7. Education and training

This chapter addresses the issues that impact on the quality of education and training for nurses and trained care assistants in terms of their competencies (skills, knowledge and attitudes) and the flexibility of models to respond to evolving needs in the sectors in which nurses work. Issues of supply are dealt with in Chapter 8, though there is a relationship between the recommendations in this chapter and the quality of care. There is no detailed material on the trained care assistant since the national training packages are relatively new. The focus is therefore on the supply of an appropriately skilled workforce of trained care assistants. The recommendations about trained care assistants are in Chapters 5 and 8.

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There is much to celebrate in the innovation, flexibility and quality of the educational preparation of Australian nurses. The considerable progress in the development of a system of education and training allows people to progress through different levels from carer to the highest levels of nursing expertise. The education and training systems offer different modes of course delivery, including part-time enrolment and distance learning.

Traineeships are available for the preparation of enrolled nurses and for trained care assistants. Even in the vexed area of national consistency of standards and preparation, key national agreements are in place. Australia is already meeting many of the fundamental principles of initial nursing education programs for nursing promulgated by the World Health Organization (WHO) (see Attachment 2.1). Compared to many other countries, Australia’s nursing students are offered a greater degree of choice and flexibility, in both programs and locations.

There have also been collaborative developments between healthcare organisations and universities in areas such as cooperative research, in the development and sharing of expertise and in education. Some of these initiatives include joint appointments of professors and tutors, advice on the curriculum, and clinical education agreements for both undergraduate and postgraduate courses. To add to these innovations there is a culture in nursing that values education and training. Collaborative arrangements exist between Australian and overseas universities. This is in part due to the expertise of Australian nursing academics and researchers.

While still in its early days in the university system, Australian nursing education is ahead of many countries moving in that direction. There are also partnerships between universities and TAFE institutions, and agreements to formal credit arrangements for linked qualifications.

Despite these successes there are tensions and pressures that put the future quality of graduates at risk and areas that need further development. Stress is not uncommon in systems that face the level of rapid change that health care and education experience. While the existing weaknesses and barriers to development are the focus of the remainder of this chapter, the achievements presented above should not be forgotten.

The growing interest in quality and assurance of quality are evident in the theme of national consistency for the preparation of registered and enrolled nurses. In the profession there is acceptance and endorsement of the Australian Nursing Council Incorporated (ANCI) competencies, although there is little support for a national curriculum. However, there is some frustration with the latitude available in the interpretation of the ANCI competencies. The course accreditation processes of individual States and Territories add to the potential for breadth of interpretation of the standards. The following comment from the School of Nursing, Monash University, summarises the position of many groups.

(School of Nursing, Monash University, response to Discussion Paper).

During the visits to universities, we talked to students who at times held very different views about the educational program from those of the academics. Hospital staff also made comments about the quality of the preparation of the students from different universities.

While research such as that by Duffield and team (2001) and Clare and colleagues (2002) shows there is no concern with the general standard of preparation of registered nurses, we believe that universities need to evaluate all aspects of their program regularly. Evaluations should include feedback from the hospitals where students gain clinical placements and employment on graduation, and from students and past students. Where universities have small remote campuses or large components of distance learning in their nursing programs, there are risks to student outcomes if these programs and their delivery are not adequately monitored for quality.

We recognise that there are systems of quality control in both universities and State and Territory nursing boards to monitor nursing curricula and that there are supporting materials for the assessment of the ANCI competencies. However, there is no system to support monitoring for a national standard. We endorse the need for a more nationally consistent approach to the accreditation of courses. This can be achieved in the absence of national accreditation of courses by the development and acceptance of national guidelines that define minimum national standards for course accreditation and assist in more coherent curriculum development. These standards should apply to both enrolled nurse and registered nurse programs. The ANCI, in association with the proposed National Nursing Council of Australia (NNCA), is in an excellent position to develop guidelines to define minimum standards for the accreditation of courses for the preparation of registered and enrolled nurses, and for the support of the transition of new graduates. While nursing does not yet appear ready for a national system of course accreditation or registration, debate on this issue is likely to continue and may be encouraged by the Australian Council for Safety and Quality in Health Care.

The system of quality assurance for the vocational education and training (VET) system has recently changed. This system is particularly important for VET because of the wide range of training providers. In some States there is a strong market of private training providers but in others most training is done by TAFE. The new national framework, the Australian Quality Training Framework (AQTF), provides standards for the accreditation of courses and registering training organisations in each State and Territory.

The AQTF is a set of nationally agreed standards to ensure the quality of VET services throughout Australia. It replaces the Australian Recognition Framework (ARF). The AQTF ensures that all registered training organisations and the qualifications they issue are recognised throughout Australia.

States and Territories are responsible for the quality of VET. They apply the Australian Quality Training Framework (AQTF) framework when:

• registering organisations to deliver training, assess competency and issue qualifications which fall under the Australian Qualifications Framework (AQF)

• auditing registered training organisations (RTOs) to ensure they meet and continue to meet the requirements established by the framework

• applying mutual recognition

• accrediting courses.

The AQTF includes two sets of standards: Standards for Registered Training Organisations and Standards for State and Territory Registering/Course Accrediting Bodies. The new framework makes auditing of training and assessment activities clearer, more transparent and more consistent. Implementation of the AQTF began in June 2001 and will be completed by 1 July 2002.

During our visits and the consultations, we had the opportunity to talk to enrolled nurses undergoing training and those involved in training them. We were concerned with the reports we received about some enrolled nurse training, in particular some traineeship options. It is evident that there are some excellent training organisations involved in enrolled nurse preparation in both the public and private sector, but there are clearly those that need greater monitoring. The same would no doubt apply to the training of care assistants. Poor training programs present a risk to safety for the public, but also undermine the continuing credit arrangements in universities that allow career progression.

Universities must ensure the quality of their graduates. If the provision of credit to enrolled nurses who are then found to be inadequately trained puts the quality of university graduates at risk, the system of articulation is likely to be undermined.

For these reasons, the involvement of the State and Territory nursing registration boards in course accreditation for enrolled nurses must be maintained. The links between the different levels of nurse preparation need to be further developed. Better linkages will depend on greater national consistency in the interpretation of the ANCI competencies by the registration nursing boards. The newly agreed revisions of the ANCI competencies for enrolled nurses should assist with the development of the links to registered nurse preparation. The requirement for the nurse registration boards to retain their involvement in course accreditation is another protection in the system. Issues of national consistency in nurse preparation were canvassed even more strongly for enrolled nurses than registered nurses. This matter has already been raised in Chapter 5 and will be discussed in more detail again later in this chapter.

Recommendation 19—Models of preparation

To assure quality programs, undergraduate and enrolled nurse courses should continue to be accredited by State and Territory registration boards in accordance with national principles developed by the ANCI and endorsed by the NNCA.

These principles should ensure that:

a) graduates from these courses meet the ANCI competency standards

b) quality assurance processes for course accreditation and the assessment of students are met

c) there is ongoing evaluation of the curricula and teaching practice in the light of changes in nursing practice, research on learning, and the broader developments in professional and para-professional preparation.

Proposed responsibility: ANCI in consultation with the NNCA

There will be ongoing developments in the areas of curriculum and assessment in nursing education. Some of these will be due to new demands in health, aged and community care; others to developing priorities or new approaches including multi-professional service delivery and integrated models to manage care.

Areas in need of development

As discussed in the material on evolving models of care, new strategic frameworks that rely on multi-professional approaches have implications for nursing curricula. These new directions are often targeted at the university preparation of nurses, but the implications for enrolled nurses should not be overlooked. Enrolled nurses work in the same work settings as registered nurses and with the same client/patient groups.

The Australian Council for Safety and Quality in Health Care (ACSQHC) was established in early 2000 by Australian Health Ministers to lead national efforts to improve the safety and quality of health care provision in Australia. It reports annually to all health ministers and is supported by State and Territory governments. It considers education a key lever to promote improvements in the safety and quality of patient care. For this reason it is supporting a number of education and training initiatives designed to achieve the following:

• raise awareness of patient safety and systems improvement

• develop knowledge and skills in specific priority areas such as risk management;

• encourage the adoption and spread of safety and quality tools and approaches.

One such project is preparing a framework of knowledge, skills and attitudes about safety and quality in health care to be included in undergraduate medical and nursing education.

Future work may focus on developing innovative, multi-disciplinary educational approaches to integrate the framework and promote uptake in medicine and nursing curricula (ACSQHC 2002).

Areas of challenge

Clare and colleagues (2002, p. 3) document a few areas they identify as matters of concern in their evaluation of nursing curricula in universities across Australia. These are listed below for consideration:

Ensuring that Indigenous health issues are part of the core elements of the curriculum is an objective of a working party established by the Office of Aboriginal and Torres Strait Islander Health (OATSIH) and the Congress of Aboriginal and Torres Strait Islander Nurses (CATSIN) with the Australian Council of Deans of Nursing, discussed earlier in Chapter 6. This issue is being addressed through the work of that working party.

As universities and TAFEs are located across Australia in both metropolitan and rural areas, there may well be an argument that one of the features that should distinguish nursing programs is the different theoretical context used by different education providers. Building comprehensive curriculum that examines issues through the particular challenges of the local area would mean that rural and metropolitan providers would use different theoretical contexts in preparing nurses. Indeed, during the consultations nurse academics argued that responding to local circumstances is important in the design of curriculum.

Rural universities and rural campuses are in an excellent position to develop programs that place a priority on the understanding of rural health issues and use the rural nursing context. Metropolitan universities may offer students rural placement. These may be part of electives in rural health and incorporate rural clinical placements (for example, Flinders University and Victoria University) but this is not always the case. Mahnken (2002) criticises the encouragement of clinical placements in rural areas for students from metropolitan universities when these placements are not contextualised within the educational program to demonstrate a rural health perspective.

Another challenge for the preparation of nurses under the comprehensive model has beento provide enough practical experience and sufficient time in the program to treat mental health and illness adequately (Clinton et al. 2001). There are various reasons why proponents of a separate undergraduate curriculum have opposed the comprehensive model as preparation for mental health nursing (Clinton et al. 2001). Despite considerable challenges, we support the existing model because all nurses in whatever context of care will need to be grounded in mental health understandings and the management of patients who have mental health problems. For those nurses who wish to specialise in mental health nursing, the undergraduate preparation must provide an adequate foundation to enable specialisation, which could be achieved by one of two models. The first is by adding an additional major study onto an extended undergraduate course; the alternative is through postgraduate education. The development of National Practice Standards for the Mental Health Workforce will inform future developments in this area (see Chapter 4).

Aged care is in a similar position to that of mental health in that all settings in which nurses work will deal with growing numbers of elderly people. Pearson and colleagues (2001) identify the limited focus given to aged care in pre-service education programs.

Most of the energy in these programs is directed to primary health care and the delivery of acute care services. A broader focus on aged care in undergraduate nursing programs is needed to respond to the external pressures of an ageing population. Enrolled nurse programs have had high coverage of aged care in the past and this will need to be maintained along with the broadening of that curriculum.

These various challenges reflect the continuous demand for nursing curricula to cover more material and/or greater depth of theory in particular fields. Other pressures arise from public health issues that bring with them expectations that the nurse will lead in educating the community about public health risk and also take a key role in promoting positive community attitudes. Examples of these areas are AIDS and hepatitis C. Nursing competencies will need to be regularly reviewed to ensure they reflect the changes in care and social attitudes. Curriculum will need careful management and decisions about the length of programs will form part of that management.

Assessment of students

One of the more challenging issues for a practice discipline is that of student assessment.

Graduates reported a low level of satisfaction with ‘assessment’ in nursing courses in university. The average ‘broad satisfaction’ score for ‘appropriate assessment’ in the Course Experience Questionnaire was between 33 and 39 in the years 1996–2000. This rating is low when compared with that of the general university student population who had a broad satisfaction rating between 84–85 across those years. While this single element of student experience is rated poorly, this is not true for other areas of experience as the overall broad satisfaction scores were between 83–91 for nursing graduates across the same period (DEST 2002b).

Although it should be remembered that while the level of satisfaction with the assessment process among nursing graduates is low, the assessment of competence to practise in nursing is a complex area (Redfern et al. 2002). The close links between competency assessment and students’ experience of practice mean that changes in hospitals and other service sites and the consequent evolving nature of scope of practice ultimately impact on student assessment. Consequently, assessment will be an area of the learning process that requires constant renewal and evaluation. New professional approaches to decision making will also lead to the need for student nurses to develop skills in self-assessment.

Improving student assessment processes will be an integral part of the development of the discipline of nursing.

A further issue for the comprehensive preparation of nurses both enrolled and registered is how to develop attitudes and understandings that enable nurses to practise safely within a culturally diverse community. To complicate this further, until recently Australians have given little attention to understanding our Indigenous population. While these issues are a challenge for the whole Australian population, nurses at the front-line of the health, aged  and community care sectors are in particular need of appropriate cultural understanding and cultural safety.

The project conducted by Eisenbruch, Rotem, Waters, Snodgrass, and Creegan (2001) for the Review examined the assumptions and concepts that formed the foundation of 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 in the following way for the research forum.

Although only a snapshot of the current situation in universities, there was a wide range of assumptions and concepts about the multicultural aspects of nurse education in Australia.

The spectrum of responses ranged from a one-dimensional view that emphasised language and ethnicity to one that attempted to 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:

• The extent to which individual or institutional exposure to diversity determines the presentation of culture within the curriculum and practice.

• The need for consensus and/or direction from peak professional nursing organisations about what aspects of multicultural health are needed for ‘cultural competency’.

• The need for a consistent framework for the multicultural context of nurse education.

• The importance 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 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.

The researchers found examples of leadership in nursing education in this area were apparent, but the degree of uncertainty expressed about the multicultural context of nurse education, coupled with the high level of interest in the project, suggest a need for further work on this issue. The leadership of the ANCI in this regard will be invaluable in progressing this area for both enrolled and registered nurses.

New Zealand has taken a lead on ‘cultural safety’, an issue debated at some length in theirrecent review (KPMG 2001). Cultural safety relates to the promotion and protection of a person’s identity, rather than merely gaining an appreciation of the ritual, customs and practices of other groups. If nurses are to be effective in their practice they will need to understand the impact of social conditioning on the efficacy of healthcare provision. This understanding will be critical to promoting self-determination, which is a key aspect of cultural safety and one that will help create a health system that is responsive to the needs of a culturally diverse population. Particular attention needs to be applied in developing understandings about Australia’s Indigenous people.

We have identified that the NNCA should promote and facilitate consistency in education and training. This role will require ongoing monitoring of competencies for their relevance.

In this regard, we would particularly seek consideration of the issues of cultural safety within the competency standards of the ANCI, though we note its expression may be different from New Zealand since not only our Indigenous people but also Australia’s diverse cultural mix challenge the community to demonstrate better understanding.

As the ways new professionals are educated and trained begins to reflect the evolving understandings of how people learn, education and training providers will need to develop systems that provide incentives and acknowledgment of the importance of clinical currency in the academics and nurse teachers responsible for the education of new professionals. The quality of the education received depends not only on the educational skills of teachers and their theoretical understandings, but also the relevancy of the application of these understandings in the practice environment. Since health care is a rapidly changing environment, which uses technologies the education system can never emulate, being current in clinical practice will require regular time working in the service environment.

Medicine has been able to achieve this more readily than nursing because the combination of research, teaching and practice is supported by the way doctors are linked to particular service facilities. For nursing—a more recent entrant to the university environment and a discipline area that produces larger numbers of graduates than medicine with considerably less funding—this will be a challenge.

A number of responses to the Review Discussion Paper urged universities to examine how they respond to this as an issue of quality in their education programs. Suggestions about how universities might assist with the development of a culture and expectation of practice include the following:

(Ron Kerr, response to the Discussion Paper)

Recommendation 20—Nurse academics and teachers

To ensure that students are exposed to current clinical practices, faculty practice should be:

a) built into the workload of those nurses who teach nursing students in universities and the VET sector

b) incorporated into annual performance appraisals.

Proposed responsibility: Education providers

The issues of credentialing and course accreditation are often linked in discussions of quality and safety. Credentialing is a recognised form of regulation, often self-regulation, that usually requires the demonstration of competence for the purpose of public accountability for the services provided. For entrants to nursing and midwifery this occurs through the registration process, which requires the nurse or midwife to meet certain qualifications and to demonstrate competency against the relevant ANCI competencies.

The courses undertaken to gain those qualifications must also be accredited. Further, some nurse registration boards register or endorse to practise mental health nurses. Nurse registration boards have also taken on this process for the nurse practitioner. The Australian Nursing Federation (ANF) has also developed competency standards for advanced practice nurses which are used in course design, though this is voluntary. Some moves have already occurred in relation to the self-regulation process in several professional bodies, with a number of nursing colleges offering credentialing to members.

The comments received on whether further credentialing of nurses in areas of specialisation or advance practice would be helpful reflected a common theme of concern about the inconsistency of standards for the different levels of education. However, respondents had mixed views about the benefit of credentialing. A number of responses called for the development of a nationally consistent framework and guidelines for the credentialing of advanced practice nursing and the accreditation of related education programs. Others felt that there was a lack of evidence that credentialing of nurses leads to better patient outcomes, stating that nurses are already strictly regulated in Australia through the requirements of the different nurses’ regulation boards. Accreditation of courses rather than the recognition of a level of qualification would be a very costly exercise and could lead to lack of flexibility to respond to new and developing areas.

The School of Nursing and Midwifery at Curtin University argued that there was a lack of evidence about the ‘benefits’ of credentialing. Table 7.1 was incorporated in their response to the Discussion Paper, and summarises a discussion around credentialing in Murphy (2001). The table outlines a series of statements supporting credentialing cited in the literature together with the School’s responses to each of these statements.

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There is growing recognition of the importance of enrolled nurses (the associate of the registered nurse) for new patterns of work organisation in all sectors involved in care work. The role of the enrolled nurse has been restricted by a number of factors, some of which are discussed in Chapter 5 in relation to regulation and legislation. Of all the groups involved in nursing work, enrolled nurses are the group for which the issue of consistency in education and training was most often raised in consultations. Further, there is frustration with the limitations imposed on their future growth by the current differences in their preparation in the different jurisdictions.

In Chapter 5 we addressed the need to remove the barriers to an appropriate scope of practice for enrolled nurses caused by some legislation and regulation. While removal of these barriers is essential, this will not on its own promote the greater consistency required to develop common career paths and recognition. To develop the appropriate level of qualification across Australia, the potential for enrolled nurses in new models of care needs to be considered. For this reason agreement on the entry level to practice needs to be based on a scope of practice that takes into account new thinking about delegation and the administration of medication and at the same time builds the fundamentals on which enrolled nurse specialisation can be developed.

Further, if the competencies of the enrolled nurse are not identified within the national training packages, their competencies are likely to be used by new roles that take up various aspects of the work of enrolled nurses. As part of the VET system, enrolled nurse preparation must take its place within the national training packages. Since the revised ANCI competencies are now available, it is time for that development to occur. We recognise that there are some challenges to the progression of this agenda due to the nature of the professional relationship between the two levels of nursing, which must be retained.

Recommendation 21—Enrolled nurse competencies

To provide links to other training and to develop national consistency for the education and training of enrolled nurses:

a) the ANCI and Community Services and Health Training Australia should meet as a matter of urgency to ensure the ANCI competencies for enrolled nurses are incorporated in existing or new Australian National Training Authority sponsored training packages

b) in establishing the appropriate level of qualification, account should be taken of the training requirements for evolving models of care and changes in supervisory practice, including those related to medication administration and new enrolled nurse specialisations.

Proposed responsibility: Implementation taskforce

7.4 Initial education - registered nurses

Table 7.2 Undergraduate actual student load (EFTSU) on a differential HECS liable basis for nursing students by HECS Band, 1997–2000

In its consideration of clinical education, the Review Discussion Paper posed questions about the features of effective partnerships, and the types of models of clinical experience for student enrolled and registered nurses that could be developed in partnerships between health and education. In doing so it acknowledged that effective clinical education occurs only where there are working partnerships between education and the settings of practice, whether these are hospitals, aged care facilities or community nursing services.

We have already addressed some of the challenges assessment of competency pose for the preparation of nurses. However, prior to assessment, students need to develop these competencies. The two areas, competency development and student assessment, will need to develop alongside each other. Dent (2001), when discussing medicine, says that the use of clinical skills centres will be a growing part of the education and training of doctors. He sees these centres as combining a wide range of strategies including simulated venues, simulated/standardised patients, and a range of simulators from models and manikins through to realistic high-tech interactive simulators. The increasing role of audio/video technology will be essential to provide the skills needed prior to clinical placements since these are likely to become more difficult to gain as the healthcare system changes. While Dent’s comments are about medicine, they are equally relevant to nursing and suggest that the costs of preparing students for clinical placements in the future will also rise.

This is not to suggest that nursing in Australia is not already combining a range of strategies to address these issues. The use of laboratory experience and assessment in simulated settings such as the objective structured clinical examination (OSCE) are part of nursing programs in some Australian universities. Escalating litigation and a change in patient attitudes is likely to increase demand for a level of competency prior to clinical placements. These factors will not only change the nature of clinical placements but could also increase the cost to nursing education. Further, the changing nature of hospitalisation will challenge the provision of effective teaching and learning in service environments.

Medical education is beginning to document the effects of changing expectations of patients in relation to standards of clinical practice and the shortened patient stay in acute settings on hospitals as the sites of learning and teaching. The Commonwealth Fund Task Force on Academic Health Centers (2002) documents the following effects of reduced hospital stay on the education of doctors in the United States:

• The educational content of the training experience is giving way to the overarching pressure to hurry patients through the stay.

• There are increasing demands for productivity which result in reduced teaching time.

• There are increasing demands for outpatient clinical preceptors as patients move to ambulatory settings while simultaneously community physicians are less willing to participate in clinical teaching due to the pressure in these environments.

The effects of these factors on medicine are not only structural but also have resource implications. Since medical education, despite its higher status and funding, is experiencing these pressures, the implications for nursing may be even more extensive.

The importance of practice settings to the quality of clinical education is often underestimated in the way resources are allocated and expertise developed. While the cost of clinical education has been raised as one of the serious concerns facing nursing education, the tight supply of clinical places and the competition for these places act as limitations on the development of nursing education. Furthermore, additional resources will have little overall effect if the quality of the experience and the education process during clinical placement does not meet the needs of the students.

The resource constraints around clinical placements are putting at risk the quality of the programs and making nursing education unattractive to universities. University leaders pointed out that, in order for them to offer additional nursing places, those places would need to better funded to accommodate the costs of clinical education. This is a key issue for the future of nursing education. Compared with medicine, nursing receives much less per student per year under current operating grant arrangements since it is funded at about 59 per cent of each EFTSU in medicine. In addition, medical education is supported by grants from the Department of Health and Ageing for rural clinical schools, and from the Department of Education, Science and Training with Teaching Hospitals Grants. The Government aimed to distribute $20 million in the 2001–2002 financial year to establish rural clinical schools. Teaching Hospitals Grants for the period 2002–2004 are set at almost $5.3 million per annum.

The importance of clinical education cannot be denied. Nurses expressed frustration with what they considered insufficient practice as part of the education and training of nurses. Sometimes this was described as a loss resulting from the shift from hospital-based training to university training. Looking back to decisions to make the transfer, the Sax report (1978) also identified inadequate clinical preparation in hospital training. This is a complex area. Apprenticeship models provide excellent arrangements to learn the tasks of nursing, but the focus tends to be diverted from education to providing service. Pure academic models provide opportunities to develop generic competencies and theory but offer little structural framework in which to apply them. New debates are about providing the ‘scaffolds’ (Gonzi 2002) between the theory and practice. To achieve this, students’ experiences need to be jointly designed by academic educators and practitioners and to take place in the practice environment. In the light of the changes occurring in the health care system discussed above, developing and maintaining quality education programs will be a continuing and expensive struggle.

A number of approaches to increasing the funding for clinical education could be considered. Assuming that operating grant arrangements to universities do not change as a result of decisions from the Higher Education Review, one approach would be to move nursing from its current position in the relative teaching cost matrix from 3 to 4.

Effectively this would increase the funding per EFTSU to nursing by about 38 per cent. Due to the numbers of students in nursing, this would be a considerable cost to the Commonwealth. While we believe more funding to address the clinical component of nursing is essential, we propose another option since we consider it is both less costly and more effective in promoting innovation and quality through the joint ownership of clinical education.

Recognising that collaboration will be needed to provide students, whether preparing to be enrolled or registered nurses, with quality clinical education, we suggest that additional funding should be allocated in a way that promotes academic educators and VET trainers and nurse clinicians to form partnerships. We acknowledge that some universities and VET providers may need to change their practices to work with the proposed funding arrangement but believe it is the best option for all stakeholders. To enable the development of partnerships, funding arrangements need to promote flexibility and accommodate the needs of the different States and Territories, as well to build on the developing and leading practices already occurring. Ownership of the funding by all the parties involved in the clinical education of students will promote greater responsibility onthe part of the various services for the clinical experience.

Such partnerships are possible as the Commonwealth project, the National Professional Development Program, a program for teacher development attests. Teaching faces many of the challenges nursing faces in relation to the range of stakeholders at all levels but it was successful in achieving partnerships through this program. Yeatman and Sachs (1995) summarised the achievements of the project noting that ‘this brilliant project in design and execution’ managed ‘to get people to move beyond their accustomed ways of doing things and their familiar relationships’ because of ‘the collaborative culture and process and the way participants feel that they own and can control the direction and pace of change’.

We propose that a program be established to provide support specifically to clinical education. This would quarantine the funding for that purpose and allow an innovative system of management to be established in each State and Territory, one that would also encourage some sharing between universities and the VET system. Further, it would allow many of the excellent arrangements that exist to continue, with additional resources and encourage evaluation. Lastly, considering the number of undergraduate nursing students (over 22 500 in 2001), we suggest approximately $20 million a year for five years with an addition $10 million to establish and evaluate the program and to provide support for disadvantaged students. This is a relatively inexpensive option to enable some direct support to both needy students and to clinical education. Part of the funding should enable local partnerships to offer some assistance to needy students for whom the cost of clinical education causes financial stress.

Since clinical education is an essential element of the preparation of all nurses and an area where the costs have increased to a point of being unsustainable, new quarantined funding over five years should be provided for clinical education in addition to the operating grant for undergraduate nursing courses. It should be administered through a new program, the Clinical Education Partnership Program.

The program should be formally evaluated in the fourth year to assess its impact and identify any changes that may be required for its continuing operation. The program should meet the following criteria:

a) promote State- and Territory-based cooperative arrangements between those sectors preparing nurses for initial registration and those employing them

b) be acquitted in terms of delivering quality clinical placement outcomes (to defined minimum standards)

c) prioritise partnership arrangements and contributions from all sectors involved in health and education

d) promote innovative approaches to clinical education

e) include some assistance to students, particularly for those who are disadvantaged by the high costs of attending clinical placements.

Proposed responsibility: Commonwealth Department of Education, Science and Training

The increasing intensity of various care environments will make it difficult to accommodate the educational expectations arising from new thinking about professional education. The Victorian Universities Rural Health Consortium provides evidence of the difficulties already arising in relation to adequate and appropriate clinical placements for nurses, at least in rural areas (Mahnken 2002). In this regard, the Victorian report makes the following point:

(Mahnken 2002, p. 32)

In rural areas the competition between professional groups and the impact of the expansion of activity in policy and program development is changing the profile of those involved in education and research in these rural areas. According to Mahnken (2002), this is changing agreements for clinical placements between rural universities and their counterpart health services from that of local negotiation to competition on an ‘intrastate, interstate and national’ basis. While better systems for the planning of nursing clinical education may alleviate some of these strains, ultimately a more coordinated approach across the health disciplines will be needed.

The flow-on of these effects means that clinical placements will need to be maximised to enable this valuable time to be highly productive for the student. Currently there is support for a model of diverse experience for students through a range of clinical placements. There is concern that this model promotes short stays in different practice sites where the student gains no sense of belonging, the staff have no ownership of the student, resulting in insufficient time to understand the student’s needs. A number of universities are already using different approaches, such as the three summarised in Exhibit 7.4 of the Discussion Paper. Some of these involve the establishment of Clinical Development Units and Dedicated Education Units.

Less structured exposure, in addition to clinical placement, could be included in nursing education programs through work experience in industry. The difference between the two is that the university has no supervision responsibility for the student while on work experience. Under current funding arrangements, approved work experience in industry is HECS-exempt for the student but does attract a small amount of operating grant to the university. A number of professions use this approach to give students real-world experience and an opportunity to build on and develop their applied knowledge. The Faculty of Engineering at the University of Technology, Sydney and the School of Accounting and Law at RMIT University are two examples of work experience in industry programs.

While an increase in the amount of work experience in industry load would need to be negotiated with the Department of Education Science and Training due to its cost implications, we encourage nursing schools to examine this option, linked with the development of collaborative clinical education approaches. If this does assist in better educational preparation of registered nurses, we encourage the Commonwealth to support this development.

(ICN Guidelines on Specialisation in Nursing, ICN Geneva 1992:12 cited in Russell et al. 1997, p. xiii).

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

• nursing resource planning with coordination of nursing education and workforce planning as an integral part of healthcare system development.

We consider that the issues of lack of consistency in nomenclature and lack of a framework for the development of nursing specialities are a problem for both quality assurance and workforce planning. Consequently, we argue this is an issue for the NNCA. As part of its role in promoting consistency in nursing education and practice the NNCA should consider the importance of a national framework for nursing specialisations.

While there are different requirements in different speciality areas, not all nurses who work in a specialist area need to be advanced practice nurses. Those who are advanced practice nurses will require both the development of competency within the practice area and additional education. One of the current weaknesses of the system is that qualifications inspeciality nursing do not require a clinical component as part of the course. We question whether courses that do not have a clinical assessment component as well as a theoretical component should be promoted as speciality courses.

Nurses use postgraduate courses for a number of different purposes. These include:

• to prepare to work in speciality areas

• to maintain competence and currency in practice

• as part of their personal development associated with lifelong learning.

Competency and currency in practice and personal development are discussed more generally in Chapter 6 because they have stronger elements of personal responsibility on the part of the nurse. The preparation for specialist practice is an important consideration for the supply of nurses needed in the workforce and it is in this context that we present the following discussion and recommendation.

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 practice and theory and the level of involvement of the health sector in their delivery. This creates confusion for employers and provides little assurance of the quality of courses. Since universities make the decision about the level at which courses are offered, there may be only one level of qualification offered in small States with few universities. The consequences for nurses could be a reduction in opportunities to further develop in a particular area or higher benchmarks to specialisations than are generally set in the rest of the country.

Most courses recognised as sufficient for nurse specialisation are at the postgraduate certificate level and postgraduate diploma level. However, there is variation between what is recognised as a sufficient level of qualification between States, even where the nurse registration board endorses for practice in an area such as mental health. For example, Victoria only requires a postgraduate certificate, yet Queensland demands a postgraduate diploma for endorsement to practise as a mental health nurse.

While postgraduate programs are studied at different levels, for labour market purposes interest is in the way the qualification provides skills for particular specialty nursing practice. While the following discussion relates largely to university postgraduate courses that prepare nurses for specialist roles and advanced practice, there is also another important player in the delivery of postgraduate certificates—the NSW College of Nursing. Most of the College’s work is in New South Wales, but there are also courses offered outside that State (for example, in the Northern Territory).

In the DEST higher education university statistics, ‘higher degrees by coursework’ relates to masters degrees and the ‘postgraduate other’ to postgraduate certificates and diplomas. Differences between the numbers in courses and the EFTSU can be attributed to the amount of part-time study in postgraduate nursing. Table 7.3 shows that the increase across the period 1994–2001 was largely in master degrees by coursework, while the growth in postgraduate certificates and diplomas was limited to the period 1994—1996, following which there has been a downwards trend with a slight upturn in 2001. Since the latter group is where most of the courses that prepare for specialisation fall, this is a matter for concern. Although there is a slight lag, similar patterns occur for HECS places. The percentage of fee-paying units has increased for master degrees across the period from 3 to 30 and for postgraduate certificates and diplomas from 27 to 59.

Table 7.3 Total non-overseas ‘higher degree by coursework’ and ‘postgraduate other’ by load and payment category 1994–2001

The trend to fee-paying postgraduate units is noted in the Higher Education Report for the 2002 to 2004 Triennium (DEST 2002a, p. 67). The report observes that:

7.6.2 Recognition

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7.7 Advanced practice

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7.8 Education for multi-professional teams

7.8.1 Interdisciplinary education

7.8.2 Encouraging multi-professional team approaches