses are not well prepared for employment due to the shift of nursing education training to the universities. It is of interest to note that the 1978 and 1994 reports on Australian nursing education identified inadequate clinical education as driving the need for change. Adequate clinical preparation is clearly a complex, multifaceted and difficult issue partly because it involves different perceptions of what is important and because its resolution involves very different players with different agendas. The roles of the health services, both government and non-government, regulatory and professional bodies and educational institutions in this aspect of preparation needs to be examined.

Placements for students are not always easy to obtain even when educators recognise the value of exposure to particular sites of practice. There are high levels of competition for placements between the range of health professional as well as Enrolled Nurses. The costs of delivering an adequately supervised programme are high. The experience of working in an unfriendly or low morale environment is counterproductive as it increases the likelihood that the students will leave the nursing course. Strategies have been developed in an attempt to address some of these concerns at the local level. The Australian Universities Teaching Committee (AUTC) nursing project, due to report at the end of the year, is examining some of these issues.

There are a number of limiting factors on the quality of clinical placements. These include:

• the length of the placement which needs to be of sufficient time for the student nurse to get to know the staff, the organisation and the ‘way things are done’;
• the culture of the organisation and the expertise of nursing staff both as practitioners and as teachers;
• the timing in relation to the links to theoretical work;
• the understanding of the nursing staff of the learning outcomes the students are seeking and what skills they have and wish to develop.

These requirements for quality suggest that more long-term in-depth placements are required. However, the shift of services to the community, and the conviction that exposure to areas like mental health and aged care, will encourage students to take up these areas of nursing, means there are arguments for a breadth of exposure.

In the survey of health and aged care services conducted on behalf of the Review, Duffield and team (2001) found that all sectors have considerable student load in some weeks with a mean range between 12 and 32 students but standard deviations are high which suggest considerable variation. A breakdown of results of the experience with undergraduate students is summarised in the report:

When these results are broken down to indicate the responses across the four categories of institution, 10–15 per cent of institutions always experience too many placement requests, inadequate supervision, and/or competing requests for the same period. 20–27 per cent indicated they ‘usually’ experience these difficulties. Both these results reflect a ‘load’ on the system, particularly too many requests and for the same period and a ‘load’ on staff if inadequate supervision is provided. However at the other end of the scale 23.7 per cent to 27 per cent responded ‘never’ to these questions. For all three aspects, ‘occasionally’ was the most frequent answer.

When the sectors are broken down, the Charitable organisation indicated ‘never’ more frequently than the others to all three questions: too many placement requests, inadequate supervision, and/or competing requests for the same period. In the public sector, where most of the students are placed, 14–16 per cent responded ‘always’ to all three questions. Both private sectors responded in a similar manner to the public sector. It is not surprising given the information above that institutions reported an increase in complaints from staff during student placements.

To increase the exposure of student nurses to the healthcare system, there is some support for the employment of both Student Enrolled Nurses and Student Registered Nurses in the healthcare system to be formalised. Individual arrangements already exist and some other more formal arrangements for both groups are being developed or are in place in some States. The challenge for the student nurse is that employers are often too inflexible to use their developing knowledge and skills. Very often the student nurse will not carry out any real nursing tasks despite doing these during clinical placements.

While such arrangements increase the exposure of nursing students to the healthcare system, give them opportunities to develop their communication skills, and to gain a better understanding of structures and ethos in these organisations, they are not strictly developed for the purpose of education. Difficulties about distinguishing between traineeships and professional education, and responsibility for insurance coverage arise unless the arrangements are clearly defined as being either employment or education. If they are employment, then the responsibility clearly is with the employer. Universities and TAFE may act to assist the healthcare institutions to establish the arrangements.

Students are already measuring clinical placements as ‘free’ service to the healthcare institutions, particularly the block final placement. The healthcare institutions in many cases are arguing that accepting students puts demands on resources that the institutions find difficult to meet. Without clear distinctions between employment and education in the health and aged care institutions the preparation of Registered Nurses could have moved by default towards an apprenticeship style preparation. The debate ensuing around more exposure to clinical experience appears to take little account of the broad general education of the professional nurse which was the reason to transfer the preparation to the university sector. The debate also fails at times to acknowledge that the principles of lifelong learning require the foundation to be established on which future learning can take place. The focus needs to be on preparing a new practitioner with the foundational knowledge and skills who is able to practice safely in an appropriately supervised initial period of employment.

While the focus is generally on clinical placements in institutional settings, there should be some discussion of the appropriateness of field placements for student nurses in the light of changing models of heathcare. Difficulties in supervision and support increase with the thin distribution of students, both factors that influence the quality of the education experience. There is already evidence of the difficulties such distribution causes in the complaints about lack of supervision of students on rural and remote placements.

The cost of the clinical component of nursing preparation is high. Although nursing was placed in a median category for the process of developing the relative funding model, it could well be argued that this level of support only accommodated the additional costs to deliver an applied science education on site in a university, since it is placed with computing and visual and performing arts. There is no direct funding to support clinical education despite the heavy cost of supervision of students on the 1:8 ratio expected in many States. The reduction in staff numbers in universities has meant that few academics are available and universities often have to employ agency staff for supervision. These costs are as high as $50 an hour according to one Dean of Nursing. In at least one State there are proposals to charge the universities for placements in healthcare institutions. During the Review the difference between support for clinical medical education compared to that available to nursing was raised with the Review many times.

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Transition to practice

Appropriate induction of new nurses is an important aspect of clinical preparation. Approaches to this vary in different hospitals. The continuity between preparation and induction is the key to an easy transition from student to practitioner. The role of the Graduate Nurse Programme is important in this regard. The States have different approaches to these programmes.

Duffield and colleagues (2001) report that from the sample of 432 institutions surveyed 38 per cent provide new graduate programmes. The highest proportion of programmes is in the public sector where 64 per cent offer programmes. The lowest proportion is in the charitable sector where only 12 per cent have programmes for new graduates. For the other two sectors approximately one quarter to one third offer graduate programmes.

The level of satisfaction with new graduates varies with the public sector significantly more satisfied than the private for-profit sector. A comparison of levels of satisfaction with new graduates undertaking specific activities within three months of commencing employment with 3–12 months shows consistent improvement on all activities. Most sectors means are greater than 3 where a response of 2 represents ‘occasionally’ and 3 represents ‘usually’. Time management has the lowest mean score for the initial period and continues to have the lowest means score in the 3 to 12 months period except for the Charitable institutions where IV medications has a slightly lower mean score in terms of satisfaction.

The NSW Project to review and examine expectations of beginning Registered Nurses in the workforce (1997) indicates that significant numbers of new graduates do not feel competent or are not sure of their competence in areas other than medical/surgical or in locations other than city or regional hospitals. They do have high expectations of themselves and assess themselves as having adequate professional and clinical competence. Nevertheless, they recognise that they will initially require guidance and assistance from Registered Nurses. Despite this the research found that within three to six months many graduates felt confident and comfortable to carry out their share of the work.

As discussed in Chapter 4 the experience of many new graduates is not a happy one. Largely this appears to be due to attitudes of colleagues and to the failure of the hospital system to adapt to graduates who are not apprentice trained. The assessment of theoretical background of university prepared nurses is generally high, but the most often claimed difficulty is that of time-management. This difficulty was also identified in the Duffield study (2001).

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Nurse educators in education and clinical settings

Two issues have arisen that are crucial to the adequate clinical preparation of nurses, whether Enrolled or Registered. These relate to the currency of the clinical skills of the educator in the education institution, and the depletion of the education infrastructure and expertise in the healthcare institution.

In the academic setting, staff find that the effort and time required to remain current and clinically competent competes with other priorities for academic advancement. To achieve the valuing of such competency in the education of a practice profession will require a shift in what is valued in academic institutions and in the policy arena where no funding derives from this type of activity.

The Review heard that the shift of the preparation of nurses into higher education had resulted in the demise of much of the infrastructure and support for nursing education in the hospitals. The roles as hospital-based educators attract little additional remuneration. There was a view that much of the educational expertise in hospitals has been lost. The effect of this change has been to alter the expectations of nurses about involvement in mentorship and preceptorship of other nurses. The current nursing shortage has further exacerbated this unwillingness.

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Costs and funding

The issue of costs to students

One of the arguments presented for the apparent drop in interest in undertaking nursing courses is that HECS acts as a disincentive. Growth in demand for nurses and the transfer of nursing into the universities does not appear to have impacted on salaries, but under the current arrangement the student pays some of the cost of nursing education and training. Figures for 2000 from the Graduate Destination Survey show an average starting salary for nurses of $31 390 compared to that of all Bachelor graduates of $32 320. Under the apprenticeship model, nursing students received some income throughout their training. With the present system earning is delayed and there has been relatively little change in relative nursing salaries, despite the higher qualifications of nurses. The transfer of training to the universities has had an impact on the earning stream of nurses both through the costs associated with HECS and the delay in earning.

Most nursing courses are HECS Band 1, that is the lowest level of contribution, although some components of the course may be Band 2. Added to HECS or fees for Enrolled Nurses are the costs of travel to clinical placements, uniforms and accommodation (often for both their usual residence and the one near the clinical site). Many also have childcare costs.

While there are some scholarships available, most target Indigenous and rural students.

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Specialists and postgraduates

Specialist education under the hospital model was generally at no cost to the nurses, but as postgraduate courses these courses attract the same fees and charges as other postgraduate courses. While postgraduate courses may be covered by HECS, a proportion of these now attract fees. There has been a decrease in the number of HECS liable places in postgraduate courses at universities and the virtual elimination of employer-funded places. Beginning in 2002, the Commonwealth Government has announced a loan scheme to assist students undertaking fee paying postgraduate courses (see Exhibit 7.1).

Ogle and team (2001) found that most postgraduate nursing research programmes were HECS funded, while coursework postgraduate nursing programmes were funded by both HECS and up-front fee-payment, with the fee-structure of individual courses appearing to vary on a year-to-year basis. Up-front fee-paying nursing courses offered at the Graduate Certificate were approximately $800 per credit point of study, while courses offered at the Graduate Diploma can vary between $800 and $1600 per credit point of study. Up-front fee-paying nursing Masters courses were difficult to determine because of the variation in programme structures.

The shortage of specialist nurses is likely to be exacerbated if the trend to increasing costs for nurses continues. Even with HECS places or the postgraduate loan for fee paying courses, nurses already carrying a HECS debt from their pre-registration nursing course may not be prepared to absorb another debt for additional specialist education unless it provides a significant increase in salary. Under most current employment arrangements there are no pay increases based on specialist training. Consequently, there are limited incentives to take on postgraduate courses, though this appears to be changing at least in some jurisdictions. For example, recent changes in the Victorian Award have meant financial incentives for higher qualifications in acute care but not mental health or aged care.

State Health budgets may contain funding for specialist nurse training places, but the amount of support varies across the system and between institutions. Further there appears to be duplication and little systematic planning associated with the support in many policy initiatives. Whether some specialisations are considered more legitimate or attract more prestige may influence the readiness of nurses to undertake specialities associated with primary and chronic healthcare.

The future strength of the system of preparation of nurses depends on the quality of nurse educators and researchers. As an evidence-based profession, dealing with a fast moving knowledge and technological environment, the quality of the nurse educator will be essential to future planning. Research that underpins innovations in practice and education will need to be current and strong if Australia is to have a nurse workforce that can remain effective in a changing environment.

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Funding implications of changes to current models of education and training

Australian registration bodies require new nurses to have completed an undergraduate course of a minimum of six semesters. While conforming to that requirement different models have developed in recent years, each with implication for the management of funding.

It is not the norm to charge fees, except in the case of Avondale College and the University of Notre Dame both of which are private institutions (Notre Dame had nursing students for the first time in 2000 and together the two private institutions had 75 students beginning Bachelor degrees in nursing). In 2000 only 0.05 per cent of the commencing student load was made up from fee-paying undergraduate domestic nursing students. Universities can charge fees to undergraduate nursing students within the HECS guidelines. They are also permitted to charge fees for summer semesters. Indeed one university is proposing to do so when it introduces summer semesters as an option within its nursing programme.

When examining the developing models of nursing education it is important to understand how they are funded and what funding issues arise out of the different models. This is a complex area as there are at least two levels of policy that impact on what funding a nursing faculty receives. The first relates to the funding arrangements for universities that were explained earlier. The second flows from the policy and distribution arrangements within the university in relation to the operating grant received. It appears that many universities reflect the relative teaching cost matrix discipline weighting developed for the relative funding model in the distribution of their funding. This matrix clusters nursing with courses such as computing, other languages and visual and performing arts. A considerably higher weighting is given to medicine and science.

Further, since nursing faculties are often large in comparison with others, the university may use this faculty to help in managing its target load. When over-target the university may transfer the effects of some of the marginally funded load to nursing. A number of nursing faculties suggested that this occurred in their universities. Any reduction in funding has a direct impact as the cost of clinical placements since these are on a per student basis and clinical placements do not receive any direct funding.

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Other challenges

Multicultural nursing education

The project conducted by Eisenbruch, Rotem, Waters, Snodgrass, Creegan (2001) for the Review examined the assumptions and concepts about the multicultural context of nurse education within Australia and mapped the ways in which nursing education addressed (or failed to address) multicultural health. The researchers summarised their findings this way:

Although representing only a snapshot of the current situation, a wide range of assumptions and concepts regarding the multicultural aspects of nurse education in Australia were apparent. The spectrum of responses ranged from a uni-dimensional view with emphasis on language and ethnicity to one that attempted to horizontally and vertically interweave culture and diversity into all units of nursing study. The stages of evolution apparent within the multicultural context of nursing education raise a number of critical issues for the profession:

• The extent to which individual or institutional exposure to diversity determines the representation of culture at the curriculum and practice level
• The need for consensus and/or direction from peak professional nursing organisations regarding what aspects of multicultural health are required for ‘cultural competency’
• The need for a consistent framework for the multicultural context of nurse education
• The role of reflection and lifelong learning in increasing awareness of the social, political and economic contexts of culture and health, and developing culturally competent care
• The development of partnership between learning environments and the workplace in which professional practice occurs
• The need for systematic investigation into the cultural needs of students, staff, patients or clients and minimal effort to engage with other disciplines or communities in this work.

Examples of leadership in nursing education are apparent, but the degree of uncertainty expressed around the multicultural context of nurse education, coupled with the high level of interest in the project, indicates a need for further work with the profession on this issue.

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Indigenous nurses

The Congress of Aboriginal and Torres Strait Islander Nurses submission to the Review notes a lack of both the recognition of the value of Indigenous nurses by the nursing professional and the lack of articulation pathways into nursing for Aboriginal Health Workers. The submission goes on to identify why universities have difficulty retaining Indigenous students:

Those universities who do recruit Indigenous students have great difficulty in retaining them. The reasons for this is:

• Inflexibility of programmes, those universities who do offer distance education do not provide adequate support systems.
• Lack of knowledge and understanding of cultural issues, particularly differences In cultural learning styles, Aboriginal terms of reference.
• Lack of knowledge and understanding of cultural issues and lack of appreciation and respect for cultural obligations.
• Inadequate educational preparation, particularly the science subjects of students entering the programmes and subsequent lack of support in those areas.
• Low self esteem of the students reinforced by failure.
• Racist attitudes and discriminatory practices exhibited by academic staff and other students.
• Lack of appropriate support system within the university/school of nursing.
• Lack of or inadequate social support systems, particularly for those students who have had to move away from their communities.

Attracting and retaining Indigenous nurses through the educational process is a challenge. While the members of the Review Panel were impressed with the strategies some institutions have in place, it is evident that this issue is complex for all concerned. One university had instituted a separate course for Indigenous students but it was not successful. Being part of the mainstream course was favoured rather than separation, in part to avoid the view that the Indigenous course was of a lesser standard. At the same time there are new proposals for courses for Indigenous nurses. Another suggestion put to the Review was the restriction of practice for those who are unable through cultural inhibition to work with particular groups such as men or women. The Northern Territory identifies the need to attract more males into the profession given the significant gender issues in providing health services to Aboriginal people (Territory Health Service, 2001).

The New Zealand Report of the Review of Undergraduate Nursing (KPMG, 2001) documents the issues raised by Maori and Pacific peoples for New Zealand nursing. Maori people regard the incorporation of cultural safety programmes as essential. They also consider that nursing education should have a detailed curriculum paper which covers the implications for nursing of Maori models of health, Maori providers, Maori development issues and the Treaty of Waitangi. The report also raises the issue of consistency in relation to cultural safety programmes.

Pacific people want nursing schools to actively recruit Pacific young people from schools, to offer parallel programmes for Pacific nurses, that the cultural safety curriculum be inclusive of Pacific people. They suggest that a fourth year of education for Pacific nurses, ‘paid in practice as in teaching’ would provide a level of emotional support that might reduce the loss in the early years of practice. In summary the report states:

Nursing educational establishments have to adapt, for if Pacific nurses are needed in the workforce at every level, the preparation must address the realities of finance, family obligations and cultural discomfort. There is no short cut, and Pacific nurses in training will need courses tailored more around them with the time and cost this involves, particularly in the transition to practice (p. 68)

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Representative population

For a number of reasons the development of a nursing workforce that is more representative of the population is an issue for nursing. There is under-representation of males²⁶ , Indigenous and other cultural groups in nursing. In addition nurses work within a multicultural population which means they need to show cultural sensitivity and understanding.

The ageing of the present population of nurses combined with the high proportion of nurses over 40 years of age and the relatively small proportion of employed nurses under 30 suggests that nursing can be characterised as a middle-aged profession²⁷ . The age mix entering nursing as a career for the first time is quite diverse, but it is still dominated by women²⁸ .

One way to respond more sensitively to the cultural diversity of the Australian population is to attract and retain a workforce whose cultural diversity reflect some of the diversity of the local population. How to address this offers some challenges to the way nursing is considered.

²⁷In 1997 only 53 % of employed Registered Nurses and 60% of Enrolled nurses were less than 35 years of age (AIHW, 2001b, pp. 77/79). 

²⁸The age profile of commencing non-overseas nursing students in pre-registration courses shows about half the group was made up of the 20 and under age group across the period 1995-99. The next largest group, the 21-30 years makes up about a quarter of the total. In 1999, about 15% were in the 31-40 age group (DETYA statistics).

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Research

The future strength of the system of preparation of nurses depends on the quality of nurse educators and researchers. As an evidence-based profession, dealing with a fast moving knowledge and technological environment, the quality of the nurse educator will be essential to future planning. Research that underpins innovations in practice and education will need to be current and strong if Australia is to have a nurse workforce that can remain effective in a changing environment. The dearth of Australian research on nursing in relation to evolving models of healthcare, and the lack of evaluation of models of education and training is evidence for this need.

A recent policy development is in the area of research. The new Commonwealth research policy, Knowledge and Innovation, a policy statement on research and research training is being implemented. The impact of the development of a more strategic focus in relation to research and greater diversity of approach in the higher education system on nursing education is unknown. It may be that there is already sufficient strength in the research training across the 31 higher education institutions involved in nursing eduction to continue the development of the nursing discipline. However, due to the recency of the transfer of nursing education into the universities, the strength and differentiation of research interests may not yet to be consolidated in many institutions.

The Research Training Scheme is being developed as a result of this new policy. The impact on nursing of this scheme as it is implemented is an issue for nursing which despite its large numbers of undergraduates has few students in Higher Degree by research. The number of commencements in Higher Degrees by research rose from 73 in 1994 to 120 in 1999 and dropped to 108 in 2000. Developments in the area of professional doctorates also have implications for nursing education.

The present research funding environment is very competitive, and much nursing research does not easily fit the type usually supported by the medical model. Consequently, nursing researchers find difficulty in gaining support in large competitive grants applications. The lack of experience and strength as a developing research discipline place it at a further disadvantage. Some evidence for this is that of the 758 continuing project grants funded in the National Health and Medical Research Council funding round in 2000, (total funding $69 571 674) only 5 (for a total of $283 970) were designated as being for nursing research.

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Information technology and nursing education

While Johnson and Preston (2001, p. 6) note the lack of Australian reports on online education for nurses, they also note that online learning is resulting in much activity in nursing course development.

McKinnley and team (2001) in their literature comment on the range of research about computer/technology assisted learning. They found evidence that the use of such technologies is associated with learning outcomes that are similar to or better than traditional methods, but there are some reports of poorer learning outcomes. The use of computer assisted learning in combination with traditional teaching and learning methods appears to be better than computer assisted learning alone.

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Interdisciplinary collaboration in education

Although this area has received little attention in the Review, it is an issue of interest in international literature, and was raised in some meetings with members of the Panel. There is some support for ways this could occur at both the undergraduate and postgraduate level. At Trinity College, Dublin research postgraduate course were being taught to doctors and nurses together, and the work of the Quality Assurance Agency for Higher Education UK on benchmarking statements mentioned at the end of Chapter 5 suggests that there is potential for this type of education.

Exhibits

• Exhibit 7.1 The funding of Australian higher education and vocational education and training
• Exhibit 7.2 Nursing in the National Vocational Education and Training System
• Exhibit 7.3 Enrolled Nurse programmes
• Exhibit 7.4 Local education/ healthcare partnership

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