5. An integrated national strategic direction

This chapter argues for greater national cohesion and visibility in the way nursing issues are addressed. We take the position that many of the challenges facing nursing cannot be met without strong and effective partnerships at all levels. Without a national whole-of-government approach endorsed by Commonwealth, State and Territory governments many of the links needed to move nursing forward cannot be established.

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Among the barriers to improving nursing care and resolving current difficulties are:

• the lack of long-term planning for the health workforce and nursing specifically

• the fragmentation of the responsibilities for different aspects of nursing and nursingeduction combined with the different contexts in which nurses work.

The lack of long-term planning is evident in the bust/boom cycles in nurse supply, the lack of consistency in the way data is collected on those who do nursing work, and the lack of visibility of nursing in national policy debate—even though it is a major contributor to health care. This lack of national cohesion is not surprising for a profession that practises in such a wide range of settings, receives its funding from various sources and is covered by State- and Territory-based legislation and regulation. However, it is a barrier to developing a national approach to an area of expertise that is becoming increasingly sought after in the global market place.

Many issues related to nursing are dealt with in isolation from other issues that are contingent on or influence them. Two important examples raised throughout the Review demonstrate this fragmentation.

• The assumptions and arrangements that isolate education from practice create blockages to the resolution of difficulties. When conditions in the workplace are not attractive it is difficult to interest new entrants in nursing. Humphris synthesised this relationship as ‘practice is the limit to growth and the limit of quality’ (2002). The current practice environment is difficult because of shortages and poor workplace culture. Those factors create problems for the transition of new nurses and the education of student nurses. Even if there was a considerable increase in demand for education places, additional supply of nurses through education would be restricted by the capacity of the healthcare system to provide quality clinical experience.

• The lack of feedback systems between workforce needs and the education system, its funding and provision mean that there is no easy way for industry to influence decisions about the availability of education and training places. The current education and training system is based largely on demand from students. Public education and training providers, the largest providers of education and training for nurses and trained care assistants, must allocate positions in an environment of competing demands for other courses. The way education funding is allocated provides few incentives for the sector to respond to service industries like health. In the higher education sector, where specialisation in areas of research and teaching strength appears to be the emerging policy direction, nursing is unlikely to bring large amounts of non government funding through commercial contracts or prestige to universities in the way courses such as medicine and law do. Universities are likely to opt to attach teaching focus to research strength.

To overcome the barriers to improvement, we have given the recommendations in this report a national focus. They are also interlinked since the factors influencing nursing are both interconnected and interdependent. In this chapter, the recommendations encourage both immediate action and the establishment of structures and processes to provide national integration and ongoing planning.

The focus of the short term is to respond to those recommendations that require immediate action and to establish an implementation task force to action, monitor and report on progress in relation to the implementation of the recommendations. The initial plan has the following elements:

• increasing the supply of nurses, both enrolled and registered

• improving access to and the quality of clinical education

• reviewing the regulatory/legislative and training barriers to effective and efficient use of the workforce involved in care work including the registered nurse, the enrolled nurse and the trained care assistant

• supporting the development of the nursing profession through education, leadership and research

• up-skilling care assistants to trained care assistants

• encouraging the retention of existing nursing staff, who are fundamental to the survival of nursing as a profession.

Since there are many stakeholders who will need to be involved in implementing the elements of this plan, the implementation task force will need to be drawn from across the health and education sectors and State, Territory and Commonwealth governments.

Recommendation 1—Implementation taskforce

Commonwealth, State and Territory health and education and training ministers should establish a national implementation taskforce to action, monitor and report on the progress of implementation of the recommendations.

Proposed responsibility: Commonwealth, State and Territory health and education and training departments

The need for a national focus, a coherent voice on nursing issues, nursing leadership and recognition and affirmation of nurses were themes of the consultations and submissions. Many stakeholders, both individuals and groups, expressed a view that the appointment of a Commonwealth Chief Nurse would help these agendas coalesce. Despite the strength of the representation on this issue, there was recognition that, without credibility and a position of influence in Commonwealth Government policy processes, such a role would do little to promote nursing.

We concur with the need for a national coherent approach, for recognition and for strong leadership in nursing, but have taken a different view on the promotion of these matters. We are of the view that the appointment of a Commonwealth Chief Nursing Officer is a matter for the Commonwealth Health Minister and her department since a person in such a role would be a government officer advising the Commonwealth Department of Health and Ageing and the Minister. Our proposal does not prejudice such a decision if the Minister wishes to make such an appointment. Indeed, we believe that all governments need systems that can provide expert advice on nursing issues, but that governments are in the best positions to judge what those systems should be.

While setting an initial direction in the work plan discussed above, the longer term vision requires the establishment of a body to provide that national focus, to bring all the stakeholders together to overview of the full range of issues related to nursing. We envisage such a body bringing together the considerable existing expertise at a national level, providing both the symbolism for the profession in terms of leadership, as well as developing leadership in nursing, promoting nursing and being a resource for government in planning health, community and aged care provision for the future.

While a national body will provide a structure to work through processes, there are three areas of strategy that form the framework for our other recommendations. The short-term work plan fits into these strategies, but the framework provides the long-term view of what we regard as the key issues for both today and the future. The three strategies are:

• building a sustainable nursing workforce

• maximising health outcomes through quality education

• capacity building.

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

The elements that will promote a sustainable workforce are as follows.

The present problems in attracting and retaining nursing staff need to be addressed immediately. There should be a major investment in retention of the existing workforce, recruitment of nurses not currently employed in nursing, and recruitment from overseas.

Recruitment from overseas must be approached with sensitivity to the effects on the country of origin. There is considerable evidence, based on current demand trends and work arrangements, that the demand for registered nurses cannot be achieved through new graduates—even if there is unlimited availability of education and training places—because nursing now competes with many career options for a limited supply of new workers.

Transition programs provide the initial sustained exposure to the daily management and application of the theory learnt during the undergraduate course or VET program. The early days of employment are a time when the new graduate will decide whether they wish to continue as a nurse. Good transition programs are therefore an essential part of any strategy to maximise the community’s investment in the education and training of the nurse by ensuring a safe and fulfilling transition from student to employee.

Appropriate skill mix and investigations about how work could be organised more productively are necessary. The evidence suggests that current arrangements are not sustainable. This is not to suggest employers should substitute other workers for professional nurses where nurses are using their expertise to the best outcomes for patients and clients. Rather, we should examine the ways in which the different skills of different groups who form the team of people doing nursing or caring work can be best organised to ensure the optimum outcomes for patients/clients. Organisations also need to use the level of expertise and competency of each nurse and trained care assistant to maximise their job satisfaction and their confidence in the work or members of the nursing team.

A sufficient supply of all levels of nursing worker is important in building a sustainable workforce. A focus on only registered nurses will not result in the appropriate use of nurses in different settings or encourage the strengthening of career pathways from trained care assistant to the range of nursing careers available. Supply needs to be increased, particularly of enrolled and registered nurses. However, achieving this requires cross-government cooperation since the preparation of registered nurses is the responsibility of the Commonwealth and that of enrolled nurses and trained care assistants of the States and Territories. It will be a considerable challenge to deal with nurses and trained care assistants as an integrated unit in thinking about issues of supply.

The availability of consistent data and a valid, reliable evidence base provides the platform for decisions on supply, skill mix and work organisation. Currently, the availability of consistent nursing workforce data is very limited. Understanding the interaction between the supply of different levels of nurse and trained care assistant in terms of the work that needs to be done is essential to making good decisions about work organisation and skill mix. Without that evidence base, decisions are often made on a limited view of what is efficient for the service provider—sometimes without much consideration of what is effective for the client/patient.

To maximise health outcomes the following need to be addressed.

The education and training of care assistants is essential to the safety of the patient/client, as well as to their comfort. Ensuring care assistants can judge when to seek assistance from those with particular expertise, perform their work and understand their boundaries and limits is essential to delivering a system that achieves the best client/patient outcomes. While there is growing recognition of the need for appropriately trained care assistants, Australia has some way to go towards ensuring that all care assistants have an appropriate level of training and even towards understanding the nature and extent of their contribution.

Clinical education is an essential component of education and training for a practice profession. As such it is an important area to ensure the quality of education for new professionals and specialists. Ensuring the appropriate funding and building collaborative relationships are key elements to providing confident and competent new professionals and specialist nurses.

Defining national standards for nurse education at all levels, including trained care assistants, and ensuring that appropriate quality assurance processes are established and maintained is important for ensuring the quality of the preparation of nurses and their assistants. Strong foundations developed through initial education and training provide the blocks on which educational pathways can be developed and career progression supported.

These transitions between careers and educational levels will become increasing important in the rapidly changing care services in which nurses work.

The capacity to develop and continue to evolve flexible and responsive education and training programs in the constantly changing environment in which health, community and aged care function is essential. Changes are occurring in many areas that influence nursing practice, from community expectations to highly sophisticated technology. With its broad professional base and range of competencies, nursing as a profession is in a uniqueposition to respond to those changes. Only if nursing education providers are attuned tothese factors and innovative in the preparation of new professionals and the development of experienced nurses will nursing be in the position to offer a potentially flexible, professional, cost effective and responsive workforce to complement the range of other health professionals.

The elements for capacity building include the following.

Nursing research and the development of nursing researchers provide the underpinning infrastructure for good decisions by policy makers and improvements in clinical nursing practice and education. As a new discipline, building up nursing research capacity is the key to better and more efficient health outcomes from nursing work. Applying the evidence to clinical practice will be an essential component of this development. Further, there will need to be ongoing research in the ways nurses are educated as new concepts of professional education and training are implemented.

Learning organisations need to develop the capacity to support and develop the knowledge and skills inside the organisation. Since the transfer of nursing education from hospitals, much of the supporting infrastructure for clinical nursing development has been lost.

Clinical development of nurses can only be done well at the site of the expertise.

Rebuilding and further developing clinical education systems in hospitals and the community and aged care sectors will provide the capacity for the services to build best practice and evaluation of practice into its systems.

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While many nurses regard the current shortages as the main factor in the increase of unregulated care workers, this appears to be a simplistic view. In the aged care sector the growth of this group has displaced many enrolled nurses. Although, the inability to attract enrolled nurses because of reduction in training places may have influenced their availability, factors like financial constraints and the flexibility of the unregulated/unlicensed worker have resulted in the overlap of the scope of practice of these workers with that of enrolled nurses, particularly in aged care. In addition, supervision requirements and restrictions on the administration of medication make the enrolled nurse less flexible than the registered nurse.

There is a lack of consistency in legislative approaches in Australia in relation to scope of practice. Scope of nursing practice refers to that which nurses are educated, authorised and competent to perform. Chiarella (2001) examined the regulation of nursing and identified the full range of responses from jurisdictions that do not define scope of practice to defining it in detail. Two approaches are evident:

• a client/patient focused approach, where client needs are identified as paramount

• an approach that defines and protects professional boundaries

These two approaches are often reflected in whether the definition of the scope of practice is permissive or restrictive (Chiarella 2001).

The scope of practice of registered nurses and enrolled nurses is treated within a regulatory framework that requires nurses to meet particular competencies to be registered. There is no regulatory framework defining the scope of practice for trained care assistants.

Approaches adopted in different jurisdictions appear to reflect nursing practice within the culture of individual healthcare systems in Australia. Queensland has developed a decision making framework to support nurses’ decisions on what fits within their scope of practice and Western Australia is using this model for some developments in this area. Other jurisdictions such as NSW use the ANCI competencies as the set of minimum standards rather than defining scope of nursing practice.

As discussed in Chapter 4, the scope of practice of nursing has changed, demanding a shift in the professional role of nurses to one encompassing the functions of care-giver and the facilitative functions related to patient education, management, communication and research.

Scope of practice is influenced by many factors. The actual scope of practice of individuals is influenced by the settings in which they practise, the health needs of people, the level of competence of the nurse and the policy requirements of the service provider (QNC 2001).

McMillan and colleagues (2001) identify contextual factors such as increased diversity in practice contexts, increased patient acuity in all nursing contexts, financial constraints, the legal and political climate, and consumer expectations. They conclude that, over the last two decades, there has been a shift in the usual practice for all levels of nursing, particularly registered nurses and enrolled nurses, with the practice of both amplified so that what was previously considered expanded practice has become the norm. Cross- and intraprofessional boundaries have become blurred.

We recognise that this is a highly complex area, one that is predominantly the responsibility of the States and Territories, but it is an area of considerable frustration to those responsible for aged care in particular because it limits the best use of staff and reduces the status of enrolled nurses. While the impact of the range of legislative approaches in the different jurisdictions has largely been on enrolled nurses, the fragmented approach to developing the nurse practitioner role and the associated legislative/regulatory frameworks may have similar consequences for that role in the future.

The Senior Nurse Advisory Group, North Western Mental Health, summarised the more general frustration for nurses this way:

(Response to the Discussion Paper).

This same report makes the case for the displacement of the enrolled nurse, evident in the statistical trends (see Chapter 5), in this way:

(ANCI 2002a, p. 15)

To achieve safe and effective medication management in aged care, the Working Group suggested a number of strategies such as:

• developing a nationally uniform extended scope of practice for enrolled nurses in medication administration

• approaching the Department of Education, Science and Training (DEST) to develop traineeships for a vocational Certificate IV in Community and Health Services

• approaching nurse regulatory authorities in the States and Territories to accredit modules in the enrolled nurse curriculum to allow enrolled nurses to administer up to and including S4 medications

• approaching the State and Territory governments to amend legislation and policy where appropriate to allow enrolled nurses with appropriate education and training to administer up to and including S4 medications

• seeking the support of the Commonwealth Government in promoting an expanded scope of practice for enrolled nurses and a nationally consistent framework for enrolled nurse practice.

There were strong representations to the Review that a new approach is needed to define and regulate the scope of practice for different types of work settings and to require training of care workers. The important attributes of this new approach were:

• responsiveness to change

• flexibility of workforce structure and work organisation

• a national approach and coverage.

Nursing must recognise the range of scope of nursing practice professionally, industrially and educationally. Scope of practice must accommodate the breadth, range, extent, effect, influence and reach of nursing activities and needs to be applicable to different practice contexts. Ongoing review of the scope of nursing practice is essential because of the changing context of care, changing patients’ and clients’ needs, and changing models of care.

The Review supports the QNC approach of using a framework that sets out principles to guide decision-making on scope of practice. A decision making framework provides the umbrella under which regulatory, sectoral and professional standards can sit. It enables linkage of all activities undertaken to ensure the competency of nurses. A similar approach is being followed in New Zealand where the Nursing Council of New Zealand is developing a competency assurance framework for nurses (2001). In contrast, the push towards the development of competencies and standards for speciality areas by different professional bodies may lead to fragmentation, not to consolidation, and to confusion and unnecessary costs.

Development of the national framework for scope of nursing practice is a major priority given the foundation role it plays in nursing work organisation and planning. National leadership is required on these matters. We therefore recommend that one of the priorities for the new National Nursing Council of Australia is to gain agreement on a professional scope of practice model that allows for a flexible workforce structure and work organisation and is based on the principles set out in this report.

Recommendation 4—Nationally consistent scope of practice

To promote a professional scope of practice for nurses and greater consistency across Australia:

a) a nationally consistent framework should be developed that allows all nurses to work within a professional scope of practice, including the administration of medications by enrolled nurses

b) to facilitate this development, all Commonwealth, State and Territory legislation and regulations that impact on nursing should be reviewed and reformed as required.

Proposed responsibility: Implementation taskforce with the NNCA

In Chapter 2 there is a summary of the developments in relation to the role of nurse practitioner in the different States and Territories. This information, combined with the more extensive material in Attachment 2.4, demonstrates that the progress has been slow and the approaches to the development of nurse practitioner have varied across the country. There is also considerable risk that, as the developments continue, the differences between States and Territories could create very different models once again fragmenting nursing.

While we hope the NNCA will be able to prevent such fragmentation occurring, we suggest that the first step towards a more cohesive national approach be the agreement on national standards for nurse practitioners. An agreed set of competencies for nurse practitioners would at least support an equivalent level of practice and the education required for the role. To assist with a more national approach, the Australian Health Ministers’ Advisory Council (AHMAC) should take an interest in this development as part of planning for a workforce that meets the needs of the health, aged and community care sectors. We believe that nurse practitioners offer considerable benefit to the aged and community care sectors as well as the acute sector and rural areas. The development of this level of nurse should be supported.

Recommendation 5—National standards for nurse practitioners

To promote a consistent national approach, the Australian Nursing Council Incorporated (ANCI) should be commissioned to establish national standards for nurse practitioners.

Proposed responsibility: Commonwealth, State and Territory health ministers

Considerable advances have been made towards a national approach to regulation and legislation for nurses under the ANCI and following the mutual recognition legislation. However, as discussed in Chapter 2, there are still some major differences between States and Territories. These differences, along with other trends such as the globalisation of nursing, the capacity to offer courses through distance modes outside the usual potential education client group and the desire to be more unified as a body of nurses, mean that discussions of national course accreditation and nurse registration continue. There is considerable support for national accreditation of undergraduate nursing courses, and consistency of enrolled nurse preparation is of particular and strong concern, but the support for national course accreditation is not unanimous. Nor is the support for a national system of registration for nurses unanimous.

Taking a contrary view, Bryant supports national regulation. She argues that, although there are some similarities between the different Nurses/Nursing Acts, the lack of a single regulatory body has resulted in varying standards for all aspects of nursing and nursing regulation in Australia. As an alternative to the ceding of powers, she suggests an ‘agreement from all jurisdictions to develop a national template for the regulation of health professionals and amendment of all relevant legislation within an agreed timeframe’  (Bryant 2001. p. 51). Of interest in this regard is the recent agreement by the Commonwealth, State and Territory ministers responsible for training (ANTA MINCO) to develop model clauses for legislation to achieve agreed national outcomes in regulating vocational education and training (Campus Review 29 May–4 June 2002, p. 7).

We observed with some interest the recent developments for a nationally consistent medical registration model. Following the draft model for medical registration developed by the Australian Council of Safety and Quality in Health Care, a working party of the Australian Health Ministers’ Advisory Council (AHMAC) prepared a discussion paper, which was released in April 2002. The paper states that:

(Department of Health and Ageing 2002a, p. 1).

Australia should also take note of the findings of The Bristol Royal Infirmary Inquiry (cited in Leap & Barclay 2001). Leap and Barclay (2001) suggest these findings put a strong argument that the system of nursing regulation needs to ensure that health professionals acquire and maintain professional competence. To achieve this the Inquiry states that the system needs to include education, regulation, training, continuing professional development, revalidation and discipline. These observations are of particular interest in the light of the significantly different approaches between the States and Territories in relation to recency of practice for nurse re-registration (Chiarella 2001). We believe this disparity needs to be resolved in a manner that promotes an approach consistent with the professional nature of nursing and the principles of lifelong learning.

In giving consideration to the developments already in place across Australia and the challenges posed in establishing national systems of course accreditation and regulation, we have come to the view that nursing needs to build on the success of the agreements already in place by developing agreed principles that underpin the nursing legislative/regulatory framework in each State and Territory. We wish to affirm the requirement that for registration or enrolment nurses must meet the ANCI competencies. One of the important challenges for future regulatory frameworks is that of ensuring that those who are registered to practise as nurses, at whatever level, are competent and current in their practice. For this reason indicators of current competence should be essential components of the agreed principles. In making the following recommendation, we believe that there will continue to be developments in this area and consider that the NNCA will need to continue to address issues related to consistency in legislative/regulatory approaches and the underpinning quality systems, such as the accreditation of courses.

Recommendation 6—National ANCI principles to underpin nursing legislation and regulation

To ensure a more nationally consistent approach to nursing, State and Territory nursing legislation and regulations should be underpinned by nationally agreed principles. These principles should include requirements for:

a) assessment against the ANCI competencies for initial registration of registered nurses and enrolled nurses

b) audited self-reporting for continuing registration of registered nurses and enrolled nurses using indicators that demonstrate currency of competence including ongoing education.

Proposed responsibility: ANCI in consultation with the NNCA

With regard to the regulation of workers who are carrying out care work, whatever their title, there was strong support for:

• mandatory training for all workers ‘undertaking nursing work’ with identified appropriate qualifications for different levels of work

• the minimum level of qualification for those involved in direct care of clients/patients to be Australian Qualifications Framework Certificate III

• articulation of Certificate III training with enrolled nurse programs to allow for career progression.

The Health and Community Services Union, in their response to the Discussion Paper, recognised the ‘increasingly significant role’ that care assistants are playing in assisting nurses with the provision of health care. However, the Union also stated that:

Protection of both the public and the worker are important for the progression of a system of care that is both viable and responsible. This protection is becoming even more necessary as demands for support in personal care increase due to population ageing. There were mixed views on whether there should be regulation of care workers. Some organisations suggested that regulation would ultimately result in another layer of worker replacing the group that has been regulated. This is a most complex issue, but it is one that needs resolution if an appropriate skill mix in the different settings of care is to be implemented.

While we take the position that the regulation of care workers may not be the best  approach in this instance, we believe that employers have the responsibility to ensure that:

• appropriate suitability checks are made

• care workers undertake only tasks for which they have the appropriate level of training and skill

• care workers have appropriate supervision for the work they are undertaking.

• Throughout the Review we received various suggestions about care workers from different

• groups on how we could achieve better outcomes in this regard.

• The Queensland Nursing Union advised us that they supported a similar model to the one proposed in the Queensland Child Care Bill and Regulation (for more detail see Attachment 5.1). The draft Bill and Regulation sets out employer record keeping obligations. These include the requirement that people working in child care services have suitability checks, and that the licensee of a child care service must keep originals or certified copies of the suitability notices of their staff as part of their records. The draft Bill also contains requirements that role statements are prepared and maintained in regard to positions in the child care service.

• Other suggestions included using the established licensing processes to require that the workforce involved in caring work have appropriate training and checks. States and Territories have various mechanisms in this regard for hospitals, both government and non-government, and there are licensing mechanisms or service contracts for aged and community services.

• Another alternative is to establish a system of credentialing workers who meet a given set of requirements, thus making them easier to identify and possibly more attractive to employers. This system would be costly to workers who are not well paid and who are often casual workers (including nursing students) and is not one we support for this reason.

As a nation, we need to ensure the protection of the public, especially those who are particularly vulnerable due to disability. This requires a system that provides the appropriate infrastructure to ensure employers take responsibility for the skills of the staff they employ for the work they are expected to undertake. We suggest that the States, Territories and the Commonwealth, in association with local governments, encourage employers to meet these obligations by introducing a system that involves one or both of the following:

• including certain requirements in either the licensing or service contract arrangements for different services

• introducing a regulatory system like the one proposed for Queensland child care services.

An agreed framework across all governments that addresses the use of care assistants and the protection of the public would prevent a new level of fragmentation in an area that affects the work of nurses.

Recommendation 7—Care workers not covered by regulation

To ensure quality and safety in the health, aged and community care sectors, all workers without relevant recognised training who are employed to provide direct care should have:

a) a common national nomenclature

b) a minimum competency level of Certificate III from the appropriate Community Services or Health Training Package

c) an appropriate suitability check.

As a matter of urgency, the Commonwealth, States and Territories should establish or utilise an appropriate system to ensure that compliance in relation to the minimum qualification and suitability checks for care assistants is achieved by 2008.

Proposed responsibility: Implementation taskforce

In Chapter 8 we propose that, as part of the response developed to meet the proposed competency requirements for care assistants, the development of systems that recognise prior learning and current competency for the vast number of experience care assistants should be implemented.

5.4 Investment in nursing

Of note in the management of the different research programs is the development of research priorities and the definition of the proportions of funding to be allocated to these priorities. The priorities are often of a highly technical nature and focus on areas considered prestigious and likely to bring overseas investment into the country. While not questioning the importance of these research investments, it is important that governments recognise that there is considerable investment in the nation’s health care, a key Australian industry. Research into nursing and the work of nurses is necessary to enable appropriate policy and practice decisions that will protect that investment and ensure the best social outcomes and ensure the effectiveness and efficiency of the healthcare system.

The Research Training Scheme (RTS) is important for the development of new researchers. The allocation of higher degree research places to institutions is made on the basis of performance under this scheme. A performance-based formula distributes places across universities based on successful research completions (50 per cent), research income (40 per cent) and research publications (10 per cent) (DEST 2002a, p. 123). Until 2004 there will be special arrangements to protect institutions from any major funding losses.

Universities offering nursing are generally among those with high proportions of undergraduate students and lower numbers of higher degrees by research. These universities will not have high numbers of completions of higher degrees by research in coming years. Consequently their performance will rank poorly in comparison with other universities with high numbers of research students. Nursing faculties are often situated in universities with an overall low ranking on research performance. Twelve of the universities offering nursing had less then 3 per cent of their students undertaking higher degrees by research in 2001. This compares unfavourably with the top three universities that had greater than 10 per cent of students undertaking higher degrees by research. None of this latter group offers nursing (DEST 2002a, p. 171).

The numbers of non-overseas nursing commencements of higher degrees by research ranged between 92 and 109 between 1996 and 2000, and the number of completions per year across the 1996 to 1999 ranged from 21 to 30. Within the broad field of health, nursing accounted for 34 out of 727 of the higher degree by research completions for all students (includes overseas students). On the basis of recent trends, a performance-based system will disadvantage nursing, particularly if universities choose to distribute research training places internally on a performance basis. There appear to be few incentives for universities to do otherwise, since nursing is likely to attract little external funding through contracts for research compared to other disciplines.

A number of possible strategies could be undertaken to develop a strong nursing discipline and research base. All will require some investment in capacity building, but the Commonwealth is not the only party with an interest in ensuring the development of research capacity in nursing. State and Territory governments and other employers also have an interest. We have targeted two areas to develop this essential capacity: the Research Training Scheme and dedicated funding for research grants and the development of cooperative research centres.

While we acknowledge the competitive funding environment, we propose that the Commonwealth with the States and Territories should examine how best to provide support for the establishment of a number of nursing research centres with research grants to support their work, and in addition to provide grants to encourage research in strategic nursing areas outside those of the research centres. More detail of the possible costings associated with our proposal is at Attachment 5.3.

Recommendation 8—Research and research training for nursing

To build capacity in a vital discipline that has only been in the university sector for a relatively short period:

a) immediate steps should be taken to ensure that the current level of postgraduate research scholarships and research training places for nurses are at least maintained, with the longer term target of doubling Research Training Scheme (RTS) commencement load by 2008.

Proposed responsibility: Implementation Taskforce and Department of Education, Science and Training

b) a dedicated pool of funding from new or existing sources should be made available over the next five years to provide research grant money and for cooperative research centres for nursing.

i. particular priority should be given to building longer term capacity and integration of research findings into practice

ii. priority areas might include evidence-based practice, aged care, work organisation, mental health nursing, and nursing in rural and remote areas.

Proposed responsibility: Implementation taskforce

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