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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 partic | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
