Introduction

On 30 April 2001, the former Commonwealth Ministers for Education, Training and Youth Affairs and for Health and Aged Care jointly announced the National Review of Nursing Education. State and Territory health ministers were consulted on the terms of reference before the announcement of the Review.

The result of these consultations is that the terms of reference encompass not only initial registered nurse preparation, an area funded by the Commonwealth, but also enrolled nurse education, which is largely funded by the States and Territories. The Review also encompasses education for specialisation, continuing education and the relationship of nursing with other groups in the health workforce. The term ‘health workforce’ is taken to include sectors such as aged and community care where nurses play an essential role.

The group impacting most directly on the work of nurses (particularly in the community and aged care sectors) is the unregulated carer group. The report pays particular attention to this group because of the impact it has on both the work of nurses and the safety of clients and patients.

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This Review was established by the Commonwealth Government to examine the future nursing educational needs of the health, community and aged care system and to advise on appropriate education policy and funding frameworks. Its role is not to define ‘nursing’, nor to enter into debates about the discipline or profession of nursing. It is for nurses themselves to resolve their concepts of professionalism and to develop their discipline.

The Review addresses nursing education in relation to patient and client health outcomes.

However, to produce useful advice to government, the Review must understand:

• the culture of nursing and the ways that culture is supporting or obstructing the work of nurses and carers

• the role of nurses in the health, community and aged care systems and the ways this role is changing

• the relationship of nurses with the other providers of health care

• the policy and funding frameworks that affect the education systems and health, community and aged care systems within which nurses are educated and work.

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The terms of reference for the National Review of Nursing Education include a contextual statement that links the current arrangements and the changes in labour markets as a key to the issues underpinning the Review. The terms of reference are as follows.

To examine:

To make recommendations on:

• models of nurse education and training to meet the emerging labour force, including practical training, processes for articulation between different levels of competency and professional expertise and re-entry into the workforce

• the types of skills and knowledge required to meet the changing needs of the labour force involved in nursing

• mechanisms for both attracting new recruits to nursing including those from different age groups (both male and female) and encouraging the commitment to lifelong learning of those already engaged in nursing.

To consider the following wider issues from the perspective of both the health industry and education:

• the changing context of nursing and health requirements and the levers influencing these changes

• the links between nursing, medicine and other groups in the health workforce (including those with no health qualifications) in the provision of health services.

To have regard to:

• regional needs and circumstances

• financing arrangements

• the work of current research projects and reviews such as the New Zealand review of nursing education, the Australian Health Workforce Advisory Committee nursing workforce review, and the British review of funding for nursing.

The terms of reference, with the supporting statements, are at Appendix A.

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Mrs Patricia Heath AM BEM RCNA (HON) (Chairman)
Ms Jenny Duncan
Ms Ella Lowe
Ms Susan Macri
Mr John Ramsay
Professor Christopher Selby Smith
Professor Robin Watts

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Listed below are the organisations invited by the Ministers to join the Reference Group for the Review. The list also shows the representative of the organisation who attended the meeting with us in April 2002 to provide advice on the developing recommendations.

• Australian Council of Deans of Nursing
  Professor Judith Clare

• Association of Australian Rural Nurses
  Ms Jenny Critchley

• Council of Remote Area Nurses of Australia Inc
  Ms Melanie Van Haaren

• Congress of Aboriginal and Torres Strait Islander Nurses
  Ms Sally Goold

• Royal College of Nursing Australia
  Ms Rosemary Bryant

• Australian Health Ministers’ Advisory Council
  Ms Judith Meppem, Ms Karen Lesley Roach

• Australian Private Hospitals Association
  Ms Cathy Miller

• TAFE Directors Australia
  Ms Marie Persson

• Youth Round Table

• Australian Vice Chancellors Committee
  Professor Lesley Barclay

• Group of Eight
  Professor Sue Armitage

• Australian Nursing Council Incorporated
  Ms Marilyn Gendek

• Australian Local Government Association
  Councillor Felicity Lewis

• Catholic Health Australia
  Ms Brigid Tracey

• Aged and Community Services Australia
  Mrs Pat Sparrow

• Department of Veterans’ Affairs
  Ms Narelle Hohnke

• National Rural Health Alliance
  Ms Sue Wade

• Australian Nursing Federation
  Ms Victoria Gilmore

• Australian Nursing Homes and Extended Care Association
  Dr Penny Flett

• Australian & New Zealand College of Mental Health Nurses Inc
  Professor Michael Clinton

• Australian Healthcare Association
  Mr Mark Cormack

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Following the announcement of the Review, the Chairman, Mrs Heath, attended the International Nursing Council Conference in Copenhagen and visited England and Ireland to establish what was happening internationally in nursing and nursing education.

In August and September 2001, we held meetings in each State and Territory with a wide range of bodies (see Appendix B for details). The organisations and sites visited included:

• State and Territory education departments

• State and Territory health departments

• State and Territory nursing boards

• State and Territory nursing unions

• TAFE institutes and universities

• open public consultations

• hospitals

• the Australian Council of Deans of Nursing

• the Australian Nursing Council Incorporated

• the Australian Nursing Federation

• the Royal College of Nursing, Australia

• the NSW College of Nursing.

Submissions

To give as wide an opportunity as possible for interested parties to influence the outcomes of the Review, we sought advice through submissions, of which 159 were received. The table ‘Distribution of submissions by State/Territory and organisation’ shows the distribution of submissions received by State or Territory and type of organisation. The list of organisations and individuals who sent submissions is at Appendix C.

In addition, we commissioned a wide range of research and six literature reviews. In October 2001, we held a research forum to explore the implications of the findings of the research with the researchers and a number of other experts. Reference to these studies in this report is to the website address giving the date first published. Consequently, page numbers for quotations are not included. The research reports have also been published collectively in hard copy to accompany this report (see Appendices D and E for details).

Discussion Paper

The release of the National Review of Nursing Education Discussion Paper in late December 2001 provided stakeholders with another opportunity to advise on issues of particular interest. The Discussion Paper was published, along with the research, on the Review website at www.dest.gov.au/highered/programmes/nursing and was also distributed widely. The Discussion Paper drew together all the views and sources of information and sought responses to a list of questions. We received over 150 responses to the Discussion Paper and found the expert advice, opinions and suggestions were invaluable in our deliberations. The table ‘Distribution of responses Discussion Paper by State/Territory and type of group’ shows the types of groups who responded and the State and Territory distribution. A synthesis of the themes from the submissions and responses to the Discussion Paper is at Attachment A.

In March 2002, we undertook another round of meetings with key stakeholder organisations before developing the recommendations of the Review. We then met the members of the Reference Group in April and representatives from the Commonwealth Departments of Education, Science and Training and Health and Ageing to test the broad directions of system level recommendations.

The Senate Community Affairs Reference Committee Inquiry into Nursing occurred over the same period as the Review, reporting in June 2002. We have taken the information and findings of the Senate Committee Inquiry into account in writing this report. The terms of reference for the Inquiry into Nursing, along with our comments on the recommendations, are at Attachment B. The findings of the Inquiry are available on the Senate Committee’s website at http://www.aph.gov.au/senate/committee/clac_ctte/nursing/index.htm.

In April 2002 the Minister for Education, Science and Training announced a review of higher education with the release of an overview paper, Higher education at the crossroads. In the preface to the paper, the Minister proposes that there should be consideration and debate of ‘the policy options that lie before us in relation to reform to the way we administer, fund and support Australian universities’ (Nelson 2002, p. v). The outcomes of this review may have implications for nursing education and training in the higher education sector.

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The report contains the summary and recommendations from the Review followed by the supporting argument for the recommendations. Both are underpinned by the extensive information found in the National Review of Nursing Education Discussion Paper, which is available in hard copy and on the Review website at http://www.dest.gov.au/highered/programmes/nursing, along with the research commissioned for the Review. A list of the commissioned research is at Appendix E.

In developing the recommendations, we sought to improve structures and process at a level that will stimulate innovation and improvement throughout the system. While some issues and groups may appear less obvious in this approach, we have not overlooked them. We have treated the needs of particular groups such as Indigenous Australians, rural and remote populations and recent immigrants within an integrated framework, but we have also specifically identified these groups in our deliberations. This is also true of particular service areas such as mental health and aged care.

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Rationale for the Report

The following seven themes provide the understandings and positions that form the basis of the report and its recommendations.

The health care of Australians is a national issue in which all levels of government have roles and responsibilities, as do different government portfolios and the non-government sectors. As a nation, we need to overcome current barriers and disconnections between the Commonwealth and the States and Territories, between the larger and the smaller States and Territories, between metropolitan and non-metropolitan areas (regional, rural or isolated) and between particular portfolios. Nurses are key players in the health, community and aged care sectors, and we believe that governments must adequately invest in both their education and work.

An effective and efficient healthcare service is essential because this is an area of enormous public investment in a climate of increasing demand on costly services. The cost of health care is rising, the population is ageing, consumer expectations of and demands on the health system are increasing, and the potential to intervene through new technologies is expanding. These changes mean that an important issue in the emerging healthcare system will be equitable access to treatment and care. In turn, the costs of litigation create serious questions for an efficient and effective healthcare service as consumers develop different attitudes to the relationship between themselves and service providers. Under these circumstances, the contribution of nursing to the efficiency and effectiveness of the system is important.

Nurses make up the largest professional group in the healthcare system, and have a unique, continuously developing role. Work organisation and management processes need to recognise their high level of education. The regulatory and legislative framework for nursing should recognise nurses’ education and professional codes. In addition, since nurses work alongside a number of other health professionals and care workers who provide varying levels of care or specific services contributing to the wellbeing of their clients, the professional role of nurses in the team should be acknowledged. Nurses as professionals need appropriate delegations to work safely with workers who form part of the nursing workforce.

Nursing expertise in Australia is high. In developing the recommendations, we have recognised the current systems and successes and have used them as the underpinning of the proposed systems of planning and development for the future. We believe that such planning and monitoring should occur at all levels of education and service provision.

These systems need to include the strengthening of workforce planning and monitoring, as well as promoting efficient and effective delivery of nursing care. To this end, we support processes that are flexible and that promote continual evaluation and improvement.

The education of nurses must be closely linked to practice, both in planning and delivery.

Maintaining links between practice and education is costly. However, educators and practitioners need to constantly update their competencies as technologies and scientific and social understandings continue to develop rapidly. Educators and clinicians need to be able to remain current in their practice—the former so that they can help their students gain an understanding of the latest treatments and new technologies, and the latter to ensure safe and competent service delivery. Students must learn to integrate both the practice and the theoretical knowledge. This can occur only when they have the opportunity to ‘learn’ in a practice environment as well as an academic environment.

The nursing profession is not representative of the Australian population. Nursing needs to move from a largely mono-cultural group of predominantly women to one that reflects current Australian society. In revising the profession, nursing will need to encourage recruitment through a wide range of pathways, support new professionals of whatever age and welcome those who move between different career options.

We believe that a partnership approach is the only way to overcome current difficulties and to set a productive direction for the future. At the national level there will be a need for partnerships between governments and portfolios to address nursing issues.

There will also need to be a range of other partnerships that manage areas of joint responsibility, particularly those related to the formation of the new professional.

On the basis of these propositions, we present a report and recommendations that seek to promote collaborative approaches to the resolution of problems, to use current expertise and systems where they are available, and to facilitate future developments.

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Nursing education in Australia

There are many ways to tell the story of nursing education. One way would be to give a recent history and overview, as if nursing education sat in a bounded space.

Another way is to examine what has happened to nursing work across Australia because of changes in the way health, community and aged care services are delivered and the way education and training are currently structured, and to situate nursing education within that story. This approach is the most productive because of the number of stakeholders and contributors to the preparation of nurses and the number of people who support the work of nurses.

While the story today is one of challenge, it is also one of achievement and innovation.

The Australian community regards nurses highly due to the eminent service they provide. The nursing profession has developed a cohesive Australian standards framework in the Australian Nursing Council Incorporated (ANCI) competencies for registered and enrolled nurses. This framework defines what the profession expects of its members and is an enormous achievement when the many complex arrangements that mark a federated system of government are considered. These achievements are testament to the leadership provided by individual nurses and nursing groups such as the ANCI, the Australian Nursing Federation, the Royal College of Nursing, Australia, the NSW College of Nursing, the Australian Council of Deans of Nursing, and the many other professional nursing bodies.

Much has happened at all levels of education across the last decade. Three changes that have had significant consequences for nursing, since they affect the structure of the education and training system and the type of education nurses receive, are:

• the development and modification of a national training framework for vocational education and training (VET) which incorporates the later years of schooling

• the finalisation of Dawkin’s restructure of higher education from a two-tiered system, consisting of colleges of advanced education and universities, to a unified single tier system of universities

• the completion of the transfer of registered nursing preparation into the higher education system (specialist nursing education has since drifted into the higher education sector as universities started to offer a variety of postgraduate nursing programs).

The changes in the VET sector and the transfer of registered nurse preparation into the higher education sector are discussed later in this report. The Dawkin’s restructure had implications for nursing as many nursing courses were already established in colleges of advanced education (CAEs) before the agreement to shift registered nurse preparation to the higher education sector in 1984. Under the restructure, CAEs became part of a rationalised system, which consisted of 35 universities by 1991. As this report goes to print, another review of higher education is occurring and it too is examining the structure of higher education.

Some of the most exciting trends that have evolved from the changes in the VET sector and the preparation of registered nurses are in the area of partnerships. Three-way partnerships between a health service, TAFE and university are examples of best practice.

Schools have also been involved in arrangements that provide training and exposure to nursing work in aged and healthcare facilities. The growing number of joint chairs and other appointments between universities and the health sector are other examples.

Moreover, developments in models of clinical education demonstrate strong relationships between universities and health organisations.

The expertise in nursing education and research capacity at universities is expanding as is evident in the international consultancies, the Australian research contracts and the increasing number of international students. In addition, the number of clinical chairs suggests that the strength of clinical research is also growing.

While the strength of the nursing profession in Australia is demonstrated by these considerable achievements, a group of workers who contribute to nursing work, particularly in the aged and community care sectors, has received little attention. These are the workers known as assistants in nursing, personal care assistants or by other titles. They also face challenges arising from the environments in which they work and from the increasing demand for caring work as the population ages and, with it, the number of people who need assistance with daily living increases.

The following chapters document in more detail the story of Australian nursing education, its current challenges and our recommendations.