3. Australian nursing  - the future

In the future, there will be continuing changes in the way health care and education are delivered, changes in the expectations of people receiving the services of workers within these sectors, and changes in the expectations of the workers themselves. Consequently, it is not possible to set detailed guidelines for the way nursing education should be planned for the future. What we can do is develop a decision making framework and vision for nursing that will assist in the development of nursing education, to ensure that nursing can meet the needs of future generations.

This chapter provides a framework for immediate decisions and for the development of nursing education and the practice of nursing. It incorporates a view of nursing that is inclusive in its practice and the values it endorses. It assumes a perspective on care that is person-centred and that promotes the dignity of the person. The advancement of nursing requires nurses to be knowledge workers who act in highly professional ways towards all those who form part of health, community and aged care teams and towards those for whom health outcomes are pursued. This role will be carried out in a whole-of-health context, one that incorporates the community and institutional care settings, and education and research settings.

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Health care and education are essential to the maintenance and development of the Australian community. While much of the debate at present is about resources, the values the Australian community espouses and the decisions that flow from these values, filtered through democratic processes, determine future Australian systems. Resource allocation is always a matter of values, whether these are made explicit or not. At the ICN Conference, Maynard (2001) proposed that there are three healthcare policy goals:

• the control of expenditure

• efficiency

• equity.

Efficiency always involves some form of rationing system and equity can be taken to mean either the geographic distribution of healthcare resources or the access for all to those resources regardless of their ability to pay. How these policy goals are actioned depends on the value system applied.

Of interest in looking towards the way Australia will address health policy in the future is the work being undertaken in Canada, a country very similar to Australia in the system of government and attitudes to social policy. Romanow (2002), in the interim report of the Commission for the Future of Health Care in Canada, begins with a discussion of the importance of values and the role they play in defining the issues facing health care. It is an important discussion because it demonstrates the influence of the value system of individuals and communities on issues as diverse as:

From his initial consultations, Romanow identifies four positions on resolving current difficulties and planning for the future, each underpinned by a set of values (2002, pp. 11–12).

Some people advocate more public investment through additional resources, to be paid by either increasing taxes or reallocating funds from other government programs. Others argue for more resources but through a greater sharing of the costs and responsibilities by means of options like co-payments, user fees, taxable benefits or private insurance. For both of these positions the role of governments is central to the allocation of services.

A third perspective is that market discipline will improve the system’s effectiveness, efficiency, productivity and consumer satisfaction. Advocates for this perspective argue for greater choice through both the public and private health sectors. Another view is that more cost-effective outcomes and consumer satisfaction can be achieved through reorganising service delivery to provide a seamless system.

Canada, like Australia, has a national insurance scheme to provide universal public coverage. The scheme is based on five principles made explicit in the Canada Health Act:

• public administration

• comprehensiveness

• universality

• portability

• accessibility.

Part of the role of the Canadian Commission is to interpret these principles as the demands on the system increase and attitudes change.

Similarly, Australia’s Medicare scheme structures much of the delivery of health care in Australia. It was developed in the 1980s to meet three objectives:

(HIC 2002)

The current healthcare system in Australia is shaped to a large degree by the way Medicare functions. The question of the capacity of Medicare to provide a sustainable system for the future is fuelling debate and some shifts in policy. Changes to the funding of health care will impact directly on the health professions and their relationships. Changes in community attitudes will be reflected in the roles governments take in relation to health care.

As with Medicare, the broad objectives for Australian higher education display a commitment to the individual, but also to economic and social outcomes.

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A common theme of managing change and the development for individuals and organisations in this information-rich age is that of drawing together the diverse sources of information and expertise. This is found in concepts like:

• lifelong learning

• integrating theory and practice

• team approaches to health care

• whole-of-health perspectives in planning services

• responsiveness to the context in which work occurs, rather than a focus on regulation and boundaries.

There is broad acceptance that underpinning a successful approach to life is the development of critical thinking and reflective practice. This approach assumes an evolutionary model of human development where individuals advance so that they are able to incorporate higher levels of complexity into their thinking and actions (Kegan 2002).

This concept is well known from the work of men like Kohlberg and Piaget. However Kegan’s research (2002) moves the thinking beyond the years of childhood and early adulthood. It contends that development needs to continue throughout adulthood by building on what has been achieved from the various stages of formal education. This type of thinking implies that to address a world of rapid change lifelong learning will be necessary for individual success, as well as economic development and social cohesion. To achieve these outcomes, education should be ‘not merely for the acquisition of skills or an increase in one’s fund of knowledge, but education for development, education for transformation’ (Kegan 2002).

There have also been significant developments in the way we think about ‘learning’ and its relationship to ‘practice’. Gonzi (2002) identifies these, along with other developments in neuroscience and the cognitive sciences and new concepts of knowledge and knowledge management, as influencing the need for change in the way educators approach learning for practice. Moreover, he suggests that new philosophical arguments are also leading to the convergence of these intellectual areas of activity and the insights they provide for education and training. These developments challenge educators to examine how to best prepare professionals to meet the challenges of practice now and in the future. Professionals will be required to embrace change in the way they work, manage changes in social values and consider the implications of shifts in economic policy.

Much of the current debate about health care assumes that the best way to develop delivery systems is to have an ‘integrated’ approach focusing on the needs of the consumer.

Trends in models of care are becoming more context-based, with networks between these contexts. There are high levels of specialisation developing in narrow technical or scientific areas related to specific diseases or conditions (for example, diabetes control). High levels of expertise often need to be mediated to the patient by links to centres where the specialisation resides. New ways for mediation to occur are possible with changes in technology such a telemedicine and telehealth. Hospitals also have outreach services to work with patients and are linked to clinics or centres that provide a specific service such as birthing centres.

Related to these developments, there is evidence of role considerations in relation to different settings of care. One role consideration is the trend to specialisation and sub-specialisation. In Australia, evidence for this is the drive to establish midwifery as a profession separate from, but related to, nursing, and the developments in defining national competencies for a range of healthcare technicians. Another approach is that of teams of professionals working in a way that reduces professional boundaries, and the development of roles and new practitioners (Cochrane et al. 1999). Healthcare teams do not preclude the increasing specialisation since some of these developments are in the area of technicians, a rapidly growing occupational group with narrow specialisations.

Healthcare teams are also important in areas of care like small rural communities, where clinicians require a broader level of advanced competencies due to the service they provide.

3.4 Nurses -  the 'wide ranging' healthcare practitioners

Drucker (2001) talks about nurses as knowledge workers. He lists nursing as the second new knowledge profession, a profession which is now working with old high knowledge professions such as medicine and a recent but expanding group of new professionals, medical technologists. The latter group is a response to the rapid increase in diverse specialisations. In turn, this development is due to the rapid obsolescence of knowledge and the need to link this new knowledge with hands-on tasks.

The drive to specialisation, which is also affecting nursing, could result in a health system that is highly fragmented and driven by technical expertise, rather than one focused on the needs of the patient in terms of care and cure. Nursing has the capacity to bring together those two aspects in a wide range of settings including acute, community, long-term aged care and public health. Due to the respect of the public, nurses also have an advantaged position to take on the role of the ‘knowledge broker’ (Stilwell 2002) between informed clients/patients and other health professions whose focus is on medical intervention or behaviour change.

As professionals respond to the demands of new knowledge and technology, employers will need to rethink the value of the intellectual capital they have available to them. The investment required to build the levels of expertise that are now available to organisations such as hospitals has been considerable. Although this expertise and knowledge are somewhat ‘intangible’, the identification of these resources is beginning to feature in the literature on performance drivers. While it may be unusual to consider service industries such as health care and education in this way, the investments in health and education mean these are large industries with high levels of intellectual capital. To achieve the best outcomes from this investment, identifying and maximising these performance drivers is essential.

Ferrier and McKenzie (2002) suggest that the shift to new performance drivers is promoting a new set of questions in organisations interested in maximising their performance. These questions are:

(Ferrier and McKenzie 2002, p. 6)

Organisations asking these sorts of questions are trying to identify, assess and manage the intellectual capital available through their employees. According to Ferrier and McKenzie, Karl-Erik Sveily offers a framework to understand intellectual capital that has as the ‘agent of business’ the people who make up the organisation. The three groups of ‘intangibles’ Sveily identifies are:

• Employee competency, which he describes as the capacity of employees to create intangible and tangible assets in different situations. It is this ‘competency’ that is the source of the other two intangibles in the framework, the internal structure of the organisation and the external structure.

• Internal structure consists of the concepts, systems and organisational culture and spirit.

• External structure involves the relationship with the clients of the organisation.

To ensure maximum productivity, organisations need to manage the ‘flows’ in these groups by monitoring for growth, renewal, efficiency and stability. Looking at the organisational assets through this lens provides a focus on the front-line worker since every single person in the organisation matters, particularly where the work involves knowledge management or knowledge creation.

Highly technical environments require current knowledge and updating of skills. Nurses and nurse educators are front-line workers in many of these environments and are actively involved in knowledge management and knowledge creation. Nurses have a key role in promoting and developing efficient systems and in building relationships with clients/patients. Nurse educators, whether in academic or practice environments, are essential in assisting other nurses and student nurses to develop high-level competencies and their theoretical underpinnings. These competencies enable nurses to function in a manner that promotes safe practice, and to have the skills and attitudes to work as part of a team to ensure the best care of the patient/client by building and promoting systems of support and good relationships with patients.

How do organisations such as health care and education, which are dependent on knowledge, achieve better productivity? They can do so by the following actions:

• Provide continuing development to all levels of workers, but particularly for those working in rapidly changing specialisations or areas where knowledge is developing rapidly.

• Invest in the development of staff to build a strong knowledge and skill resource base that will help the organisation meet new demands. Staff development can be achieved through mentoring, training and providing opportunities to use and extend skills, as well as incentives to develop and fill new and developing roles and transit within the organisation.

• Provide incentives for participation in sharing ideas and knowledge to improve the effectiveness of staff. Rigid hierarchies will be barriers to this occurring, as will strict professional boundaries.

• Use external networks and partnerships to add new competencies and/or knowledge.

• Promote evidence-based decision making and support research and its application.

A range of partnerships offers the potential to improve care services and develop nursing. The partnerships need to be developed at all levels, from those people and organisations working on government policy, to those supporting particular community groups, to those that provide the links between education and practice.

Among the key partnerships for health organisations are those with education providers. Both systems depend on each other. Education and training need to be relevant to the services in which the new professional will work. Conversely health care  depends on the quality of the education to accomplish its role effectively. Overarching the work of these two types of organisations and the systems in which they operate are the policies and funding systems of governments. If either policies or funding are considered in isolation, it will be difficult to achieve the types of operations that allow the relationship between education and health care to be productive. The result will be ad hoc decision making and contested responsibilities.

As mentioned earlier in this chapter, research is leading to new thinking about the education of professionals. According to Gonzi the result is a shift of focus in ‘learning theory from the individual to the social setting’ (2002, pp. 14–15). He suggests the way forward is a much stronger involvement of the practice community in education.

We need, too, a wider conception of learning which acknowledges that learning is developed through doing, through acting in the world. It is a process which involves the emotions and the formation of identity through adapting the world in which the person is situated—in the communities of practice that we live and act in.

The challenge is to shift the focus of professional and vocational education from training the individual mind, to the social setting in which the individual becomes part of the community of practice; from facts and rules stored in the brain until the need to use them, to enacting knowledge through activity; from a conception of humanity centred exclusively on the brain to a wider conception where humans are seen as embodied centres embedded in the world.

(Gonzi 2002, pp. 15–16).

The importance of the partnership approach is particularly evident at the time of induction of new health professionals. The Organisation for Economic Co-operation and Development (OECD) report suggests that the new professional has to bring together theoretical and practical knowledge developed during education and training when they begin to practise. The transition from student to worker is often a problem from the novice’s point of view. While the following material is discussing engineering rather than nursing, the comments show the importance of the link between education and the industries in which the practice professions are found.

Linking the two types of learning is one of the most daunting challenges in the education of professionals. Greater interaction between academe and industry in relation to knowledge production could usefully spill over into the investigation of best practices in the education and training of engineers, with useful lessons of mutual value. Whilst lessons from industry to the university are potentially important for the pre-service training of engineers, lessons from the university to industry will be of growing importance for the lifelong learning and continuing development required for practitioner engineers.

(OECD 2000, p. 55)

Coming out of difficult times there has been the growth in rural areas of what are termed ‘healthy communities’. Vibrance, resilience and sustainability mark these communities. There is a sense that the community believes the future is in their hands. These communities value and invest in education and training at all levels, including support for career transitions (Strengthening Community Unit 2000). Since health, aged and community care are essential components of all communities there is considerable potential for these types of rural communities to form alliances to promote educational pathways (and thus career pathways in nursing) and through this means sustain their hospital and aged care facilities.

The opportunity to develop throughout the adult years can be maximised when the system of education and training encourages people to broaden their skills or increase their skill levels while acknowledging the knowledge and skills they have already gained. The capacity of the education and training system to assist those workers who have already gained competencies relevant to another occupation or professional preparation should be enhanced and access to further education and training encouraged. For the future, when competition for workers will increase, the facility to use and develop employees interested in progressing in a career in health care, whatever their initial starting point will be important for the flexibility of the various sectors involved in care and support work.

The current systems of education and training are building in the recognition of current competencies and cross-sector qualification linkages. The national training packages developed under the Australian Qualifications Framework map between competencies to facilitate movement between different levels and occupational streams. In addition, the Australian Vice Chancellors Committee (AVCC) has a policy to support cross-sector qualification linkages in order to develop closer links between VET and higher education (AVCC 2001). The guidelines promote more efficient pathways between qualifications within the same, similar or complementary specialisation or fields of study. Used well, this system has encouraged universities to give significant credit to enrolled nurses beginning undergraduate nursing programs.

Some of the current barriers to maximising this system have been the different preparation of enrolled nurses in the various States and the assorted attitudes of universities to the provision of credit. Despite these limitations, the Australian system has been remarkably flexible in providing opportunities to enter nursing from a range of different entry points, with credit where appropriate, whether through graduate programs, enrolled nursing, TER applications or adult entry provisions. Australia is in an excellent position under the established arrangements and policies to maximise the flow into and between different levels of nursing. Nursing now needs to build its education and training to maximise on the principle of articulation between courses and training modules and also those of related professions.

The characteristics of flexibility and adaptability are identified as important in the evolving healthcare system (Department of Health 2000; Pew Health Professions Commission 1995 & 1998). More generally, research points to positive outcomes associated with the adoption of flexible workplace strategies. Flexible workplaces are associated with particular work practices and behaviours including flatter management structures, greater devolution of authority, work teams, fewer job classifications and higher levels of training of front-line workers (Selby Smith et al. 2000).

Nursing, as the largest professional group in health care, contributes significantly to the level of flexibility available to the system. The literature identifies two types of flexibility:

numerical flexibility and functional flexibility (Selby Smith et al. 2000). Numerical flexibility relates to the ability to change the amount of labour available and functional flexibility relates to the quality of labour. While there is evidence that Australian hospitals have developed policies to promote numerical flexibility through casual nursing labour, the evidence also suggests that maximising functional flexibility has received insufficient attention.

The broad-based, comprehensive preparation of nurses support functional flexibility in organisations. It is a particular strength of Australian nursing. This is demonstrated by the responsiveness of nurses in the development of new skills and specialisations.

Nurses are in a responsive role in our system because they follow medical breakthroughs in terms of developing new roles and new programs of education. This can be traced from the 60s when ventilators enabled individuals to be kept alive and doctors became intensivists and needed skilled nurses to nurse patient on ventilators. Without nurses, medical specialists cannot practice. So given this framework , we know that tomorrow if medicine changes and a new role emerges for nursing then immediately nursing will require a new specialty or model of care. As surgeons have been able to turn patients over more quickly they have developed the role of Case Manager to ensure their patients have the same or a better level of care than previously when they remained in hospital until they had healed.

(NSW College of Nursing, response to Discussion Paper)

There are growing pressures to specialisation and sub-specialisation in nursing, which in response to the highly technical developments in medicine. Care should to be taken to ensure that nursing does not lose the innate flexibility and adaptability that is its strength by pursuing increasing levels of sub-specialisation.

There are also lessons to be learnt from overseas experiences in relation to skill mix and work organisation. In the United States and Canada, the escalating costs of providing health care, combined with shortages of nurses, have driven changes in work structure in hospitals. Many healthcare institutions have been downsizing, increasing the proportion of casual workers, reducing nurse management positions and introducing larger numbers of unskilled or semi-skilled workers. These changes have made particular demands on the flexibility and adaptability of nurses, often with unintended consequences.

Some of the consequences of the use of a multi-skill level workforce could be a decrease in the ability of organisations to restructure work in response to a shift in demand. Some patterns of work structure and practice produce a reduction in the attractiveness of nursing as a career, impact negatively on patient outcomes and may not be cost effective (Aiken & Havens 2000; Aiken, Clarke, Sloan, Sochalski, Busse, Clarke, Giovannetti, Hunt, Rafferty, & Shamian, 2001; Fagin 2001). Aitken and team (2001) say that Vincent (1996) argues that to achieve restructuring, employees must be able to function autonomously, be  selfdirected, knowledgeable, flexible, empowered and require little supervision. Vincent puts the position that the use of unregulated workers is likely to increase traditional supervision and has the potential to create a reductionist and mechanistic view of nursing. There is some evidence that this is what has occurred in aged care in Australia due to similar pressures.

The above findings suggest that to achieve the right balance of skill mix and work organisation to enable nurses to work at the level of their education and training will require some careful and sophisticated research. The answer will be context-dependent since the work of a nurse in community care is very different from that of a nurse in intensive care in a hospital. One of the factors that will need to be considered in the research is the impact of different arrangements on the capacity of the workforce to respond to future shifts in demand for services. Another issue to be addressed in work restructure is the need to ensure nurses are not removed from the work of direct patient care, since this is likely to make nursing less attractive as a career.

Nursing should reflect the ethnic mix of the Australian community. As a service in a multicultural nation, reflecting the mix of culture will enable nursing to be more responsive and sensitive to the different expectations, beliefs, values and understandings of people. If being a nurse entails developing ‘an interactive/interpersonal therapeutic relationship that permits her/him to gain knowledge of the whole person and the ways in which each person defines their experience of illness’ (Marles 1988, S28 p. 26), then cultural understanding, sensitivity and safety are essential. These qualities form the essence of such a relationship and are best gained within a profession that is representative of the different cultural groups.

Indigenous Australians also need to be well represented in the nursing profession. Sufficient Indigenous nurses provide an opportunity for Aboriginal communities, particularly remote communities, to control their healthcare services. Indigenous nurses assist non-Indigenous nurses to better understand the different issues that affect health and so create more inclusive and effective health services for Aboriginal and Torres Strait Islander people.

Further, men are not well represented in the nursing profession. Attracting more men into the profession is essential as nursing needs to revise its profile so that it becomes, like most other new professions, gender-neutral. In a competitive employment environment, nursing will need to capture all those who have an interest in this work. Nurses need to position their profession as one that promotes an inclusive image.

While positioning itself as a competitive profession, nursing has already the advantage of pathways that enable those who have been disadvantaged in their schooling to make their way into the profession. Promoting these pathways and supporting those who wish to develop their careers will be essential to the development of the nursing profession.  Strengthening the linkages between industry, VET and higher education will be part of promoting an inclusive profession that offers a range of career options and possibilities for development.

Governments will need to play an important role in supporting education and training for nurses and trained care assistants and ensuring access for those from disadvantaged backgrounds. The community depends on the competence and caring of nurses and trained care assistants, most of whom will work in areas that will not be able to offer the sorts of remuneration other professions (such as law and medicine) can. Promoting the value of community service is a matter of being seen to value the work of those who provide this service.

A range of evolving technologies will challenge both the way healthcare services are delivered and the education and training needed for health professionals. Information and communication technology in particular offers the potential to overcome the limitations imposed by vast distances and sparsely populated lands that challenge the delivery of health and education services in rural and remote Australia.

The OECD (2000) suggests that the impact of information and communication technologies on potential developments in health and education could be in two significant and contradictory directions. The technologies can increase the use of centralised, linear models of knowledge production, mediation and use, and at the same time offer the potential to generate new forms of de-centralised networks that will produce and disseminate knowledge in radically new ways.

While the former use encourages centralised policy development and dissemination of best practice, this could lead to a simplistic belief that all that is needed to achieve good practice is to define and share information about it. Such centralist approaches will have little ultimate influence without recognition of the many factors that cause dissemination and implementation to fail.

In contrast, the possibilities of new forms of networking between individuals and  organisations could cause radical changes in organisation structure. The OECD report (2000, p. 57) lists questions asked by Coombs and team (1996), three of which have particular relevance to this discussion:

• Are networks a temporary phenomenon created by the novelty of ICT [information and communication technologies] or does it open radically new ways of conceptualising knowledge production and dissemination?

• Will collaborative networking lead to a revision of understanding of processes of competition and wealth production?

• What changes might this make to our understanding of organisations (firms, hospitals, schools) and the way they are managed?

Whatever the direction the different technologies take education and health care, they will have a radical impact on both, and consequently on decisions about nursing education, research and practice.

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At the conference ‘Designing the future clinical healthcare workforce’, 11–12 June 2002 in Brisbane, Mullan listed the issues for health care in the 20th century as access to services, by which he meant the availability of primary care, drugs and basic hospital services. In addition to access he noted other issues were the distribution of services, their quality and cost, as well as getting the number of staff right. In contrast, he predicts the 21st century will be one of rolling innovation and patient empowerment, stimulated to some degree in response to information and communication technology innovation. If he is correct, planning for the future must include evolving a system of care and education that has the capacity to judge judiciously and respond effectively. Evolving a system of care is dependent on the values that underpin these two systems, education and  health, because these values influence the outcomes expected of the systems—that is, what will be considered as the achievements of the system. The responsiveness of the system is very much reliant on the attitudes and capacity of the people delivering these services.

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