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2. Nursing education and practice todayThis chapter provides background information on international nursing trends. It documents the current arrangements for the education and training of Australian nurses and for those who directly support the work of nurses. It also examines the role nurses play in the health, community and aged care sectors, the challenges posed by changing conditions in education and health care, and the professional and regulatory arrangements related to nursing in Australia. The information supplied in this chapter comes from a range of data sources. Use caution when comparing different sets of data as they may be based on different assumptions or reporting periods. Nurses play an essential role in promoting and achieving the health outcomes of the Australian community. In many cases they form part of a team of health professionals and workers. The team in which they work may include nurses registered for different levels or types of practice contingent on their education and training and on the restrictions on practice imposed by legislation and regulation. Other nurses work in isolated situations where the community is dependent on their breadth of experience. Nurses also work in public health or community health areas as individual operators. 2.1 What is a nurse?In Australia, nursing has two levels:
State and Territory nursing registration boards are at various stages in the development of another higher level within the registered nurse group, the nurse practitioner, which will have a regulatory framework that includes education and practice. The growth of collective understandings, the ability to relate, to self-regulate and to set standards and systems of protection in place, mark the development of a profession (Kemmis 2001). Through its various bodies, the profession of nursing contributes to the education of nurses, to the regulation of practice, to practice development and to the continuing development and evolution of the discipline. Through these processes, the profession establishes itself in a way that it can contribute to the development of the healthcare system, its procedures and arrangements, and in the formation of policy. Nursing is defined by its practice which, in turn, is characterised by distinctive traditions, skills, knowledge, values and qualities—that is, it forms a discipline. One of these values is ‘caring’. Defining this intrinsic nursing value is part of the development of the discipline of nursing as it evolves to meets the emerging needs of the community. Articulating that value to the community is one of the challenges nursing faces as it evolves to respond to very different practice environments. Baumann and colleagues (2001) capture the essence of this challenge when they state: While there is individual variation in how nurses see their roles, most nurses subscribe to a holistic philosophy of care and their work has most meaning when they are able to attend to all aspects of a patient’s health. In the contemporary healthcare environment, the nursing model of caring often takes second place to a treatment-oriented medical model. Due to high workloads, nurses only have time for tasks related to patient’s immediate physical needs. As a result they often become discouraged and feel guilty when they neglect patients’ psycho-social and spiritual needs. (Baumann et al. 2001, p. 9) The changing nature of hospitalisation makes it increasingly difficult to work as a ‘carer’ (White 2001). The rapid turnover of patients means there is less time spent in hospital preparing for surgery and recovering. Some restructuring of work has left nurses more involved in care planning and coordination than in care delivery—and feeling distanced from patients as a result. Both factors—the speed of turnover and the restructure of work—affect patients’ experience of care and create tensions for a profession that has developed the sort of collective understanding detailed above. 2.2 Who does nursing work?One of the most contentious issues raised throughout the Review is nursing work and the right to use the title ‘nurse’ in the current environment in Australia. All States and Territories protect the titles ‘registered nurse’, ‘enrolled nurse’, ‘midwife’ and, where applicable, ‘nurse practitioner’. In addition, the use of the title ‘nurse’ is protected by legislation in four of these jurisdictions. While enrolled and registered nurses are regulated, there is a wide range of other workers undertaking direct patient/client care work that could be described as nursing work. The majority of unregulated/unlicensed carers are currently in the community and aged care sectors. The development of some health training packages is also beginning to challenge some of the nursing work boundaries in acute care settings with the introduction of technicians with diploma qualifications. The unregulated/unlicensed care worker is given many titles in the aged and community care sectors. These include ‘assistant in nursing’ (AIN), ‘personal care assistant’ (PCA), ‘aged person carer’ and ‘disabled person carer’. Debate about a consistent title for these workers—whether it should identify them as working in the domain of nursing or not— continues. Resolution of this issue has a range of ramifications, including workforce planning, industrial coverage and protection of the public. Without a common nomenclature it is difficult to count those contributing to nursing work, and impossible to establish standards that cover their work. While we advocate an agreed name, we do not take a position on what nomenclature is appropriate. For simplicity, throughout this report this group of workers will be referred to as ‘trained care assistants’. This choice of title is not to prejudice the debate on the issue or decisions about the industrial coverage of these workers. It is designed to acknowledge the role these workers have in caring for those who need assistance in matters of direct personal care regardless of the setting. The term ‘trained care assistant’ will be used in the report except for the following circumstances:
2.2.1 Nursing workforceWe have included the following groups when discussing the nursing workforce:
Midwives and mental health nurses The situation regarding midwives and mental health nurses varies across Australia. In one State registered nurses must have special registration to practice as a mental health nurse or require supervision by a registered mental health nurse. In some jurisdictions there are restrictions on the practice of those nurses trained only to be registered mental health nurses under previous direct entry education arrangements. At present registered nurses must gain an additional qualification to register or be endorsed to practise as a midwife. Universities in South Australia and Victoria introduced direct entry undergraduate programs in midwifery in 2002 and other universities plan to do so in the near future. The terms of reference for the Review assumed that midwifery would be covered under nursing specialisations. Consequently, midwives are discussed throughout this report as an integral part of the nursing workforce. We acknowledge the growing debate about the nature of midwifery, but we believe this is an issue for the profession, with all its members, to resolve. While we note the strong representation to change the title of the Review to ‘nursing and midwifery’, we also observe that none of the National Nursing Organisations have yet changed their names to reflect the inclusion of midwifery. 2.3 International nursingThe terms of reference require the Review ‘to have regard to 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 findings of the international reports and reviews are summarised in Attachment 2.1. The relevant Australian reports are discussed in the appropriate place in the text of this report. Keeping current with the many reports and activities, both internationally and in Australia, has been a particular challenge for us throughout the review due to the level of activity, and apart from the report of the Senate Inquiry, we have not included any new reports or findings since 14 June 2002. An interesting monitor of the importance of nursing on the international arena has been through the agendas of the Organisation for Economic Co-operation and Development (OECD) and the World Health Organization (WHO). Many countries are facing shortages in the supply of nurses and their concerns have raised the visibility of nursing. A number of trends have appeared in international nursing reports and activities which include:
2.3.1 International trendsThe following information gives some examples of the approaches in different countries and organisations. More information is at Attachment 2.1. National strategic nursing approaches are evident in the developments in a number of places including Canada and the United Kingdom. In 1999, the Conference of Deputy Ministers/Ministers of Health directed the Advisory Committee on Health and Human Resources to develop a strategy for Canadian nursing. As part of the strategy they appointed a multi-stakeholder Canadian Nursing Advisory Committee to give priority to providing advice on improving the quality of the work life for nurses. The National Health Service (NHS) plan for the United Kingdom also provides a national framework for the development and resourcing of nursing as part of the health workforce (NHS 2000). The quality and level of education required for nurses are the focus of a number of activities. Part of the development of a WHO European Strategy for nursing and midwifery includes fundamental principles for initial and continuing education of nurses and midwives (WHO 2001a). These principles identify the entry to practice qualification of a nurse or midwife as a university degree in nursing or midwifery. Ireland, in response to its Commission on Nursing report (1998), is in the process of transferring all nursing education into the universities. The province of Ontario, Canada, has a target that the entry to practice will be a Bachelor of Science (Nursing) by 2005 (Ontario Ministry of Health 1999). Considerable investment in the education and salaries of nurses is part of various strategies by the British Government, which aims to increase the supply of nurses from initial training and other sources such as migration in order to provide an additional 35 000 nurses by 2008. Large investments in nursing are also part of initiatives by provincial governments in Canada. The plans include bursaries for nurses to upgrade in Saskatchewan, reduction of the workload of mentors of graduate nurses and funding for the education of more specialty nurses in British Columbia, and additional nursing positions to provide floating relief staff in Prince Edward (Baumann et al. 2001, Appendix B). The development of the workforce planning process has been another strategy in response to nursing shortages. Of particular interest is an OECD project that plans to explore which human resource policies for health care best contribute to the efficient and effective delivery of health services across OECD health systems. More information on this project is in Chapter 8. As stated above, a number of countries have shortages of nurses. Countries reporting shortages include Zimbabwe, India, Vietnam, the United States, the United Kingdom and Canada. Zurn, Dal Poz, Stilwell and Adams (2002) document reports from different countries related to the supply of nurses. The comparison of nurses per one million population in Europe and Africa shows the relativity of the concept ‘shortage’. While nursing shortages have been reported in both Africa and Europe, there is substantial variation in the nurse–population ratio of countries in these regions. On the basis of WHO data, the highest nurse–population ratios were in Finland and Norway. After these leading countries, Malta and Belgium had similar nurse–population ratios, but they were about half that of Finland. The United Kingdom, Spain and France also had similar nurse–population ratios but again these were about half those of Belgium (Zurn et al. 2002, p. 6). Of particular interest is the fact that some of these countries, including Canada and the United Kingdom, have an expectation that they will need to attract nurses through immigration. 2.4 The Australian nursing workforce and related occupationsThe Review commissioned a research study to investigate job growth and turnover in nursing occupations in the period 2001–2006 (Shah and Burke 2001). This section and Attachment 2.2 are based on that work. The definition of ‘nursing worker’ used by Shah and Burke is more restricted than that used in the rest of this report when discussing the ‘nursing workforce’ due to categories used in the data source. The need to explain this here highlights the challenges presented in trying to understand the nursing workforce in Australia. In this section, ‘nursing workers’ are defined to include the occupations of directors of nursing, nursing professionals, enrolled nurses, and personal care and nursing assistants. Separate analysis is included on aged or disabled person carers, an occupation that the Australian Institute of Health and Welfare (AIHW) excludes from the nursing workforce. Details of the models used by Shah and Burke for their investigation, the assumptions underpinning them and the data used to estimate them are not included here, but are available in their paper which is available on the Review website. The paper also provides a detailed picture of the employment and demographic changes that have occurred in each of the above occupations over the last decade and a half. These include age and gender profiles and hours of work. Table 2.1 shows employment changes in the different nursing, aged and community care occupations between 1987 and 2001. The table shows two nursing occupations, enrolled nurses and personal care and nursing assistants, with negative growth over this period. Table 2.1 Change in employment in nursing and aged and disability person carer occupations, Australia, 1987–2001
Changes in the relative proportions of the three main groups classified as nursing workers—nursing professionals, enrolled nurses, and personal care and nursing assistants— suggest the growth in the first group has been at the expense of the other two groups. This pattern of substitution is not uniform across States and Territories and does not take into account the aged or disabled person carers. The employment of this latter group grew in all States and Territories. Karmel and Li (2002) note: the importance of the missing group (missing because we don not have the data to include them in the analysis): nursing assistants and personal carers. Presumably, the reason that the ratio of nurses to patients has declined is because some of the work of nurses has increasingly been undertaken by this group. 2.5 Nursing ShortagesThe nursing shortages in hospitals have consequences not only for patient outcomes but also for education outcomes. In an environment where nurses are trying to respond to high demands on service, there is little time or energy to take on professional roles with students, or with other staff. A measure of the current climate is the information on vacant positions or positions difficult to fill. Reference to the National and State Skill Shortage Lists at February 2002 show that the problem of shortages appears to have increased in some States since the commentary in the Review’s Discussion Paper (National Review of Nursing Education 2001, pp. 83–86). These lists are based on labour market intelligence undertaken by the Department of Employment and Workplace Relations (DEWR). At March 2001, and again at February 2002, the lists showed a number of nursing categories in which shortages were reflected nationally (Table 2.2). The actual nursing specialisations experiencing shortages did not change between the two reports. However, there were changes in individual categories across States and Territories. For Queensland, South Australia and Western Australia, the February 2002 report now shows shortages against all categories of nurse specialisations, which was not the case in March 2001. Table 2.2 Shortages of registered nurses by specialisation and enrolled nurses—March 2001 & February 2002*
Though there were few online courses at undergraduate level, over half (55.6 per cent) of all undergraduate units currently contain an online component. Most of those units were web-supplemented rather than web-dependent or fully online and 44.5 per cent of units in the broad Health discipline were web-supplemented (Bell et al. 2002). It is important to remember that the use of information and communication technologies in teaching and learning is a relatively recent practice and much more research needs to be done on the pedagogy, quality and cost effectiveness of online education. Online learning is bringing about fundamental changes to the delivery of education and training and has even affected the way people learn. For many, it contributes to an enriched learning experience, while for the ‘time poor’, the availability of online learning is of enormous benefit. However, online learning is not the complete panacea that many originally envisaged. (Bell et al. 2002). With the expansion of this mode of delivery the concerns of rural students should be noted. In their submission to the review, the Association of Australian Rural Nurses commented: It is becoming increasingly popular for education providers to offer education using web based learning material. While the arguments for the uses of this technology are sound (Gray 1994), they are problematic for many rural nurses. Many rural communities lack the efficient tele-communication facilities found in urban and provincial areas, and the associated costs for students to purchase hard and software combined with inadequate access to local computer support, means that this mode of delivery is often ineffective. (Submission No. 57) Increased flexibility in mode, delivery and selection criteria may hold many advantages for the education consumer, but these factors may affect the likelihood of completion of study at university. In their study of university completion rates, Urban, Jones, Smith, Evans, Maclachlan and Karmel (1999, p. 1) suggest that full-time students have the highest completion rates and external students the lowest completion rates. Tertiary Entrance Rank (TER) is a significant indicator of completing a university course. Of students entering university on a basis other than TER, those with previous higher education experience and professional qualifications have the highest completion rates. These findings should be a caution for the way nursing education programs develop in the future. Another caution in the development of nursing courses for undergraduate students is finding the appropriate balance between distance or online provision versus face-to-face delivery for a practice profession. Defining the balance will need further research and the monitoring of developing practices in this area. The VET sector is responding to student needs through the application of information technologies and communications in its programs. The CEOs of the Australian National Training Authority (ANTA) endorsed the Australian Flexible Learning Framework (AFL Framework) in 1999. This framework drives improved access to and increased take-up of flexible learning by training organisations across the public, private and community sectors. In Strategy 2002, ANTA notes the progress they have made to date:
(ANTA 2002, p. 1) 2.9 Registered NursesA registered nurse is a person licensed to practise nursing under an Australian State or Territory Nurses/Nursing Act (ANCI 2001). Nurses make up over half the health professional workforce (Duckett 2000). According to Shah and Burke (2001), the employed number of nursing professionals was 183 900 in 2001. Just over 51 per cent of registered nurses worked in acute care/psychiatric hospitals in 1997 (AIHW 2001d). 2.9.1 Initial education of registered nursesThe year 1994 marked the end of the transition from an apprenticeship model of registered nurse training to an academic model of nursing education. The State and Territory Governments contributed funding to the Commonwealth education portfolio in that year. Under the transfer agreement, the States and Territories provided 75 per cent of the average funding rate for a nursing place through offsets to State and Territory grants. Considerable information about the shift from hospital training to university education for registered nurses is documented in the 1978 Committee of Inquiry into Nurse Education and Training Report (Sax, chair) and the Report of national review of nurse education in the higher education sector: 1994 and beyond (Reid, chair). Since that time all registered nurses in Australia have been educated to a bachelor degree level at university. In addition to requiring a bachelor degree in nursing, graduates must meet the Australian Nursing Council Incorporated (ANCI) competencies for registration in their State or Territory. All pre-registration nursing curricula must have accreditation from the State or Territory nursing registration board as well as meet the university’s requirements for course approval. Funding Once the transfer was complete, the Commonwealth education portfolio assumed the funding of undergraduate nursing courses in higher education. The funding level initially differed between institutions as it was based on an agreed transfer cost between the States and Territories and the Commonwealth. Current funding arrangements treat nursing within the general operating grant model, that is, as any other course at the university. Under this model, universities receive an operating grant based on their teaching profile and are expected to provide a given number of equivalent full-time student units (EFTSU) for the funding. Details of the funding model can be found in the Review’s Discussion Paper at pages 136–139. Undergraduate nursing students may be fee-paying or may fall under the Higher Education Contribution Scheme (HECS). There are few fee-paying Bachelor of Nursing students. In the 2000 Department of Education, Science and Training (DEST) statistical collection, the units recorded were all at Avondale College which does not have any HECS places for nursing. At the University of Notre Dame, another private higher education institution, most nursing students are fee-paying. The University now has a small number of HECS funded EFTSU allocated for the Broome campus. Some of these are for nursing. The University of Notre Dame nursing students are not included in the statistics quoted from DEST but are included in information reported from the work of Ogle and team in this section. The University currently has 156 undergraduate nursing students. In additional to these few fee-paying places, at least one State health department provided funding for undergraduate nursing places in 2002. Undergraduate student numbers The general trend in domestic (non-overseas) undergraduate nursing is for a decrease in both commencing student numbers and the EFTSU load allocated to nursing within universities. (The difference between EFTSU and number of students is due to the proportion of part-time students.) In 1998 there was a slight reversal of the trend, but the decrease continued in 1999 and 2000. The number of domestic commencing nursing students fell from 11 274 in 1994 to 8248 in 2000. Some of the decrease can be accounted for by the reduction in the number of nurses upgrading from hospital training to a degree, but it is not all due to this factor. During the early part of the period 1994–2000 there was some difficulty in finding work in nursing (see Section 6: Graduate Destination Survey in DEST 2002b). The level of interest in nursing as a career appeared to drop and with it applications to the universities across much of the period (see Section 8: Applications and Offers for Nursing Courses in DEST 2002b). Although the official DEST statistics have a category called ‘basic nursing’ to identify pre-registration students, there are some anomalies in the data due to misclassification by the universities, so the category we have used here is ‘undergraduate’. Ogle and colleagues (2001 and 2002) attempt to separate the two groups (pre-registration and post-registration) and also to provide more current estimates of completions than are available from DEST. Ogle and team report university undergraduate commencements for pre-registration domestic students in 2001 and 2002 at 7597 and 8305 respectively. This increase is due to growth in most States and Territories, but particularly in Queensland. They also report completions of pre-registration domestic students for 2001 were 5219 and post-registration undergraduate domestic students were 466 (Ogle 2002, Table B8). Universities project completions for pre-registration domestic students to be slightly higher in 2002 than those in 2001, largely due to an increase in student numbers in Victoria. Other States and Territories, apart from Western Australia, the Northern Territory, Queensland and Tasmania, project falls in completion rates (Ogle et al. 2002). Caution is needed when interpreting projections. Comparing university projections for 2001 (Ogle et al. 2001) and completions in pre-registration domestic students (Ogle et al. 2002) shows that universities overestimated by approximately 5 per cent. Table 2.5 shows a loss of overall load and with it funding for undergraduate non-overseas nursing across the period. Some of the load/funding may have moved to postgraduate courses in nursing but much has been lost from nursing. When the total proportion of funded load is compared, there is very little increase in the postgraduate nursing area compared to the loss in the undergraduate area. Even if the fee-paying load in the postgraduate area is ignored, the total EFTSU load in non-overseas nursing, both postgraduate and undergraduate, decreased by approximately 12 per cent across the period, showing resources have moved out of nursing education since 1994. Table 2.5 Bachelor degree non-overseas students and load 1994–2000
Approximately 30 per cent of undergraduate students come from rural and remote areas (National Review of Nursing Education 2001, Exhibit 6.10). The number of students attending rural campuses grew between 2001 and 2002 in Victoria, New South Wales and Queensland. Supporting this report is a document, Higher Education Statistics for Nursing Students, which is a rich resource of detailed information on university nursing courses and students (DEST 2002b). Overseas students Overseas students make a contribution to the Australian economy as they are usually feepaying. They provide Australian students with the opportunity to study within a diverse cultural group, and are a potential source of additional nurses for Australia. In 2001 the total load for overseas students doing Bachelor of Nursing degrees was 2323 EFTSU. The majority of the teaching load was for offshore delivery (1345 EFTSU). According to the Department of Immigration and Multicultural and Indigenous Affairs, some overseas students remain in Australia after completion of their studies. Under a recent immigration announcement, three initiatives to assist entry of nurses were announced. One of these announcements relates to a change in visa requirements to allow all students and their dependents to apply onshore for long stay temporary residence if they have a recognised nursing qualification. Nursing programs There has been a great deal of innovation in the types of courses offered and the ways in which they are delivered since the transfer to universities. Universities have attempted to be flexible in the delivery of courses to increase access for students wishing to undertake a nursing degree. Table 2.4 earlier in this chapter provides an overview of the diversity of these programs. Some of the programs listed in the table cater for nurses upgrading from hospital-based training to a degree, while others are for students beginning nursing education in order to meet requirements for registration. Undergraduate nursing programs are offered at 29 universities as well as Avondale College. While universities in each State and Territory are most likely to supply new graduates to that particular jurisdiction, this is not always the case. An increasing number of programs is offered by distance mode and universities are sometimes contracted for the delivery of programs to students located in a different State or Territory. Furthermore, new graduates are mobile. Western Australia and the Northern Territory both indicated during consultations that they rely on graduates from New South Wales and Victoria. Six universities have over 1000 commencing pre-registration domestic students in 2002 (Ogle et al. 2002). In comparison, the University of Melbourne entered the undergraduate nursing market this year, enrolling 19 students in a graduate entry program. In total, fulltime or part-time nursing programs are delivered on 59 campuses across Australia, including Geraldton and Whyalla. The location and programs are listed in the report by Ogle and colleagues (2002). Clinical education Clinical education for a practice discipline such as nursing is an integral and essential component. While university programs may skill students on particular procedures in laboratory situations, the actual exposure to nursing in its various settings is essential to their understanding of the profession and to the development of competence at the beginning practice level for registration. Programs offer different lengths and types of clinical experience. Even the total number of hours of clinical experience varies widely both within and between States and Territories. In some cases students are offered elective placements in addition to a core set of experiences. Ogle and team (2002) provide comparative information about the amount of clinical experience and laboratory experience in undergraduate nursing programs. The information compares both States and Territories and the universities within each of the States and Territories where there is more than one university. Most universities require students to spend between 600 and 1100 hours in clinical placements. Laboratory hours varied widely from 50 to over 400 hours (Ogle et al. 2002). It should not be assumed that the number of hours of clinical experience is an indicator of quality. Ogle and team point out that researchers have challenged the assumption that the quantity of clinical experience correlated with competent nursing graduates (2002). The involvement of hospitals and other facilities in the clinical education of undergraduate students is examined in a survey commissioned for the Review. Duffield, Donoghue, Uyeda, Mitten-Lewis and Forbes (2001) designed and analysed a questionnaire seeking the experience and views of health and aged care institutions concerning clinical placements for student nurses (enrolled, registered and specialist) as well as transition programs for new graduates. A total of 432 questionnaires were returned with approximately half from metropolitan and half from non-metropolitan areas. While responses were received from all States, none was received from either Territory. The sample analysed represented four sectors:
It 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). Public hospitals, a major employer of new graduates, were under-represented in the respondents to the questionnaire. Sixty-four per cent of these organisations offered clinical placements to undergraduates and between 40 and 60 per cent in the other categories accept undergraduate students. If the sample excludes day facilities and hostels and community care, over 80 per cent of health and aged care institutions accept students. Only a small number of day facilities appeared to take students for placements. Some nursing homes provide undergraduate nursing student clinical placements. However, the number is not large. 2.9.2 Transition to practiceTransition to the workplace is a difficult period for new graduates. Clare and colleagues (2002) indicate that transition issues are a constant area of concern in nursing. Of particular concern is how the new graduate is valued and included in the team or unit. Despite this, they found that 77 per cent of the 140 directors of nursing who responded to their survey rated the performance of new graduates as outstanding or good. An even higher proportion of graduates (104 useable responses) rated their experience as a graduate as outstanding or good (91 per cent of these had undertaken a structured graduate program). A similar picture is found in the Nurses Registration Board of New South Wales project to review and examine expectations of beginning registered nurses in the workforce (Nurses Registration Board of NSW 1997). The graduates had high expectations of themselves and assessed that they had adequate professional and clinical competence. Nevertheless, they recognised that they initially required guidance and assistance from experienced registered nurses. This project also indicated 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. Not all graduates are able to gain positions in new graduate programs. Duffield and colleagues (2001) report that only 38 per cent from the sample of 432 institutions surveyed provide new graduate programs. The highest proportion of programs is in the public sector where 64 per cent offered these programs. The lowest proportion is in the charitable sector where only 12 per cent had programs for new graduates. For the other two sectors (private for-profit and private not-for-profit), approximately one-quarter to one-third offered graduate programs. Even if a facility has a graduate program there is no guarantee that all new graduates employed there will be offered a place on the program. Clare and team found that ‘in 39 per cent of facilities all new graduates are offered a graduate nurse program (GNP) while in 41 per cent of facilities, less then 20 per cent of new graduates are offered a GNP’ (2002, p. 112). The level of satisfaction with new graduates commencing employment varied in Duffield and team’s study. The public sector was significantly more satisfied than the private for-profit sector, but generally institutions are ‘usually’ satisfied with the level of knowledge of new graduates. Duffield and colleagues also studied the levels of satisfaction with graduates when undertaking specific activities. They compared the results from the first three months of employment and the period between three to twelve months of commencing employment. They found that new graduates showed consistent improvement on all activities. Most sectors showed a mean score of greater than 3, which represents ‘usually’ satisfied with the level of performance. Time management had the lowest mean score for the initial period and continued to have the lowest mean score in the following three to twelve month period except for the charitable institutions where administering level IV medications had a slightly lower mean score in terms of satisfaction with graduates (Duffield et al. 2001). 2.9.3 PracticeIn Australia, nurses work in a wide range of environments including the community, prisons, acute hospitals, mental health, child care, doctors’ practices and midwifery, to name a few. Despite this, hospitals continue to employ most of the nursing workforce, so it is not surprising that the majority of graduates begin work in this setting. If the sample in the study of Clare and colleagues is representative of the population of graduates, most graduates (70 per cent) work in public general hospitals, and overall graduates work in large (55 per cent) or medium (37 per cent) sized facilities (Clare et al. 2002, p. 113). The AIHW (2001d, p. 10) indicates that the proportion of registered nurses working as clinicians in 1997 was 88 per cent. The greatest proportion of these worked in the medical/surgical area (30 per cent) with the next largest group in gerontology/geriatrics (13 per cent). The remainder were spread across a range of other contexts including obstetrics/gynaecology/midwifery (13 per cent), operating theatre (8 per cent) and mental health (7 per cent). Changes in acute hospitals mean that graduates need higher order skills than previously. Hospitals now have high levels of acuity and patients only stay in hospital for a very short length of time. Staff in acute hospitals also have to contend with the effects of the de-institutionalisation of people with mental health problems and the ageing population. All these factors require staff to have a wide range of skills and expertise. Of great interest was the need for community knowledge, the sense that nurses need to function within the community with acute skills and with community and ‘social work’ skills in acute settings. Nurses advised that more and more of their focus involves interfaces of care, multiple networks with which they liaise and a greater emphasis on health promotion, healthy lifestyle and disease or injury prevention to facilitate living and health often among an ageing population with increasing chronic disease. Death and grief, however, still colour nursing work where not all nurses are well equipped for this dimension of practice. The shape of nursing, based on the insights from participants, is changing from a hospital based model to needing one of greater seamlessness and collaboration. (Jones & Cheek 2001) Nursing has also become far more scientifically based, with technological innovations leading to a blurring of diagnostic testing and clinical monitoring. Equipment that was once used for testing is now at the bedside providing continuous data, and nurses are required to be able to use the devices and understand the data they produce. (Aitken et al. 2001). In addition, new technologies and the rapid expansion in knowledge has led to increasing specialisation among health workers and an expansion of the nursing role. The increasing specialisation resulting from developments in science and technology is well represented by Driscoll in her submission to the Review about critical care specialist nursing: Workplaces and technology are constantly changing and impacting dramatically upon nursing practice. A prime example is Coronary Care nursing. The advent and explosion of Interventional Cardiology has necessitated an urgent need for Coronary Care nurses to revolutionize their nursing practice … There is a high demand for new technology nursing skill acquisition, yet insufficient supply of nurse educators and clinical support nurses to train the nurses. In today’s highly technological healthcare system, nurses must demonstrate a high level of skills including humanistic and technological elements incorporating the knowledge and understanding underpinning the skill. (Submission No. 69)
2.10 Specialist nursesThe specialist nurse is difficult to define as there are a number of different perceptions and interpretations. The more common perception of the specialist nurse is of one who has developed high levels of specialisation in a clinical area such as critical care nursing. Another kind of specialist nurse is one who has specialised in nursing a particular group of clients such as rural and remote nurses, aged care nurses or mental health nurses. All these nurses have developed the skills and expertise necessary for a particular setting of care or specific client group. 2.10.1 EducationSpecialist education for nurses has largely drifted from hospital-based certificates into postgraduate programs at universities, although many of these programs are delivered on a cooperative basis. Unlike undergraduate nursing education, no additional funding was given to the universities to accommodate this shift. Another important player in this arena, the New South Wales College of Nursing, offers specialist courses in New South Wales and some other States and Territories. Postgraduate courses at university include higher degrees by research, higher degrees by coursework and other postgraduate qualifications that include postgraduate certificates and diplomas. Most nursing students are enrolled in higher degrees by coursework (masters level) or postgraduate certificates and diplomas, because these are the courses that provide for specialist practice. Higher degrees by research are not relevant to a discussion of the preparation for specialisation and are discussed in Chapter 7. Both reports of Ogle and team (2001, 2002) document the level of flexibility in the modes of delivery of postgraduate courses in universities. There is a wide range of access through external and mixed (a combination of internal and external) modes of delivery and a high proportion of postgraduate students are part-time. Universities are also becoming more flexible by offering an increasing number of courses online. The DEST study of online education in Australian universities in 2001 found that of a total of 187 fully online courses offered at postgraduate level 29 were in Health. Online postgraduate Health courses showed the broadest range of specialisations offered online and the number of nursing-specific courses was high. Online postgraduate nursing courses include:
While universities are identified as the provider, Duffield and colleagues comment that preparation of specialist practitioners is a feature of many collaborative arrangements between universities and health facilities. From their sample they found approximately 27 per cent of health facilities had agreements with one or more university to provide clinical experience for postgraduate students. Public institutions were the largest group and these provided a broader range of specialisations (Duffield et al. 2001). Postgraduate student numbers Across the period 1994–2000, the number and load allocated to higher education by coursework (masters degrees) increased from 403 commencing domestic students in 1994 to 820 students in 1999, and then fell to 766 students in 2000 (339 EFTSU) (Table 2.6). There is a similar pattern for domestic commencements in the ‘postgraduate other’ classifications (postgraduate certificates and diplomas); however, the peak occurred one year earlier. There were 2084 commencements in ‘postgraduate other’ courses in 2000 (1190 EFTSU). Table 2.6 Non-overseas ‘higher degree by coursework’ and ‘postgraduate other’ commencements and completions 1994–2000
Information on specific specialty courses is found in the Ogle and team reports (2001, 2002), which can be accessed on the Review’s website. In 2001 they obtained projections for the numbers likely to complete that year. In 2002, in the second part of the project, they tested the projections made for 2001 with the actual number of graduates. Projections of graduates from the 2001 data proved very unreliable in many cases and were overestimated by about 20 per cent, suggesting postgraduate projections should be treated with caution. In some instances universities overestimated in particular specialist categories by 50 per cent. Some States and Territories appear to have difficulty projecting numbers. This may be due to the increasing levels of flexibility in intakes to courses. Based on their work using broad categories, the number of actual graduates from 2001 is shown in Table 2.7. The greatest numbers of 2001 postgraduate speciality graduates were in the high dependency category (32 per cent), followed by midwifery (20 per cent) and the area labelled generic (11 per cent). The growth projected for 2002 in the high dependency category and in the community health category is of interest (Table 2.7). Table 2.7 Number of 2001 postgraduate completions compared to projections for 2002 by nursing speciality across Australia
The ‘high dependency’ area (shown in Table 2.7) has been further broken down in the 2002 project, and this is presented in Table 2.8. At the time of data collection, critical care and perioperative students were the most dominant. The Australian Capital Territory and Tasmania were not recorded in Table 2.8 due to the small number of students in the high dependency area. The Northern Territory has no students in that category in 2002 (Ogle et al. 2002). Table 2.8 2002 total number of domestic students in high dependency sub-categories for each State and Territory
2.11 Nurse PractitionerThe National Nursing Organisations (2000) in National Consensus Statement on the Recognition of Nurse Practitioners in Australia define a nurse practitioner as:…a registered nurse educated to function in an advanced clinical role. The scope of practice of nurse practitioner will be determined by the context in which the nurse practitioner is authorised to practise and will include legislative authority not currently within the scope of practice. The role of the nurse practitioner has been explored at length within the profession and in recent years a number of States and the Australian Capital Territory have undertaken nurse practitioner projects. All of these projects have made recommendations to protect the title ‘nurse practitioner’ in some manner to ensure that only nurses who hold an approved educational qualification, and who are registered or authorised as a nurse practitioner, will be able to practise in the role. Different State jurisdictions in Australia have approached the issue of nurse practitioner to varying degrees, but progress has been slow, partly due to the lack of support from some parts of the medical profession. The list below summarises the situation at the time of writing the report (additional material is at Attachment 2.4). New South Wales has progressed further than other States in implementing the role of nurse practitioner. The Nurses Act 1991 (NSW) was amended in late 1999. In October 2001 NSW Health reported that there were nine nurse practitioners authorised by the Nurses Registration Board, and that up to 40 nurse practitioner positions were to be considered for approval (NSW Health 2001a). The Australian Capital Territory Nurse Practitioner trial, recently completed, is being evaluated. The project piloted four nurse practitioner service models. The Department of Health and Community Care anticipates that the evaluation will support changes to legislation to protect the title of nurse practitioner (ACT Department of Health and Community Care 2002). In Western Australia, the April 2002 Issues Paper for the Nurse Practitioner project (Health Department of Western Australia 2002) advised that legislation required to enact the nurse practitioner role is in the process of being drafted. In the interim a tender for the provision of appropriate courses had been called. In Victoria, the Nurses Board has had, since November 2001, power to endorse eligible nurses for the nurse practitioner role. The Department of Human Services (Department of Human Services [Victoria] 2002) recently called for submissions for sustainable models of practice for nurse practitioners in targeted areas. The Nursing Board in South Australia, in September 2001, endorsed the Professional Standards Statement for Nurse Practitioner Practice, including the definition of nurse practitioner and protection of the title. An Information Kit about the nurse practitioner role was released in March 2002 (South Australian Department of Human Services 2002). 2.12 Vocational education and training (VET) systemThe responsibility for the management and funding of the Vocational Education and Training (VET) system lies with State and Territory Governments and it is through this system that enrolled nurses and trained care assistants are prepared. Although Commonwealth funds support the training sector, its contribution is through the ANTA or through targeted programs administered directly by the Commonwealth (for example, the New Apprenticeships program). The providers of vocational education and training in Australia include the State and Territory TAFE systems, adult and community education providers, agricultural colleges, the VET operations of some universities, schools, private providers, community organisations, industry skill centres, and commercial and enterprise training providers. New Apprenticeship training has been designed by industry. The program provides incentives to employers who employ a trainee, as well as personal benefits and support services for the trainee. Some enrolled nurse preparation is undertaken through traineeships and some care assistant training. 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. Industry training packages provide the framework for competencies for a particular industry or occupation, through a range of flexible training pathways. The ITAB that controls the areas relevant to nursing work is the Community Services and Health Industry Training Advisory Board. New Apprenticeships combine paid work with structured training and are ‘competency based’. Group Training Companies employ apprentices and trainees, and then ‘lease’ or place them with ‘host employers’, to complete their training. This arrangement means that businesses can become involved in the training of new apprentices without the commitment of full-time permanent employment. Under this arrangement, the host employer gains apprentices and trainees without providing assurances of long-term employment, and the apprentice or trainee is assured of continuous work and training culminating in a national qualification. New Apprenticeships offer a new training pathway for enrolled nurses. Under this arrangement there are traineeships in both Victoria and Tasmania. On completion the trainee qualifies with the Certificate IV Health (nursing). As this qualification is recognised as a New Apprenticeship under the National Training Framework, Commonwealth Government support is available to facilitate its implementation. 2.13 Enrolled nursesEnrolled nurses work in a range of settings. The AIHW (2001b, p. 11) indicates that the proportion of enrolled nurses working in medical/surgical and in gerontology/geriatrics was about one-third each for 1997. The remainder were spread across a range of other contexts including mental health and operating theatres. Despite the high concentrations in two settings, the recently published ANCI rep ort, An Examination of the Role and Function of the Enrolled Nurse and Revision of Competency Standards (ANCI 2002a), records an extensive variety of places within these setting where enrolled nurses work:Within the hospital settings enrolled nurses work predominantly in medical and surgical wards, but are also employed in a range of other wards or units, such as cardiology, renal, haemodialysis, intensive care, medical imaging, operating theatre and day surgery, outpatient clinics, geriatric assessment units, palliative care/oncology and rehabilitation spinal injury units. Within the aged care setting, enrolled nurses were employed in both high (nursing home) and low care (hostel) areas as well as dementia units and rehabilitation units. (ANCI 2002a, p. 24) The enrolled nurse is an ‘associate to the registered nurse’. They are included under the various State and Territory Nursing/Nurses Acts. All States and Territories use the title ‘enrolled nurse’ except Victoria, which refers to this level of nurse as Registered Nurse Division Two. According to the ANCI (2002a), the majority of Nurses/Nursing Acts and/or accompanying regulations require that the enrolled nurse be supervised by a registered nurse, and must only undertake lawfully delegated tasks. However, the definition of ‘supervision’ differs between States and Territories as does the length and content of the training for enrolled nurses. In revising the enrolled nurse competencies, the ANCI included the same domains as the registered nurse competencies but differentiated between the registered nurse and the enrolled nurse roles, competency units, elements and cues (ANCI 2002a p.41). The competency domains are:
Currently, enrolled nurse preparation is not included in any of the national training packages, although some training providers give recognition for some Certificates II and III developed by the Community Services and Health Industry Training Board for credit in enrolled nurse training. The inclusion of enrolled nursing in one of these packages would enable the development of articulated pathways between enrolled nursing and other occupations in the health services sector. This is particularly important at this time, as packages for training health technicians are under development at the Certificate IV and Diploma level. 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. 2.13.1 Initial education and training—enrolled nursesInformation on enrolled nurse education and training comes mostly from the work by McKenna, Long, Sadler, and Burke (2001), commissioned for the Review. In most cases, the enrolled nurse curriculum is determined through the agreements of TAFE institutes and nurse registering authorities, though there are some private providers in some States. The development of programs by different providers within the VET sector in the various States and Territories has resulted in considerable variation. In 2001, 22 capital city providers and 32 regional providers offered programs in enrolled nursing. Although most programs are offered at AQF Certificate IV, Queensland requires a diploma of 18 months duration. The Certificate IV programs are predominantly offered over 12 months full-time study or equivalent, except in Western Australia where the program takes 18 months full-time. Enrolled nurse student numbers It is difficult to provide completion data in the VET system as students enrol in modules rather than courses. As a result only numbers of commencing student enrolled nurses are shown here. Since 1997 the numbers of commencing student enrolled nurses have increased according to National Centre for Vocational Education Research (NCVER) from 3688 to 6 090 (Table 2.9). This is not the trend in all States. Western Australian numbers show considerable variation between years as do those of New South Wales and Queensland, but to a lesser extent. TAFE institutions reported that competition for places in enrolled nurse courses is high. Table 2.9 Enrolled nurse commencements by State and Territory
Programs The flexibility of programs varies considerably around Australia. In New South Wales all students undertake a full-time employment model. In 2001 there was no option available for part-time studies in that State. Western Australia also offered only full-time programs. Within the other States and Territories, there is greater flexibility for students to study either full-time or part-time. As well as TAFE institutions, there are a number of private training organisations that deliver enrolled nurse training. Some of these use traineeships as the mode of delivery. The Royal Adelaide Hospital in South Australia, for example, is an accredited private training organisation delivering enrolled nurse training through a hospital-based program. Many TAFE institutes are considering means for improving the flexibility of program 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 program across State borders for students in other States including Tasmania and Queensland. Some Queensland students travel to South Australia to undertake clinical experience. Clinical training The study by Duffield and team shows that, in contrast to the student registered nurses, student enrolled nurses were more likely to gain clinical training in the private and charitable category than in public institutions (2001 p. 36). This is not surprising since it is likely that a significant amount of that training is focused on the aged care sector. The employment status of enrolled nurses varied in relation to institutional profiles. Seventy eight per cent of institutions in the public category indicated that the students were supernumerary and most of the remainder counted them as full-time staff. A similar profile exists in the private for-profit category of institution. Enrolled nurse students usually undertake block placements in health and community settings throughout their programs. The focus for clinical practice experiences varies between States and Territories, but they all include significant amounts of aged care and rehabilitation experience. Increasingly however, programs are reducing their emphasis on aged care and rehabilitation. All the programs included in the McKenna study (2001) provided 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. Many programs have introduced placements within mental health and community care, 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 by the study, even emergency. This exposure is opening up new practice possibilities for enrolled nurses on completion of their programs. 2.13.2 Transition to practiceThere are few transition programs for enrolled nurses. The study by Duffield and team shows that supervising nurses reported that new enrolled nurse graduates have problems with time management and documentation at three months but generally the scores for satisfaction are above 2 (occasionally satisfied) (2001). The emphasis on documentation in the charitable and not-for-profit institutions represents the interests of aged care in these two types of institutions. 2.14 Trained care assistantsWhile there is an expanding body of literature on nursing skill mix, particularly in the United States and Canada (Crisp 2001), there appears to be little attention in the literature to the role of trained care assistants (by whatever name). This is an area the Review also overlooked in commissioning its research. 2.14.1 Training for care assistantsThe Community Services and Health Industry Training Advisory Body has developed two training packages that accommodate occupations and skills in related fields of health. The Community Services Training Package, which is being reviewed, currently encompasses three relevant occupations in the fields of Aged Care Work, Community Work and Disability Work. The specific Certificates that have direct relevance to people wishing to become trained care assistants are the Certificate III in Aged Care, Certificate III in Community Care and Certificate III in Disability work. Other areas with relevance to nursing work are the Certificate IV Community Services (Service Coordination) and the Advanced Diploma of Disability Work. The Health Training Package was endorsed in December 2001. The package contains qualifications from Certificate II to Advanced Diploma in areas of general health service delivery, ambulance, dental technology and dental prosthetics, dental assisting, and complementary and alternative health care. The addition of the technical health workers sector to the Health Training Package is due to be completed in 2002. While qualifications at Certificate II and III level do not encompass nurses, they do prepare a range of workers whose work is often done under the supervision of a nurse. This is particularly true in aged care. Schools in some States and Territories have begun to introduce students to care work through the senior school curriculum via these VET programs. These courses may be at Certificate II level and can articulate into Certificate III, which should be the minimum entry for trained care assistants. A range of models in education and training showing the pathway from the Certificate III trained care assistant to the nursing doctorate are shown in Table 2.4 (earlier in this chapter). These models include traineeships involving paid work and structured training, which can be on-the-job, off-the-job or a combination of both. On-the-job training is also possible under the New Apprenticeships program. Numbers in training Table 2.10 shows the number of people commencing training for 1999 to 2001 from the Community Services Training Package, which has only been in operation since February 1999. The Health Training Package is even more recent and therefore there are no commencements for these two years. Although newly introduced, the uptake of the Certificate III qualification in Community Services (Aged Care Work) has risen significantly over the three years from 1136 enrolments nationally in 1999 to 17 048 in 2001. Between 1999 and 2001, States where growth compared to size has been most rapid are South Australia, from 3 to 2473 enrolments and Victoria where the growth was from 279 enrolments to 5915 (See Tables 2.10 and 8.1). During consultations in South Australia, we heard that up to 80 per cent of unregulated workers in the aged care sector had achieved Certificate III qualifications under the Community Services Training Package due to the ‘strong leadership of the South Australian Directors of Nursing’ working in the aged care sector. There is also an increase in the number of people starting the Certificate IV in Community Services (Aged Care Work). In the same period, 1999–2001, the number of commencements in this course increased from 67 to 2308 nationally, with Queensland showing the most significant increase at the State level. Although not to the same extent as that of Certificate III in the Aged Care Work, growth occurred in commencements in Certificate III in Community Work and also Disability Work. Table 2.10 Vocational course enrolments in specific Community Services Training Packages across Australia for 1999–2001
2.15 Working relationshipsPositive working relationships are important to patient care and involve a wide range of workers and professionals with different levels of skills. Jones and Cheek (2001), in summarising the views of the nurses they interviewed, put the case this way: Strengths and positive gains for consumers were felt to occur when nurses were able to collaborate with others, to be recognised as part of a team with equal input. Many nurses gave examples of flexible working structures that see the nurse based in a number of venues with a diverse client group perhaps community based yet have acute facility input. In these examples nurses have developed ways of working positively with other health professionals and at times take on a strong leadership role. Nurses also work in teams with unregulated workers such as PCAs or AINs who provide continuity with the patient and support for a nursing role. In community health centres, the prison setting or emergency department in rural areas nurses work with greater degrees of autonomy, although they may not be recognised for such independent practice. The relationships between registered nurses and enrolled nurses are usually based on direct supervision and delegation. However, there appears to be considerable ambiguity about what the role of the enrolled nurses should be. As the associate nurse, Jones and Cheek (2001) found that enrolled nurses often regarded their practice as very similar to that of a registered nurse, except for the areas of paperwork and medication. In some settings enrolled nurses had greater input into both these aspects of the registered nurse role. Nevertheless, the enrolled nurses in the study were concerned about the apparent inconsistency, on an almost daily basis, in what they were allowed or expected to do. They argued that variation in expectations and role function occurred between wards or units within an institution and even between registered nurses on the same shift. 2.16 Legal and regulatory environmentBroad policy frameworks, as well as specific legislation and regulation, affect nursing. One policy, the National Competition Policy, has resulted in a review of current State and Territory legislation, including that covering health workers. Australian governments agreed that legislation should not restrict competition unless it could be shown that the benefits of the restriction to the community as a whole outweigh the costs, and the objectives of the legislation can be achieved only by restricting competition. Over 1700 pieces of legislation were identified by governments for review, extending across a range of industries and sectors. As part of the process, the Nurses/Nursing Acts for all States and Territories have been, or are being, reviewed as part of this process. The Legislation Review Program was most interested in restrictions on entry, registration, title, practice, advertising and disciplinary provisions of the different Nurses/Nursing Acts. To date the review has been completed in all States and Territories, with the exception of Queensland and Western Australia. In some States and Territories new or amended legislation has eventuated from the review. Some States are still considering the final report from the review in their State, with the restrictions that were the subject of the review being explored differently in the various jurisdictions. The appropriateness of applying National Competition Policy to health sector legislation, and in particular to nursing, has been questioned. The Queensland Nursing Union’s submission to the Legislation Review Program set out its concerns, stating that the regulation of nursing can be justified to protect the health of the community. The submission drew attention to the fact that nurses do not set their own fees, onerous limitations on entry are not placed for speciality practice, and nurses cannot be accused of supplier-induced demand. The report states ‘We also believe that the objective of the Nursing Act 1992, "to make provision for ensuring safe and competent nursing practice" can only be achieved by "restricting competition". That is, the safety of the community can only be assured by regulating nursing practice and those who can undertake it’. (Queensland Nurses’ Union 2001). 2.16.1 Nursing legislation and regulationIn Australia, nursing registration boards in each State or Territory established under a State or Territory Act decide whether a person has the qualifications and experience to allow them to be registered as a nurse. The State and Territory nurse registration boards come together in the ANCI, which aims to lead a national approach in evolving standards for statutory nurse regulation. All boards have agreed that new nurses must meet the ANCI Competencies (ANCI 2002a) for registration. The boards also accredit nursing preparation courses to ensure they enable students to meet these competencies. Some of the boards also accredit the institutions that deliver nursing courses. Mutual recognition To overcome the constraints posed by differing regulatory arrangements for nursing across jurisdictions in Australia, the States and Territories agreed to introduce mutual recognition legislation. As outlined in Selected Review of Nurse Regulation (Chiarella 2001), mutual recognition agreements between different States and Territories, or even countries, mean that nurses who are registered to practise in one jurisdiction can apply for registration in participating jurisdictions with a minimum of documentation. In Australia, the relevant legislation is the Mutual Recognition (Commonwealth) Act 1992. Mutual recognition arrangements came into being in May 1992 when premiers and chief ministers of Australian States and Territories signed the Intergovernmental Agreement on Mutual Recognition committing jurisdictions to implement mutual recognition from 1 March 1993. The Commonwealth legislation used to implement the Agreement is the Mutual Recognition (Commonwealth) Act, which commenced on 1 March 1993, with all States and Territories subsequently passing legislation to join the scheme. Under the Trans Tasman Mutual Recognition (Commonwealth) Act 1997, mutual recognition was extended to New Zealand. Mutual recognition has streamlined the process of registration for those nurses who wish to move between jurisdictions. This means nurses and midwives registered in one State or Territory can apply with ease for registration in another jurisdiction. While mutual recognition has simplified many of the operational matters for nurses wishing to move between States and Territories, there are differences in approach between the jurisdictions that create tensions. One of these areas is the requirement for recency of practice or evidence of continuing competence. New South Wales is the only State without such a requirement for continuing registration (Chiarella 2001). Another area of difference is the approach to decisions on the scope of practice of enrolled nurses and registered nurses, particularly in the treatment of issues such as delegation, though these may be more directly influenced by State and Territory factors other than the Nurses/Nursing Acts. In addition, mental health nursing is treated differently across the jurisdictions. Mental health nurses In the past, nurses who had completed a direct entry mental health program (psychiatric nurse education program) were placed on a register kept for this purpose. In recent times many of the States and Territories have revised their respective nurses Acts and the names of all nurses are now placed on a single register. Nurses with mental health qualifications are registered on the same register as all other nurses. In South Australia, to work as a mental health nurse, a nurse must be registered as a mental health nurse or be supervised by a Registered Mental Health Nurse. In some jurisdictions direct entry mental health nurses are registered on the single register and are authorised to practise in mental health only, for example Western Australia. This authorisation is noted on their practicing certificate/licence to practise. In most jurisdictions nurses who hold current registration can work in the mental health area whether or not they hold mental health qualifications. Midwives In all States and Territories, to work as a midwife a person must hold current registration as a midwife or be authorised or endorsed to work as a midwife. Other countries that consider midwifery to be a distinct discipline from nursing either regulate it in a separate statute or make specific provisions for midwives as distinct from nurses (Chiarella 2001). In the light of the introduction of direct entry midwifery courses in some Australian universities in 2002, the legislation in at least one jurisdiction has had to be revised. Extending regulation One of the challenges for this Review is to find the best way to protect the public while using the appropriate range of workers to do ‘nursing work’ in its broadest sense. The question of the regulation of all workers involved in nursing work, either by title or by area of work, is one that has had considerable debate. As new workers enter the health, community and aged care areas, the issue of regulation arises. To introduce regulation for a new group of workers the case for public protection needs to outweigh the restrictions on competition. This is a particular issue when considering the growth of care workers such as personal care assistants, assistants in nursing and aged personal carers. Summary of regulatory issues Despite the different types of national policy agreements, much of the legislation and regulation in areas covering health is State or Territory based, due to the division of constitutional responsibilities. This includes the legislation and regulation related to doctors and nurses, as well as a range of legislation that affects their work. These arrangements have implications for the consistency of nursing education and the concept of supervision, particularly for enrolled nurses, which is discussed in more detail in Chapter 5. 3. For the purpose of this survey, a course is defined by DETYA (2001) for its statistical collection as ‘a program of study formally approved or accredited by the institution or any other relevant accreditation authority and which leads to an academic award granted by the institution, or which qualifies a student to enter a course at a level higher than a bachelor’s degree’. A unit is defined as ‘the basic unit of a course or program, which a student may undertake and on successful completion of the unit’s requirements, gain credit towards completion of the course or program’. Units of study are sometimes referred to as ‘subjects’.
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