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National Review of Nursing Education
Jointly commissioned by the Minister for Health and Ageing and the Minister for Education, Science and Training
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Information Paper No. 2
Selective Summary of Report:
Report of the Commission on Nursing – A Blueprint for
the Future
The report of the Commission on Nursing was submitted
to the Minister for Health and Children in Ireland in July 1998. It covers
the Republic of Ireland only as Northern Ireland is part of the United
Kingdom, and nursing education has had a different history. A copy of the
report may be found on the An Bord Altranais (the Nursing Board) website
at www.nursingboard.ie/NursingCommission
. An Bord Altranais was established by the Nurses Act 1950 to take over
the functions of two bodies, the Central Midwives Board and the General
Nursing Council.
The Minister for Health appointed Ms Justice Mella
Carroll as the Chair of the Commission, plus fourteen Members.
The Commission was asked to examine and report on the
role of nurses in the health service including:
- The evolving role of nurses, reflecting their professional
development and their role in the overall management of services;
- Promotional opportunities and related difficulties;
- Structural and work changes appropriate for the effective and
efficient discharge of that role;
- The requirements placed on nurses, both in training and the delivery
of services; and
- Training and education requirements.
As part of their inquiry, the Commission also travelled
to Australia and New Zealand in March 1998 to meet with key players in the
nursing profession, including Chief Nursing Officers in most States, Area
Directors of Nursing of many New South Wales Area Health Services, members
of the Council of Deans of Nursing, the Nursing Council of NSW, the Royal
College of Nursing, the Faculty of Nursing at the University of Newcastle,
John Hunter Hospital and the Royal Alexandra New Children’s Hospital
(Parramatta), and officers of the Department of Health and Aged Care, and
the then Department of Employment, Education, Training and Youth Affairs (DEETYA).
The report tabled by the Commission drew heavily on overseas experience in
moving nursing education and training to degree programs.
The Report covers a broad range of issues relevant to
the future direction of nursing in Ireland, including regulatory,
educational and professional development, and considers the roles of nurse
managers, and the requirements of community nursing, aged nursing and
mental health nursing. Some 787 organisations and individuals made
submissions to the Commission. The Commission in turn made over 100 main
recommendations in its Report on regulation of the profession, preparation
for the profession, professional development, the role of nurses and
midwives in the management of services, and on various aspects of
specialist nursing.
The Commission made their recommendations for the
future of nursing and midwifery in Ireland within the context of a
changing health service environment. While nurses and midwives were
recognised as providing an excellent service, the rapidly changing pace of
the health service was placing increasing demands and expectations on the
profession. In acute general hospitals, trends such as shorter length of
stay resulting in high patient turnover, had affected the type of care
that patients require. Many patients are being discharged earlier into
step-down facilities or into the community. As a result they are more
dependent on intervention care that previously was only carried out in the
acute care hospitals.
The report noted that nurses and midwives themselves
acknowledged that there was a need to evaluate nursing critically as
approaches to it change from the old mechanistic, but nevertheless
effective way of task oriented nursing and midwifery, to a modern holistic
and individualised style of patient care. Such critical analysis can only
occur in the context of research and evidenced based practice.
The following sections of this paper summarise those
aspects of the Report of the Commission on Nursing which most directly
relate to the terms of reference of the current National Review of Nursing
Education.
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The Commission, considered the future needs of the
health service and international developments in nursing education, and
examined the preparation of students for entry to the profession. It
sought to provide a framework which would prepare nurses to meet future
health care needs into the next century. It believed that in the future
nurses would need to possess increased flexibility and the ability to work
autonomously.
Pre-registration nursing education in Ireland had moved
to a Diploma Program from the apprenticeship model only as recently as
1994, originally as a pilot at University College, Galway. This pilot was
extended over the following few years to all Schools of Nursing. Many
submissions to the Commission expressed concerns over the course content
and implementation of the Diploma Program. They also questioned the
concept of the program, which was seen by many as half way between the
traditional apprenticeship model of education and a degree program. The
Commission felt that the program did not reflect the culture of
self-directed learning in third-level (tertiary) institutions.
Submissions to the Commission had also suggested that
the Diploma program did not reflect international trends in nursing
education. A literature review on international developments in nursing
education, undertaken as part of the Commission, identified the increasing
integration of pre-registration nursing education into the tertiary
sector, and the fact that student nurses in Australia, New Zealand, Canada
and the United States were educated to degree level, and had been for a
number of years. This literature review identified that moves to tertiary
level degree courses in other countries had been because of a perceived
need to better prepare nurses for an ever more complex and technological
system of health provision. Graduate education was viewed as offering
nurses a more effective base on which to develop their practice skills and
master a wide variety of skills. The Commission also noted that the
clinical skills of nurses graduating from some degree programs appeared to
have been a cause of concern to health service employers in Australia
(1). However, it was also noted that after one
year of nursing practice, graduates demonstrated an improvement in their
ability to prioritise work, manage the delivery of care and in their
technical skills (2).
The Commission considered that the health service of
the future would require greater inter-disciplinary co-operation in the
delivery of health care. All other professionals in the provision of acute
health care had graduate status, and graduate education was being
increasingly demanded of the nurse of the future. The Commission
recommended that the new model of nursing for Ireland should be a four
year degree program to be introduced for the commencement of the 2002
academic year. The program would encompass clinical placements, including
twelve months continuous clinical placement as a paid employee of the
health service. The Commission believed that clinical placement was
essential in ensuring the clinical competence of nurses on graduation and
registration, and that this twelve month placement should take place
between the third and forth years of the program. This would allow
students to return for the final year of their degree and apply
theoretical knowledge to their clinical experience. Normal student
holidays would not take place during the placement period. A degree
program would provide nurses with a level of theoretical underpinning
which would allow them to develop their clinical skills to a greater
extent and to respond to future challenges in health care.
In its recommendations regarding the model of education
program to be adopted, the Commission referred to nursing degree programs
in Australia which followed a generic model whereby at the end of the
program, students are qualified to work in a variety of settings such as
general nursing, psychiatric nursing, children’s nursing and community
nursing. Midwifery was not included in the general program in Australia.
The Commission expressed concerns in relation to this generic model,
particularly in relation to some disciplines (such as psychiatric nursing)
where a student could graduate and enter practice as a general nurse with
little or no theoretical and/or clinical experience of the discipline. The
Commission decided that there was a need to retain distinct
pre-registration education programs for general, mental handicap and
psychiatric nursing to ensure the competence of nurses to work in these
areas.
The Commission envisaged that the degree program would
operate in the same manner as all other degree programs in Ireland, under
the remit of the free education system. Under such a system the State pays
the course fees provided a student does not have a previous degree from an
Irish third-level institute. The Commission was conscious that the
integration of nursing students onto the campuses of tertiary institutes
might require substantial capital investment. The Commission recommended
that the student be paid a salary during the twelve months of continuous
clinical placement at the level of eighty per cent of the first year staff
nurses salary. Following graduation, the nurse would then commence
employment at the second increment point on the staff nurse salary scale.
In recognition of the importance of mature applicants
for nursing, the Commission recommended that mature students should have a
certain percentage of tertiary level places assigned to them. Each
institute would have their own selection process for mature students, in
association with a joint interview conducted by the health service
providers and the universities. The Commission further recommended a
bursary/sponsorship system be put in place by the Department of Health and
Children to promote applications to all disciplines by mature students.
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The Commission noted that for many years, nurses and
midwives had been furthering their own education either through full time
study, distance learning courses or in-service training. This professional
development had enabled nurses and midwives to cope more effectively with
change, but many nurses undertook additional courses in an unstructured
and ad hoc manner, without a sense of direction as to which career pathway
they wished to pursue.
The consultative process of the Commission identified a
number of personal development issues facing nurses and midwives. Nurses
called for a comprehensive system of continuing professional education
providing equity in access, availability of programs and funding for
courses. The Commission also received a number of submissions calling for
support in developing expanded/extended roles for nurses and midwives.
Specialist and expanded roles in nursing had largely developed in an
informal, unstructured manner. The Commission noted that nurses needed
career guidance when selecting post-registration programs, given the
proliferation of post-registration courses of varying length, content and
academic award. The Commission sought to provide a framework which would
give cohesion to further education for nurses and midwives by accrediting
post-registration courses, taking account of standards of professional
practice, geographical spread and access by nurses and midwives, and in
particular, service need.
In considering a framework for
post-registration/continuing nursing education, the Commission gave
consideration to a number of papers, including the Australian report National
Review of Specialist Nursing Education (3).
The Commission recommended that the Minister for Health and Children make
provision for three main areas of professional development for nursing
(in-service training, continuing education, and specialist training) to be
further developed.
The Commission recommended the establishment of a
National Council for the Professional Development of Nursing and Midwifery
(the National Council) to be funded by the Department of Health and
Children, which would give guidance and direction in relation to the
development of specialist nursing and midwifery posts, and post
registration educational programs offered to nurses and midwives. A large
component of the work of the National Council would be to bring a coherent
approach to the progression of specialisation and the development of a
clinical career pathway for nursing and midwifery. It was envisaged that
the National Council would develop a comprehensive database in relation to
the provision of specialist post-registration nursing education, and would
determine the appropriate level of qualification and experience required
for entry into speciality practice (4).
Further information regarding the National Council may be found on its
web-site at
http://www.ncnm.ie/default.asp?V_DOC_ID=880
In relation to continuing education, the Commission
also recommended the establishment of a Nursing and Midwifery Planning and
Development unit at the Health Board level which would oversee the
provision of continuing nursing and midwifery education for the area
covered by each Health Board. While acknowledging the financial
implications for employers, the Commission further recommended that the
contract for service for every nurse and midwife should entitle them to
release by their employer for a minimum of two days paid study leave each
year for continuing professional development. This leave could be
accumulated over three years.
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The Commission sought to provide a framework for a
clinical career pathway in nursing and midwifery. The development of a
clinical career pathway was seen as an important step for nurses wishing
to remain in direct patient care, while at the same time advancing their
own career. In addition, the absence of a clinical career pathway in
nursing and midwifery was seen as increasingly limiting the development of
the profession.
The Commission considered a number of submissions, and
referred to a number of previous reviews, reports and UK organisations. In
additional, it drew on site visits made during the visit of the Commission
to Australia. During this visit the Commission spoke with nurse managers
and nurse educators; the New South Wales Nurses Regulatory Body, the
Australian College of Nurses, and the Council of Deans of Nursing in
Australia. Discussions were held on a range of issues including the work
of clinical nurse specialists (CNS) and clinical nurse consultants (CNC).
At the time of the Commission’s report there was no
career pathway in Ireland for nurses wishing to advance their practice in
clinical nursing and midwifery. Clinical nursing includes registered
nurse/midwife, clinical nurse or midwife specialist (CNS), and advanced
nurse or midwife specialist (ANP). The Commission recommended the
establishment of a multi-stage pathway for clinical nursing and that
progression along the clinical career ladder should be in terms of
practice and education guidelines set by the National Council.
In organising the clinical career pathway, the
Commission drew heavily on the experiences outlined in the National
Review of Specialist Nursing Education in Australia (5).
That report recommended that the career structure for nursing be guided by
seven broadband nomenclatures with related sub-specialties. These were
maternal and child health nursing, high dependency nursing, mental health
nursing, rehabilitation nursing, medical/surgical nursing, community
health nursing and functional nursing (management). The Commission
suggested that the proposed Australian model be used as a guide and
modified for the Irish nursing environment, and considered that the seven
broad band nursing categories within the disciplines should offer
flexibility to individual nurses and midwives when considering future
career plans.
The National Review of Specialist Nursing Education had
identified that the proliferation of nursing specialties in Australia, and
the equally rapid development in educational provision had resulted in a
lack of a unified scheme by which to determine requirements and
qualifications for entry to particular areas of nursing speciality
practice. The Commission was aware of a similar proliferation of
post-registration nursing courses in Ireland, with many of the courses
having an imbalance between theory and clinical practice. The Commission
suggested that the seven broad bands be used as a guide in the future
post-graduate nursing educational developments in Ireland, and that
programs should comprise theoretical instruction and a significant amount
of clinical practice. The Commission recommended that the development of
post graduate programs should be a collaborative effort by the National
Council, universities, the health service providers and the centres of
nursing education.
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The Report covered a number of other issues which were
raised during the consultative process. A short summary of the Commission’s
recommendations, in no particular order, follows:
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A number of submissions to the Commission expressed
concerns that the two year program for the education of midwives, which
includes only thirteen weeks of theoretical instruction, may no longer
prepare them to meet future service needs. There were concerns that
midwives are being trained as obstetric nurses and did not have the
preparation necessary to develop them as autonomous practitioners. The
members of the Commission drew on their visit to Australia, where they
visited a midwife-led birthing centre attached to a maternity hospital in
Sydney. The Commission felt that for midwives to offer a similar
intervention-free maternity service in Ireland, there would need to be an
improved educational program for entry to midwifery. The Commission
recommended an urgent review of the current midwifery program in Ireland,
particularly in relation to the level of theoretical instruction. The
Commission further recommended that a direct entry midwifery course should
be piloted by the Board in a maternity hospital. Such a program would
initially be provided at a Diploma level, but would move to a degree
program by 2002.
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The Commission recommended the Establishment of the
Nursing Education Forum. Its primary objective was to develop a strategic
framework for the introduction of a pre-registration nursing degree
programme in general, psychiatric and mental handicap nursing (6).
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The Commission recommended that schools of nursing
become centres of nursing education, providing a range of educational and
training services to nurses in the health service. The centres of nursing
education would have a crucial role to play during the clinical placement
of students of a degree program, and in the professional development of
registered nurses and midwives where nurses continuously need to update
their knowledge and skills.
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Traditionally there has been little difficulty in
attracting students to nursing in Ireland. In 1998, there were
approximately four applications for each place in nursing. However, the
Commission noted that the range of career options for women in the public
and private sector may have a particular impact on the numbers entering
nursing, and recommended that the Department of Health and Children, and
the Nursing Board examine mechanisms of promoting the profession as a
career option among school leavers. It further recommended that the Board
examine mechanisms for increasing the number of male candidates applying
to enter the profession.
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There appears to be little consensus within the
profession in relation to the future direction of nursing and midwifery in
the community. The Commission recommended that the Planning and
Development Unit in each health board should develop strategies to improve
communication and integration between nursing services in community care
areas. It recommended that the Department of Health and Children issue a
revised strategy statement of the role of public health nursing. Public
nurses should be allowed to focus to a greater extent on a health
promotion and preventative role in the community.
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The Commission recommended that the Department of
Health and Children examined as a matter of urgency the staffing levels in
the care of elderly services, and the Centres of Nursing Education develop
nurse education programs to meet the needs of nurses working in the care
of the elderly.
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The Commission recommended that the Nursing Board
develop a strategy in consultation with nurse educators, mental handicap
nurses and service providers, to promote mental handicap nursing as a
career.
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The Commission received a number of submissions from
state enrolled nurses regarding their access to conversion courses to
become registered nurses, that they could undertake in Ireland. The state
enrolled nurse is a UK qualification which is not recognised in Ireland.
The United Kingdom Central Council for Nurses, Midwives and Health
Visitors recognises the state enrolled nurse qualification alone as
sufficient to access conversion courses in the UK. As there is no
tradition in Ireland of a registrable nursing qualification other than
registered nurse, the Commission decided not to make any recommendations
regarding the provision of conversion courses in Ireland.
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The Commission recommended that health service
providers support nurse tutors in upgrading their educational or other
qualifications to facilitate their transition to their desired career
pathway.
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The Commission recommended that first line nursing and
midwifery managers be required to do management training before taking up
a post and be supported in continuing to development management skills.
Where appropriate, nursing and midwifery management development programs
should be run in conjunction with management programs for other
professional groups and general managers.
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The Commission recommended that health service
providers, nursing and midwifery management and nursing organisations
examine opportunities for the increased use of care assistants and other
non-nursing personnel in the performance of non-nursing tasks.
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Dianne McKenna Hantas
Nursing Education Review Secretariat
June 2001
Ms Peta Taaffe RGN RM Chief Nursing Officer,
Department of Health and Children. Has previously held posts as Director
of Nursing, St James Hospital, Dublin. Matron, Royal City of Dublin
Hospital, Baggot Street, Mercers Hospital, and Dogheda Cottage Hospital.
She is currently a member of An Board Altranais, and is Past President of
the Irish Matrons’ Association. Was a Member of the Commission on
Nursing. Representative of the Department of Health and Children on the
National Council for the Professional Development of Nursing and
Midwifery.
Professor Margaret (Pearl) Treacy BA (Lond), Msc
(Lond), PhD (Lond), RGN, Professor of Nursing and Head of the School of
Nursing and Midwifery Studies, University College Dublin. Focus of work in
recent years has been on the development of nursing practice through the
expansion of nurse education programs. She has particular interests in
qualitative research and nurses’ health promotion activities.
Representative of Third Level (Tertiary) Institutions on the National
Council for the Professional Development of Nursing and Midwifery.
Dr Cecily Begley RGN, RM, RNT, Msc, PhD,
Director of School of Nursing and Midwifery, TCD, Dublin. Has previously
worked in the Coombe Hospital as a midwife teacher and researcher and at
the Faculty of Nursing, Royal College of Surgeons in Ireland as a Lecturer
and Senior Lecturer. Representative of Third Level (Tertiary) Institutions
on the National Council for the Professional Development of Nursing and
Midwifery
Professor Anne Scott, Head of the School of
Nursing, Dublin City University. The first female professor appointed to
the University. Recently elected to the DCU’s Governing Authority. The
DCU School of Nursing offers nursing programs at both degree and diploma
level. Five hospitals provide the practical base for the DCU School of
Nursing programs: Beaumont Hospital; James Connolly Memorial Hospital,
Blanchardstown; St Vincent’s Hospital, Fairview; St Ita’s Hospital,
Portrane and St Joseph’s Hospital in Clonsilla. Professor Scott was
recently appointed to the Board of St Vincent’s Hospital, Fairview by
Desmond Cardinal Connell.
Professor Hugh P. McKenna D. Phil, B.Sc(Hons),
RMN, RGN, RNT, Dip N (Lond), Ad, Dip Ed FFN FRCSI. Professor and Head of
School of Health Sciences, University of Ulster at Jordanstown.
Coordinator of Nursing Research, University of Ulster.
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| (1) |
University of Newcastle, Central Coast Area Health Services and New South Wales Nurses Registration Board (1997) Project to Review and Examine Expectations of Beginning Registered Nurses in the Workforce. Sydney. Nurses Registration Board of New South Wales. |
| (2) |
Robertson, F. (1993) Survey of Directors of Nursing and Employer Organisations and Comparisons with Students and Faculties of Ratings of Nursing Degree Programs. Study Prepared for the National Review of Nursing Education in the High Education Sector, National Institute of Labour Studies, Flinders University and Melbourne University. |
| (3) |
Russell, R.L. Gething, L and Convery, P. (1997) National Review of Specialist Nursing Education. Canberra. Commonwealth of Australia. |
| (4) |
The National Council had its inaugural meeting in January 2000. |
| (5) |
Russell, R.L. Gething, L and Convery, P. (1997) National Review of Specialist Nursing Education. Canberra. Commonwealth of Australia. |
| (6) |
The Nursing Education Forum was
established in February 1999 and comprises 34 nominated
representatives from various organisations active in nursing education
in Ireland and an independent Chair. The Strategy was launched on 24
January 2001. The strategy called for a need for partnership between
tertiary institutions, health service providers in the provision of
nursing education, and referred to experiences of other countries
where there was a danger of nursing education being taken over by the
tertiary sector, with health service providers no longer have any
influence over it. Effective clinical placements and a clinical
environment that is conducive to learning were considered vital in the
nursing education program. |
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