Summary

Nurses are a vital part of the health, aged and community care systems in Australia. The work they do not only supports those who have particular care needs but also underpins much of the social structure in communities and care facilities. Therefore there is a wide range of stakeholders with an interest in ensuring that nursing functions well in the many settings that require nursing knowledge and expertise. These stakeholders range from hospitals to remote communities, from prisons to the Australian defence forces, from homes to schools.

Australian nurses should be proud of the contribution they have made, often with limited acknowledgment other than the community’s trust. Nurses have developed as a profession, establishing a number of important bodies to draw together different aspects of nursing on a national basis. Other achievements include the important developments in nursing education. The preparation of enrolled nurses has become established in the vocational education and training system and that of registered nurses in the higher education system.

There is also progress towards the development of a strong evidence base for nursing through research training and developments such as clinical chairs—though there is much work yet to be done in consolidating that evidence base and applying it in clinical settings.

Nurses have received attention not only in Australia but also in many other countries because of growing shortages and increasing demands for care as populations age and community expectations of care change. There is a remarkable similarity in the findings of our report and recent reports from other countries and from within Australia. We reflect the same issues and offer many similar solutions.

During the Review, we used many information sources and people to try to understand nursing, its practice and the drivers that influence change. Combined with increased demands for nursing work, the rapid growth in knowledge and technology has changed and continues to change the nature of that work, presenting ongoing challenges for nursing education and practice. These rapid developments require solutions that set standards and build the capacity to address and plan for change—not prescriptive models of education and training that will be outdated before they are implemented. Rapidly evolving technical knowledge environments also make heavy demands on organisations to develop and extend their staff through ongoing education and training. While not all care environments fit this description, many nurses work in areas demanding high levels of technical competency. Consequently, the initial preparation of nurses needs to set the foundation for ongoing learning.

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Despite the progress and the important role nurses have had in caring for the Australian people—whether in the cities or in rural and remote settings, where they often form the front-line of health care—there are a number of barriers to nursing development. Many of these flow from the fragmentation brought about by different policy and funding responsibilities. These barriers need to be removed and replaced with a more coordinated national approach.

To provide nursing with a means of responding to these challenges and at the same time promote the ongoing development of nursing, we have taken a strategic approach to our recommendations. This approach supports flexibility and responsiveness and builds capacity to enable nursing to be best placed to respond to the changing healthcare environment.

As part of our longer term vision, we propose a national nursing council, the National Nursing Council of Australia, which would provide a national focus that brings together all stakeholders to overview the full range of issues related to nursing. We envisage this body drawing on the considerable existing expertise at a national level and providing a focus for nursing leadership, while also developing nursing leadership and management at all levels.

A national body offers a new way of promoting nursing both at home and in the international arena and a resource for government in planning health, aged and community care provision for the future.

We identify the potential contribution of the National Nursing Council of Australia as:

• providing national leadership on nursing policy, education, training and practice

• facilitating the work and activities of other nursing bodies

• promoting and facilitating consistency in nursing education, training and practice to improve the quality and safety of nursing care throughout Australia

• developing and promoting nursing leadership at all levels

• building capacity in the nursing profession and workforce.

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In addressing our other recommendations, we used a broad framework aimed at responding to current challenges, consolidating and building on existing achievements and providing the support and infrastructure for the future development of nursing. Since nursing is a practice discipline, nursing education and nursing practice are interdependent.

Therefore, although the focus of our review is education, this cannot be examined in isolation from the current situation for nursing practice.

While conducting the Review, we faced the complex situation of nurse shortages. Under these conditions it is difficult to provide new graduates with the support they need and are entitled to expect as new entrants to a profession, and to find quality clinical placements for all students. At the same time, there is growing pressure to increase the number of nursing students to meet both the current demands and those of the near future when a high proportion of the nursing workforce will retire. These different pressures show how important it is to find solutions that bring together all the parties responsible for the different elements of the solution.

Our recommendations support one or more of the elements of three strategies designed to draw together the parties responsible and the issues that must be addressed. These strategies are:

• building a sustainable nursing workforce

• maximising health outcomes through quality education

• capacity building.

The strategies themselves are interdependent, so the recommendations in some cases form part of the platform for more than one strategy.

Strategy 1: Building a sustainable nursing workforce

In the context of our report and recommendations we define the nursing workforce, in the broadest sense, to encompass:

• registered nurses (general and specialist), midwives and mental health nurses

• enrolled nurses

• nurse practitioners

• nurse managers

• nurse educators (working in hospitals, universities and the vocational education and training sector)

• trained care assistants.

We use the name ‘trained care assistants’ to represent the group of workers involved in care work who are known by a range of titles, including assistants in nursing, personal care assistants, and aged and disabled person carers. While we argue that this group of workers needs both a common name and a minimum level of competency, we do not advocate a particular name. Rather, we have called the group ‘trained care assistants’ to enable us to discuss them in this report.

Elements of a sustainable workforce

There needs to be a major investment in retention of the existing workforce, recruitment of nurses not currently employed in nursing, and recruitment from overseas. All the evidence suggests that it will be impossible to meet the demands for nursing services by focusing on new graduates alone. The most crucial factor in ensuring an adequate supply of nurses for the future will be to retain as many of those nurses currently employed as possible, particularly those in the earlier years of their careers.

Transition programs provide the initial sustained exposure to the daily management and application of the theory learnt during the undergraduate course for the new registered nurse, or vocational education and training for the new enrolled nurse. Good transition programs encourage new nurses to remain in the workforce. These programs are an essential part of any strategy to maximise the community’s investment in the education and training of nurses.

Appropriate skill mix and investigations about how work could be better organised are necessary. The evidence points to the unsustainability of current arrangements. This is not to suggest the substitution of professional nurses where they are using their expertise to achieve the best outcomes for patients/clients. Rather, there should be an examination of the ways in which the different skills of different groups who form the team of people doing nursing or care work can be best organised to ensure optimum outcomes for patients/clients.

Supply of all levels of nurse and trained care assistants is important in building a sustainable workforce. A focus on only registered nurses will not result in the appropriate use of nurses in different settings, nor encourage the strengthening of career pathways from trained care assistants to the range of nursing career options, including nurse practitioner. Supply needs to be increased, particularly of enrolled and registered nurses.

The availability of sound data and a valid, reliable evidence base provides the platform for decisions on supply, skill mix, work organisation and policy. Currently, the availability of quality data and evidence in relation to the nursing workforce and nursing work is very limited.

Strategy 2: Maximising health outcomes through quality education

The appropriate level of education and training of care assistants is essential to the safety of the patient/client as well as their comfort. While there is growing recognition of the need for appropriately trained care assistants, Australia has yet to ensure that all those involved in care work have an appropriate level of competency to secure safe practice. Moreover, as a country, we need to develop an understanding of the nature and extent of their contribution.

Clinical education is an essential component of education and training for a practice profession and is required to ensure the quality of preparation for new professionals and specialist nurses. Providing the appropriate funding and building collaborative relationships are key to developing confident and competent new professionals and specialist nurses for the various settings of care.

Defining national standards for nurse education at all levels and for trained care assistants, combined with appropriate quality assurance processes, is an important part of the process of ensuring quality education of the nursing workforce. The underpinning of quality education and training is fundamental to the development of educational pathways that facilitate transition between careers. In a world of rapid change, efficient transition processes are important to both the individual and to the health, aged and community care systems because they broaden the group of people who can be educated and trained to carry out the work required.

The capacity to develop and continue to evolve flexible and responsive education and training programs in the constantly changing environment in which health, community and aged care function is essential. With its broad professional base and range of competencies, nursing is in a unique position to respond to those changes. To achieve this responsiveness, nursing education providers need to be current in their understanding of practice, be attuned to changes and be innovative in their education processes for all levels of nurses.

Strategy 3: Capacity building

Nursing research and the development of nursing researchers provide the underpinning infrastructure for good decisions by policy makers and for improvements in clinical nursing practice and education. The means to more efficient, effective health outcomes from nursing work and to quality education of nurses is building nursing research capacity and developing the ability to apply the findings of that research.

Learning organisations need to develop the capacity to support and develop the knowledge and skills within the organisation. Since the transfer of registered nursing education from hospitals, much of the supporting infrastructure for clinical nursing development has been lost. Clinical development of nurses can only be done well where the expertise is located— and that is usually with the nurse clinician. Rebuilding and further developing clinical education systems in hospitals, and the community and aged care sectors will provide the capacity for care services to build best practice and evaluation of practice into their systems.

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Given the number of players with different responsibilities for diverse but intertwined elements of nursing, Australia will need to develop collaborative partnerships at all levels to make progress in many of the problem areas faced by nursing today, and to plan and respond to future challenges. At present there is little opportunity for this to occur in a way that interfaces all the different interests.

We believe it is in the national interest to promote arrangements that bring together the Commonwealth, State and Territory health and education interests, nursing bodies, and the range of service providers, including government and non-government, that represent the different contexts in which nurses work. Promoting these partnerships is the vision we share in presenting our report and recommendations. The figure ‘Overview of strategies and recommendations’ shows how the strategies and recommendations in this report are linked.