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National Review of Nursing Education
Information Paper No. 1Recent Australian Changes to Nurse Education and Training
1. Prior HistoryThe information provided on the historical Background to Australian Nursing Education comes from
Prior to the Second World War the pattern of education and training of registered nurses and nurse aides in Australia had been modelled on apprenticeship. Students were carefully selected by the matron on the basis of both their educational and moral standards. Vocational training, board, lodging and uniforms were provided without charge and the students received a minimal wage. In return for their training, students were expected to provide for the service needs of the hospital. Student nurses were rotated through specific clinical areas to gain experience under the direct supervision of the ‘ward sister’ in each area. It was considered essential that the ward sisters should themselves be trained nurses who were well qualified and both able and willing to teach and supervise the student nurses. Eventually this system known as the ‘Nightingale System’ became so fundamental to nursing that this method of training remained substantially unchanged in Australia for some 100 years. 2. 1943-1984This period covers the history of nursing in Australia from the first major investigation into nursing in 1943 until the in-principle national decision to make the transfer to higher education in 1984. It is characterised by the increasing pressure on the old system of preparation. The driving force, creating a sense of endemic crisis, was the recurring labour shortages that bedevilled nursing. The shortages were exacerbated by a high ‘wastage rate’ (resignation rate) among practising nurses and high dropout rates among nurses in training. For example, between 1962 and 1968, 21 213 trainees entered general nurse preparation in NSW and the Australian Capital Territory (ACT), and only 10 516 completed the course, a dropout rate of 50.4 per cent. These problems were seen by many as linked to the status of nursing and its wages, levels and conditions of work; and, in turn, these factors were linked to inadequacies in training. Increasingly – as at the turn of the century – it was training that became seen as the generic solution to these problems. However, there were fewer consensuses on where the upgraded training should take place. Major reports and inquiries show us the process of changes in the system of nurse education and training at that time. 2.1 1943-Kelly ReportThe first major investigation of the modern nursing profession in Australia could be said to date from the Kelly Report of 1943 in New South Wales. In his address to the Committee for Re-organisation of the Nursing Profession the Chairman, Mr C.A. Kelly, suggested that the primary purpose of the inquiry was to ‘improve the status and training of nurses’ and stated that he "would be pleased…if the Committee would address the formulation of a long range policy for complete reconstruction of the training of nurses and the safe-guarding of the trained nurses of the future" (Sax, 1978, p. 8). The Committee made a suggestions for better study conditions by means of a block system, for sister tutors and sister instructors to be appointed to all training schools, for postgraduate training and for the establishment of a College of Nursing. These recommendations were implemented. 2.2 1967-The Institute of Hospital Matrons of NSW and ACT CommitteeThe Institute of Hospital Matrons of New South Wales and Australian Capital Territory appointed a Committee to consider all aspects of nursing. The Report of the Committee stated that "emphasis had been placed during training on nursing procedures in order to prepare a nurse as quickly as possible for ward duties without providing the necessary correlated theoretical instruction. This had resulted in the production of a nurse who was restricted in outlook, resistant to change, and unable to cope confidently with the scientific and technical advances in medicine and the social problems of nurses" (Sax, 1978, p. 9). Part 2 of this report, published in 1969, dealt with the education of the general nurse and it stated that "it is widely held that the education of the general nurse has not kept pace with the advances in medicine and the population and social changes which have taken place in the community" (Sax, 1978, p. 9). The Committee recommended that training should no longer be the responsibility of hospitals and that Schools of Nursing should be established. It also recommended that combined university and nursing courses should be further encouraged, and that students should not be required to undertake duties other than nursing. The Committee emphasised that the program should be developed to a standard, which would enable the interest of the intelligent student to be maintained. 2.3 1968-Assignment Report, World Health Organisation, Regional Office of the PacificDr Rae Chittick, World Health Organisation consultant, examined the basic nursing program in New South Wales in 1968. He commented that "…Nursing education at the basic level remains a trade which students learn over a period of three or four years in a very limited environment. Perhaps no other group of young people in modern society receives such a narrow restricted and unimaginative type of education" (Sax, 1978, p. 10). 2.4 1970-NSW, Victorian and ACT State InquiriesThe NSW Minister for Health appointed the Committee to inquire into education of nurses in New South Wales. The Report of the Committee was published in 1970. It recommended that the education of nurses should come within the responsibility of the Ministry of Education. It further recommended that the Higher School Certificate should be the standard of entry; that Colleges of Advanced Education or Schools of Nursing should have responsibility for courses with appropriate certificates or diplomas leading to nurse registration; that the combined university degree/nurse registration courses should be extended; that small hospitals should no longer undertake training, and scholarships and financial support during education were also recommended. In Victoria, the Minister of Health established a committee of inquiry into nursing. The Committee recommended that as a pilot project, a course for the education of general nurses as full time students should be conducted under the aegis of the Victoria Institute of Colleges. It was argued that a basic university course for a limited number of student nurses might profitably be introduced on an experimental basis. The Committee drew attention to the high rate of student wastage and suggested that studies of nurse wastage rates should be undertaken. In May 1970, the Report of the Committee to Investigate and Plan Future Nursing Education in the Australian Capital Territory recommended that a Central School of Nursing should be established which would be an educational institution, in close proximity to other educational institutions and that a tertiary level basic nursing course as well as post-graduate courses in nursing should be established at the Canberra College of Advanced Education. 2.5 1973-South Australia Major Inquiry into Health Services of the StateSouth Australia instigated a major enquiry into health services in that State in 1973. It recommended that "the statutory body responsible for nurse education should ensure projections are made… of numbers required… and should carry out constant curriculum review" (Sax, 1978, p. 12) 2.6 1974 Reports from Queensland and New South WalesIn 1974 the College of Nursing Australia conducted an inquiry on education of nurses in Queensland. Its report on possible redevelopments in nurse education for Queensland considered that the community of that time needed educational programmes conducted in educational institutions, where the student was regarded as a student rather than a trainee, where an atmosphere of learning prevailed, and where learning could occur more readily. In 1974 the Nurses Education Board of New South Wales looked on the future development of nurse education in New South Wales. It commented that the lack of nursing programs in educational institutions contributed to the isolation of nursing education from the mainstream of educational thought and expertise. Other recommendations were that the range of educational institutions in which student nurses undertook courses leading to registration should be increased and that student nurses should be given full student status. 2.7 1975 "Nurse Education-What Future?" Goals in Nursing Education Report on a Conference in the ACTIn December 1975 a conference was held in the Australian Capital Territory to consider the goals in nursing education report. The report of this conference "Nurse Education – What Future?" sounded a cautionary note about the placement of nurse education in academic institutions. It pointed out that nurse education had traditionally been squeezed and deprived by service requirements so there were understandable pressures to take it out of hospitals and into exclusively educational institutions. However, there was a growing tendency to conceive of all institutions as potential learning environments and to seek to locate more of formal education in the workplace rather than away on college campuses. Academic and professional courses in tertiary institutions were under increasing criticism as being unpractical, remote and esoteric. 2.8 1978-Inquiry into Nurse Education and Training to the Tertiary Education CommissionOn 23 September 1977 the Minister for Education, Senator J. L. Carrick, announced that the Commonwealth Government had agreed to the establishment of a committee to inquire into and make recommendations to the Tertiary Education Commission on possible developments and changes in nurse education and training including whether such education should take place in hospitals or educational institutions or both. The Report 1978 addressed some problems related to hospital based nurse education and training:
Also an issue was the extent to which student nurses should have full student status with education divorced from employment and whether basic nurse training should be provided in education institutions. At the time of the Report basic training courses were offered in general nursing, geriatric nursing, nursing of the intellectually handicapped and psychiatric nursing. Most courses were of three years duration and were conducted in hospital training schools. The overwhelming majority of nurses were trained in hospital schools and there were marked variations in the quality and type of training received in them. The variations were both between States and within States. In the late 70’s the preparation of nurses remained one of the major areas of vocational education, which had not been substantially integrated within the general post-secondary education system. The opinion that nurses should be full-time tertiary students was one of the most commonly reiterated over the decade. However it was felt that moving the education and training of registered nurses into the tertiary education system and requiring a tertiary qualification for registration would:
Opposition to its transfer from hospital-based modes stemmed from a belief that hospital-based programs at that time:
Another reason for hesitation was the risk of credentialism resulting in students obtaining nursing qualifications that may not be essential to do particular jobs. Employers could then use such graduates in jobs for which their level of qualification was not necessary. Graduates may in turn become dissatisfied because their job aspirations are frustrated by the realities of the labour market. The Report stated that nursing education frequently concentrated on training in techniques to the detriment of general education. Theory and practice were poorly integrated. The report examined courses offered for the training of nurse educators separately from and in more detail than other post-basic nursing coursed because of the importance of this particular group for the education and training of nurse. The increasing need for adequate educational preparation for nurses had caused a proportionate increase in the need for adequate and well trained nurse educators. There was, in general, a shortage of fully qualified nurse educators. 3. Transfer of Nurse Education into Higher Education SectorIn line with the global movement of preparatory nursing courses into Universities, in August 1984 the Commonwealth announced its in-principle support for the transfer of registered nurse preparation from the hospitals into the higher education sector. This transfer was a staged process with different States changing at different times, but the transfer was complete by the end of 1993. 3.1 1994-National Review of Nurse EducationNational Review of Nurse Education 1994 was the first national evaluation of nurse preparation since the decision on 24 August 1984 to transfer pre-registration nursing from hospitals to higher education institutions. It became apparent to the Committee, that in some respects the transfer was not yet complete and that its effects would take at least another decade to be completely realised and understood. The Committee’s major recommendations related to the principal strategic issues before the Review including principles underlying theoretical and clinical education, assessment of competence and articulation to the first year of practice The 1994 Review of Nursing Education had as its key objective to assess whether the transfer on nursing into the higher education sector had resulted in wider professional preparation and career choices for nurses. The Review examined in particular, the provision of wider professional preparation and increased career choices for nurses. The findings of the review were that the effects of the transfer of nurse education to the universities had been uneven. The review also found that the broader professional preparation of nurses had been an achievement of the transfer, but tensions between this preparation and the conditions of institutional employment existed. Further, there were outstanding issues of the status of nursing in the universities and the relationships between the various stakeholders and their divergent expectations. 3.2. Effectiveness of Arrangements for The Education and Training of NursesNational Review of Nursing Education 1994 made the following points about the status of nursing education and training at that time:
The report included a list of broad principles, which the Committee considered should underpin quality clinical education. Clinical education needed to be negotiated formally between higher education and health agencies with transparent procedures, defined expectations and unambiguous allocation of costs. In sum, the Committee found the achievements of the transfer to higher education to have been considerable. 3.3 Articulation ArrangementsThe Committee strongly supported the development of comprehensive articulation arrangements between the different providers and the various levels of nursing education but recognised that, to be established at a general level, articulation must be based on negotiated educational commonality in which the curricula being articulated are compatible. 3.4 Labour Force PlanningThe Report underlined the nursing labour force varied between undersupply and oversupply. Shortages occur when nurses’ relative conditions and rates of pay deteriorate, and when this coincided with an economic upsurge. The end of the transfer of nurse education to the tertiary sector on 31 December 1993 was also the end of an era in nurse labour force planning. The Committee identified a need for a new system of labour force planning and coordination. The Committee recommended that each State and Territory maintained appropriate health-education cooperative planning committee(s), and associated mechanisms, to monitor and advise on the nursing labour force and/or health industry labour force in the short, medium and long term, including the number of graduates and the mix of skills required. At the State and Territory level a key role would be played by the Higher Education coordinating authorities and the State Health departments. It was envisaged that national issues would be coordinated through the Australian Health Ministers’ Advisory Council (AHMAC) and the Commonwealth-State Joint Working Group on Higher Education. 3.5 Changing ConditionsThe Report noted that the population of Australia was aging, with implications for the proportion to those who are chronically ill and permanently disabled, and the health of Aboriginal and Torres Strait Islander peoples had come sharply into focus. New management and financial arrangements, such as casemix funding, devolution and the purchaser-provider split, had become prominent. The demands of consumers had increased and became more informed. Hospital stays were becoming shorter; and, on average, people with more complex and acute conditions were being cared for at home. There was a greater emphasis on illness prevention, health promotion and participation of communities in their own health care. 4. 2001 Senate Inquiry into NursingThe current Senate Inquiry into Nursing has the following terms of reference:
The Inquiry is to report by 25 October 2001. 5. 2001 National Review of Nursing Education and TrainingOn 30 April 2001 The Honourable Dr David Kemp, Minister for Education, Training and Youth Affairs and the Honourable Dr Michael Wooldridge, Minister for Health and Aged Care announced a Review into Nursing Education. The Review has the following terms of reference:
The National Review of Nursing Education and Training is to report in April 2002. ReferencesSax, S. 1978, Nurse education and training, report of the Committee of Inquiry into Nurse Education and Training to the Tertiary Education Commission (TEC), Canberra. Reid, J. C. 1994, Nursing education in Australian universities, report of the national review of nurse education in the higher education sector.
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