National Review of Nursing Education

Contents

1. Background and Objectives

1.1 Workforce Issues

1.2 Sources of Data

1.3 Nursing Education Issues

1.4 Project Objectives

In January 2002 the National Review of Nurse Education commissioned a research team from the School of Nursing, Deakin University to undertake a project on Nursing Education in Australia. The project was a follow-up to an earlier study commissioned for the National Review of Nursing Education conducted in 2001. The present study was commissioned with the purpose of mapping nursing education programs for 2002, nursing graduate numbers for 2001 and projections for 2002, excluding data pertaining to State enrolled nurses. The project aimed to validate undergraduate and postgraduate nursing education data collected in the EIP Ogle, Bethune, Nugent and Walker (2001) study. It also aimed to explore undergraduate clinical learning programs and, at the postgraduate level, to refine the 2001 specialist categories to reflect current workplace trends.

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1.1 Workforce Issues

In Australia, nurse labour force studies are regularly conducted at both national and State levels, either in response to perceived nurse shortages or as part of routine workforce planning functions (VDHS, 2001). As part of these labour force studies nurse supply and demand is commonly assessed. Nurse supply is the available pool of nurses (mainly from tertiary institutions in Australia), while demand is usually expressed in terms of filled and vacant nursing positions in hospitals and nursing homes (Connecticut Department of Public Health, 2000). According to the South Australian Department of Human Services (SADHS, 2001), a number of factors have been identified as influencing the supply and demand of the nursing workforce. These include the average age of the population, the rate of use of health care services, technology, policy, productivity, nurse workforce attrition and the number of students entering nursing. Whilst all the factors influencing nurse supply and demand are considered important, not all these factors can be measured. For example, data on the number of nurses leaving the workforce is subjective and can be influenced by definitions of ‘leaving’. For example, leaving the workforce can be interpreted as leaving permanently, leaving for an extended period of time with the intention of returning at a later date, or leaving to take up maternity leave.

Nursing workforce issues have attracted considerable research attention, particularly in relation to human resource planning (Buchan, 1994), turnover and absence (Gauci Borda & Norman, 1997), job satisfaction, professionalism and intent to stay (Yoder, 1995). Matrunola (1996) in a study of hospital nurses identified that whilst there was no definite relationship between job satisfaction and absenteeism there was a significant inverse correlation between job satisfaction and burnout. This confirmed the finding of Irvine and Evans (1995), who found a negative relationship between job satisfaction and turnover. Poor job satisfaction equated with burnout and turnover. Numerous studies have investigated factors influencing job satisfaction and burnout, particularly in specialty nursing units (Freeman & O’Brien –Pallas, 1998) and adult critical care units (Cronin-Stubbs & Rooks, 1985).

Workforce studies, particularly in regard to stress, burnout and attrition of critical care nurses in critical care units are numerous (Cole, Slocumb, & Mastey, 2001; Cronqvist, Theorell, Burns & Lutzen, 2001; Le Blanc, de Jonge, de Rijk & Schaufeli, 2001; Turner & Ogle, 1999; Erlen & Sereika, 1997; Sawatzky 1996; Stechmiller & Yarandi, 1993; Bartz & Maloney, 1986 ; Cronin-Stubbs & Rooks, 1985; Norbeck 1985; Dear, Weisman, Alexander & Chase, 1982). High levels of work-related stress for critical care nurses is well established through these studies.

Whilst the following studies are dated it is interesting to note that McCloskey (1990), and Dear, Weisman, Alexander and Chase (1982), demonstrated that the work satisfaction of nurses in medical wards was lower than that of nurses employed in critical care units. Autonomy in practice was strongly linked to work satisfaction, and nurses in medical wards perceived that they had comparatively little autonomy in their practice. Attrition rates within medical wards could not be established. In a more recent USA study, Kippenbrock (1995) surveyed Chief Nursing Officers and found that the most common duration of employment for these senior nurses was 1 and 3 years. This suggests that perhaps equal thought should be extended to the work satisfaction and attrition of nurses in areas other than high dependency. Nevertheless, due to reports of specific shortages, high dependency areas are further explored in the present study. It is interesting to note the dominance of critical care and high dependency areas in postgraduate nursing educational programs offered in Australia.

A recent Victorian nurse labour force study identified clinical workloads, education, career structure and attrition as important factors affecting nurse recruitment and retention in the State (VDHS, 2001). In addition, recruitment and retention in some specialty areas has been identified as particularly troublesome. The study found that clinical workloads have increased to the extent that nurses no longer feel that they have control over their working conditions and environment, which may contribute to a heightened attrition rate. Further, issues relating to the cost of and access to postgraduate specialist nurse education were highlighted as a cause of stress to the nursing workforce in Victoria. Nurses in the current workforce have indicated their intention to leave the industry within the short term unless changes to working conditions occur. Improved conditions include coherent career paths and recognition of expertise and skill. Comparable nurse labour force studies have been undertaken in New South Wales, Queensland, South Australia, Western Australia and Tasmania over the last few years. Similar findings are reported by most of these studies, particularly in relation to nurse recruitment and retention. Concerns include educational issues, particularly in relation to specialist nurse education; career pathways for nurses; nursing management issues; inflexible working hours or rosters; and child care issues (Bizrac, Edith Cowan University, 1997; NSW Health Department, Nursing Branch, 2000; Queensland Health, 1999; SADHS, 1998; Tasmania Department of Human Services [TDHS], 2001).

Undergraduate nurse education is predominately covered by the Higher Education Contribution Scheme (HECS). In contrast, most postgraduate nurse education is currently full fee paying with course costs ranging from $8,000 - $10,000 (VDHS, 2001). Should limited postgraduate HECS places be available, allocation of any places is decided by the universities. At the end of their undergraduate nurse education, many nurses have a large HECS debt, currently in the order of $11,000 which makes undertaking a full fee paying postgraduate course financially difficult and which may in turn contribute to the shortage of nurses in various nursing specialties.

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1.2 Sources of Data

Accurate and timely data from which reliable information can be obtained is necessary for nurse workforce planning (Johnson & Preston, 2001; TDHS, 2001). Although there is a large body of literature suggesting an historical worldwide shortage of nurses, including Australia, there appears to be a lack of definitive data on the extent of such shortages, both locally and internationally (VDHS, 2001). Buchan and O’May (1998), in their review of commonly used indicators to assess nurse shortages, which included job vacancies, turnover rates, use of agency nurses, overtime rates, and unemployment rates, found that there were potential shortcomings of each of these indicators. For example, some nurse vacancies may not be advertised or data may be collected at an atypical point in time (such as during winter when nurse demand may be higher), and this could underestimate or inflate actual shortages. Similarly, overtime rates may not be formally recorded, particularly if paid as ‘time in lieu’, and may also underestimate actual nurse shortages.

The Australian Institute of Health and Welfare (AIHW) conducts a biannual national nursing labour force survey in association with the renewal of nurse registrations with the Nurses’ Registration Authority in each State or Territory. However, due to the enormity and complexity of the task, there is a time lapse of approximately two years between data collection and publication of the nurse workforce statistics for each State or Territory, resulting in data that may be out of date when it becomes available (Johnson & Preston, 2001; Williams, 1997). In addition, methodological problems such as unpredictable response rates, multi-state registrations, and the possible exclusion of first time registrants who may not have been required to renew their registration at the standard renewal date, may limit the use of nurse registration statistics as a sound measure for labour force planning (AIHW, 2000; Johnson & Preston, 2001).

The higher education student statistical data collection conducted by the Department of Education, Science and Training (DEST), provides data on nursing student profiles at the undergraduate and postgraduate levels by State and institution and is commonly used to inform workforce planning. From 2001, at the undergraduate level, pre-registration and post-registration student data has been combined. For some States this may have little consequence, due to the small number of students enrolled in and completing post-registration undergraduate Bachelor degrees. However, as post-registration students are already registered nurses, for some States, such as Western Australia, there are greater implications due to larger numbers of post-registration nursing students. This may erroneously imply greater numbers of new nurses entering the workforce than is actually the case. (See, Ogle et al. 2001 for a comprehensive profile of pre-registration and post-registration student numbers by State and institution). Prior to 2001, at the postgraduate level, the Commonwealth data did not represent student numbers according to workplace specialties. (From 2001, data on the following nursing specialties was collected: midwifery; mental health; community; critical care; aged care; palliative care; family and child health). In addition, national student nursing data from institutions with multi-state campuses (e.g. Australian Catholic University) does not represent students as coming from their respective States (namely, New South Wales, Queensland, and Victoria), but as appearing collectively as ‘multi-state’ data.

The EIP Ogle et al. (2001) study profiled postgraduate student numbers according to nursing specialty by State and institution, using a modified version of the broad-bands of nursing specialties identified by Russell, Gething and Convery (1997). The 10 modified broad-bands of nursing specialty used by Ogle et al. were: family and child health; midwifery; high dependency; mental health; rehabilitation/ habilitation; medical/surgical; community health; functional; research and generic. The generic category was derived from courses that did not fit any other category because specialisations were either not available in the course or were unable to be separated within the data provided. The advent of and trend towards generic courses by some institutions complicated the process of trying to accurately quantify the number of enrolled and completing postgraduate nursing students in specialty courses and was an acknowledged limitation of that study. In addition, it was found that the high dependency category did not specifically reflect workplace nursing specialties and needed further refinement. For example, representing high dependency sub-specialties such as critical care, perioperative, emergency and cardiac as separate categories may better inform workforce planning.

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1.3 Nursing Education Issues

There is ongoing debate regarding the number of HECS places made available for pre-registration nursing courses in Australia and the number of applicants for these courses. Institutions make autonomous decisions regarding the allocation and distribution of HECS places across and between disciplines and factors other than workforce planning can lead to the reallocation of student places away from the discipline of nursing. There has been a perception that there is a lack of applicants for pre-registration nursing courses and, as a consequence, the number of HECS places made available in these courses has been restricted. This response has occurred in an environment where there is strong competition between and within universities for the allocation of HECS places.

The clinical learning programs of undergraduate pre-registration nursing courses are an important part of nurse education. Nursing is a practice-based discipline and a minimum level of clinical competence is required for nurse registration, with criteria for competence being derived from the Australian Nursing Council Incorporated (ANCI) competency standards statements (The National Review of Nurse Education [NRNE], 1994). The nurse registration authority in each State or Territory is responsible for regulating the discipline of nursing. Each acts independently to monitor the clinical competency standards required by students on the completion of a pre-registration nursing program (Bethune, Wellard, Williams, Mischkulnig & Rushton, 1999).

Clinical learning experience can be a combination of off-campus clinical experience in a variety of health settings and on-campus laboratory-based skill acquisition (NRNE, 1994). The off-campus/on-campus ratio can vary across universities and depends on a number of factors including the:

Requirements of each State/Territory registering authority;
Education program of each School of Nursing;
Clinical resources available.

The NRNE (1994) found that the total number of hours in clinical learning programs in undergraduate pre-registration nursing courses ranged from 354 – 1770 hours across universities with the larger schools providing approximately 600 hours of clinical experience. An earlier study conducted in 1992 by the Australian Council of Deans of Health Sciences (cited in Bethune et al., 1999) found that the average number of hours spent in clinical experience was 894, with the range varying from 508 – 1226 hours across universities. (However, it is unclear whether the number of hours reported in these studies included on-campus laboratory-based skill acquisition). Battersby and Hemmings (1991) challenged the assumption that quantity of clinical hours resulted in more competent nursing graduates. These authors concluded that the quality of the clinical experience was more important than the quantity of clinical hours.

Quality and quantity of clinical experience in undergraduate pre-registration nursing courses is an area of ongoing discussion. To best prepare nurses for beginning practice, clinical experience in a wide variety of settings across all years of the course is essential (NRNE, 1994; VDHS, 2001). However, in a climate of fierce competition among universities, a number of economic and political factors may impact on the institutions’ ability to provide clinical experience in a variety of settings. Bethune et al. (1999) found that medical/surgical nursing was the dominant area of practice in clinical learning programs with an average of 60% of the clinical hours being spent in these areas.

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1.4 Project Objectives

The difficulties associated with capturing accurate nursing labour force statistics presents an opportunity to improve and systemise data collection policies and procedures (VDHS, 2001). One method of being able to better inform workforce planning is to have accurate data sets on student profiles at both the undergraduate and postgraduate levels. The main project objectives were to:

Validate and update the existing data to map, by State, all institutions providing undergraduate nursing courses that lead to initial nurse registration and specialty nursing practice;
Provide State profiles of current trends in domestic undergraduate nursing numbers by metropolitan, regional and rural/remote campus locations, including quantification of graduate outcomes for 2001 and projected graduate outcomes for 2002;
Provide State profiles of current trends in domestic postgraduate nursing numbers by broad-band nursing specialty, including quantification of graduate outcomes for 2001 and projected graduate outcomes for 2002;
Validate projected data from the Ogle et al. (2001) study;
Ensure that international student numbers were excluded from the data collected;
Map the hours of on-campus clinical laboratory and off-campus clinical experience in three-year undergraduate pre-registration nursing courses.

For the purposes of this study and to delineate nursing postgraduate study from small episodes of in-service education and other postgraduate study options, a postgraduate nursing course was defined as a minimum of a Graduate Certificate within the university sector. This is at least one semester of full-time study or equivalent (Australian Qualification Framework [AQF ] Implementation Handbook, 1998).

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