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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.3
Summary of KPMG Final Report to Nursing Council of New
Zealand May 2001:
Strategic Review of Undergraduate Nursing Education
The Nursing Council of New Zealand (the Council)
governs the practice of nurses and midwives. The Council sets and
monitors standards in the interests of the public and the professions, and
recently appointed KPMG Consulting to undertake a strategic review of
undergraduate nursing education in New Zealand. The overall objective of
the review was to provide detailed recommendations to the Council on the
preparation of nurses to meet health sector requirements in 2010.
The review commenced in February 2000 and KPMG provided
its Final Report to the Council in May 2001. The Review employed both
formal and informal consultation processes. Approximately 120 submissions
were received from organisations and individuals during the conduct of the
review. A virtual reference group was established to provide an advisory
role in relation to the consultation processes with specific groups.
Formal consultations were held with key groups and individuals during the
Review process with the aim of identifying and clarifying issues and
exploring themes and concepts as they were formulated throughout the
Review process.
The Final Report consolidates the findings and issues
identified in a series of discussion papers prepared for the Review, and
provides a series of recommendations that, when implemented, should enable
the Council to prepare comprehensive nurses to meet expected health care
requirements in the year 2010. This report can be found on the Council’s
web site at
http://www.nursingcouncil.org.nz
The New Zealand review is of interest because of its
wide treatment of the changing context of nursing and the attributes
required of nurses of the future. The Final Report also covers such issues
as practical training, first entry to practice after graduation, and Maori
and Pacific Islander issues around health education and health service
provision. Consistent with the objectives of the review, the report
focuses on the preparation of registered nurses, but acknowledges the
relationship of the newly registered nurse to the preparation of the Nurse
Practitioner at one end of the clinical continuum, and the team support
assistant or "second level carer" at the other. The report notes
that the need for recognition of this clinical continuum cannot be
overemphasised, as the risk of a fragmented approach will do little to
support integrated workforce development strategies.
Nurses of the future will need to be responsive to a
range of forces that may shape the future environment in which they will
practise, and which will determine the key attributes and skills they
require. The logic of the review process was based on the premise that in
order to understand the educational requirements for the preparation of
nurses in the future, it is critical to understand both the context in
which practice may occur and the nature of the future practice.
For this reason the Review was conducted in three
phases, commencing with an environmental scan in Phase 1 that was used to
inform the subsequent phases. The review used the discussion paper
approach for each phase to engage debate about the issues. The papers were
placed on the Council’s web site and comments were invited. The papers
may be found at
http://www.nursingcouncil.org.nz/pub.html
The Final Report includes a summary of the outcomes
from the environmental scan which highlight the expected health care needs
of the community and the likely environment in which services will be
provided in 2010. Phase 2 provides a vision for the nurse of the future,
identifying the key skills and attributes that will be required by the
nurse of 2010. These two sections provide the basis for the major
component of the report in Phase 3 that focuses on the educational
preparation required for the future. The three phases are examined in
depth in the report. A brief summary of each phase follows.
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The report observed that Health service and education
provision is deeply affected by political, social and economic forces.
Because both education and health services in New Zealand are largely
funded and planned for by governments, they are particularly subject to
prevailing political philosophies. Phase 1 of the review was to define,
describe and assess the impact of the influences on current undergraduate
nursing education and therefore on the health sector. Two papers were
published for Phase 1:
- Trends and Influences on Health and Nursing - this paper was
designed to encourage discussion about the strategic issues
influencing the health and disability support sector, in order that
any planning for the nurse of the future anticipates what health and
disability support services may be like in 2010, and
- Trends and Influences on Nursing Education - this paper was
designed to encourage discussion about the strategic issues
influencing the education sector, to challenge thinking about what
education may look like in the year 2010 and in particular how the
wider influences may impact on nursing education.
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During the 1980s and 1990s in New Zealand, economic
rationalism underpinned some major changes to public sector management and
led to alterations in the financing and structure of the health and
disability support section. The present New Zealand labour government,
reflecting some worldwide political trends, is attempting to redress the
balance of focus on the individual, with focus on the public good.
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The health system is similarly influenced by political
ideologies, but is more markedly influenced by technological, scientific
and professional advances. Many of the future trends are already impacting
on the health system – decreasing hospital stays, changes in surgical
techniques, demographic pressures and changing disease patterns.
Further, over the last decade there has also been a
greater degree of political scrutiny of health and education sector
activities, through contracting requirements and a shift in emphasis from
inputs and outputs to outcomes, combined with less of an emphasis on
public policy regulation.
The report notes that the present New Zealand
government is promoting a culture of prevention, population health and
evidence based care, but the system may not change as quickly as expected
due to the need to change both consumer and professional attitudes in a
climate where forces have a tendency to promote the status quo as opposed
to readily embracing the opportunity to change.
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The report identifies three driving forces for the
future: consumer and community need, global and electronic connectedness
and scientific developments.
-
Better education and the
increased availability of information is creating more informed and
demanding consumers. Collectively, public expectations regarding
health and health care are also rising. The workforce of the future
will need to be equipped to relate effectively to an informed and
demanding community.
-
Continued investment in
telecommunications will lead to global and electronic connectivity, as
people are able to access information and expertise anywhere in the
world. Geographic isolation, a major impediment to access and
communication in the delivery of health services, will be largely
overcome. Increasingly, the health workforce will be required to
up-skill in the area of information, information systems and
information management while also managing the implications arising
from the ability to access global information and global expertise.
-
Scientific developments and
resultant advances in medical technologies continue to transform the
way in which services are organised and delivered. In the future,
health care providers, including nurses, will be required to redefine
their relationships with increasingly independent patients who are
more informed about treatment and provider options.
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The report observed it was critical that nurses have a
comprehensive understanding of the socio-political and economic
environment, and constraints inherent in any publicly funded resource
allocation system. The report stated that it will be professionalism in
conjunction with a flexible and innovative approach to providing patient
care, which will enable those who are within nursing to meet the
challenges of the future.
The environmental scan identified a number of key
forces and trends impacting on the health care environment which were
fundamental to the future role and scope of practice for registered
nurses.
2.4.1 Technology and consumer
driven health care - is without doubt the strongest and most
consistent implication. The challenge for the nurse of 2010 will be how to
work in partnership with consumers from a range of cultures and varying
situations to meet their often complex needs and technological literacy.
2.4.2 Developments in medical
technology and information technology - will present
opportunities for nurses in terms of specific skill development. The need
for nurses in a robotic and technological consumer driven health care
system, will depend upon them adding value in ways which are very
different to the year 2000.
2.4.3 Multi-disciplinary,
inter-sectoral service provision will be the norm with health
care operating from both real and virtual settings. A range of new titles
reflective of roles rather than professional groupings will describe the
care providers of 2010. Nurse practitioner roles will be established in a
range of settings, and nurses will need a well developed understanding of
the practice of nursing in order to establish a clear nursing focus within
the multi-disciplinary team.
2.4.4 Consumer expectations for
hospital care at home will be far stronger and nursing skills
previously confined to hospitals will be more common in the home
environment.
2.4.5 An outcome focused service environment
will describe the context for nursing practice in the future. Evidence
based nursing practice will be the norm and clinical governance and an
emphasis on efficiency, accessibility and quality will drive the
development of care protocols and case management. Nurses will need
enhanced business and management skills to take advantage of the
opportunities presented in this environment.
2.4.6 Care of people with chronic illness
and increased screening and prevention programs will provide opportunities
for development of nursing roles in 2010. New nurse-led roles in care
coordination and case management will draw upon clinical as well as
enhanced information management skills.
2.4.7 Job re-engineering and uptake of new roles
- flexibility and adaptability will be fundamental requirements for nurses
and the strong role delineation between professional groups will be
diminished. Practices currently in the domain of nursing may be undertaken
by others and those skills currently practised by other health
professionals, for instance the prescribing of medications, may be within
the domain of nursing.
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A discussion paper Defining the Nurse of the Future
was developed for this phase of the Review to ascertain the scope of
practice in 2010. This section of the Final Report focused on the key
skills and attributes that the nurse of 2010 will require in order to
operative effectively in providing health care services to individuals and
communities.
For policy makers and funders in New Zealand the major
driver for service delivery and funding changes has been increased
efficiencies and developing local solutions to problems. The report noted
that there may be a shift in emphasis to increasing effectiveness of
service provision in the near future, and that the challenge for nursing
will be to promote change and enhanced practice.
The predominant influences on the enhancement of
nursing practice over the next few years are thought to be enhanced scope
of practice; more favourable funding, employment and contracting
mechanisms for nursing service delivery; and a focus on patient outcomes.
Additionally, the report identified areas of growth for nursing practice
including multi-disciplinary practices, working in culturally appropriate
and/or remotely situated positions, working with the elderly, working in
less medically dominated models, and working in highly technical
environments. In order to facilitate this change in practice, and to take
advantage of new and exciting delivery challenges, nurses will need to
increase their political and financial awareness - a need highlighted in a
number of submissions to the review. More nurses will need to position
themselves politically within policy and funding organisations to ensure a
nursing perspective is brought to strategies and solutions.
The report further identified a number of issues
specific to Maori and Pacific Island communities that had been identified
in submissions to the Review, such as continuing health disparities in an
increasing population of Pacific peoples in New Zealand, and an
understanding of the Maori holistic views of health.
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The report identifies key attributes or qualities that
it feels will distinguish the nurses of 2010 and that will enable them to
operate effectively as a health professional.
3.1.1 Clinical Inquiry
- Nurses with comprehensive skills will be required in the health care
system of 2010, but there will be an increasing emphasis on practice
specialisation. The development and redefining of roles such as nurse
practitioners are indicative of this trend. Nurses will increasingly find
themselves in specialist roles.
3.1.2 People Skills -
Nurses will need the ability to communicate, consult and negotiate to
operate effectively in a consumer driver environment, where the context of
care delivery will be increasingly multi-disciplinary and team based in
focus. Further, the ability of nurses to consult with and negotiate across
professional, government, private and consumer organisations will be
critical to ensuring that nurses retain a strong voice in shaping health
care policy.
3.1.3 Health Technology Skills
Advances - in health technology, either in the area of
equipment or pharmaceuticals, will continue to impact on every aspect of
nursing.
3.1.4 Information Technology
Skills - Information technology skills will be important to
the nurse of the future and they will need to be an integral part of the
nursing curriculum. The nursing education process should foster and
support the development of information technology skills.
3.1.5 Business and Management
- the funders of health care services will expect greater accountability
for their investment in the system. Sound business skills will be
essential to nurses operating or establishing practices in such diverse
areas of advocacy, health promotion, direct care, education, research,
management or consultation.
3.1.6 Culturally safe
- over the next decade service delivery models and health care facilities
will evolve to reflect the changed cultural profile of New Zealand.
Increasingly the services provided to Maori, Pacific and Asian communities
will be determined by the needs and expectations of each group. Nurses
will work in partnerships with specific communities to determine and
define the location, type, and range of services required.
3.1.7 Flexible and Adaptable
- nurses will be increasingly challenged as they are asked to operate in a
fluid and dynamic practice environment, presenting challenges to the way
they may have traditionally interacted with their patients and other
professionals.
3.1.8 Knowledgeable -
the nurse of the future will need to base practice on a core set of
clinical skills that reflect and build upon nursing knowledge. Fundamental
skills of problem identification, analysis and synthesis of information
will be essential, as well as a commitment to continual learning.
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The discussion paper developed for Phase 3 of the
Review, "Preparation of the Nurse of the Future" outlined some
of the key developments since the transfer of nursing education from
hospitals to polytechnics, and puts forward a number of models for nursing
education in the future to stimulate debate on how nursing education
should look and how it can best prepare nurses for the future health care
environment.
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The importance of nursing recruitment for the future
cannot be understated. Nursing is one of many choices for school leavers
and mature students, and suffers from common stereotypical imagery amongst
potential applicants. The report recommended that nursing recruitment
should be nationally co-ordinated, high profile and targeted at the
recruitment of specific groups. The report further recommended that
flexible approaches to support distance learning in rural settings needed
to be established, including contracting rural nurses to assist in the
delivery of the necessary education, provided quality monitoring systems
and support were present.
The report noted that the recruitment to nursing and
promotion of positive aspects of nursing is a worldwide challenge and
significant resources are being invested across the world to encourage
university entrants to select nursing. The issues of marketing and
recruitment to the profession are intrinsically linked to the education
preparation and the challenge is to combine these so as to ensure future
programs both attract and retain students as well as prepare them for the
realities of their chosen profession.
On the issue of entry into nursing programs, the
importance of preparation courses for nursing, cadetships, school career
education and counselling programs, articulation and recognition of prior
learning were identified. The report recommended a nationally funded and
co-ordinated program to promote nursing to career education counsellors.
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It is necessary in the educational preparation of
nurses, that partnerships between service providers and support for
students in their teaching and learning, can help new graduates to have a
realistic expectation of their chosen practice environment. The report
recommended that collection of data at renewal of practising certificates
remain mandatory in order to inform and improve workforce planning and
understanding of nursing employment and retention issues. The report also
recommended a national professional forum be established to enable all key
nursing groups to plan and work together in promoting a consistent
approach to promotion and development of the profession.
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4.3.1 Curriculum
On the basis of the submissions received and
examination of details included in the Australian, Irish and UKCC reviews,
there were a number of consistent threads which could be identified as
being critical to a comprehensive curriculum. The review recommended that
undergraduate nursing curriculum be required at a minimum to demonstrate
incorporation of the following threads:
- Professional nursing practice
- Social and behavioural science
- Maori health
- Mental Health
- Cultural safety
- Evidence based practice and
- Health assessment.
The report also recommended that education providers
demonstrate how outcomes such as critical thinking, clinical inquiry and
decision making skills will be achieved through their curriculum.
It was recommended that mental health nursing
preparation continues as part of a comprehensive undergraduate program
that integrates with structured entry to speciality practice programs, and
that all undergraduate students have access to appropriate mental health
learning environments. Further undergraduate programs should include
modules to facilitate focused experience for students seeking to focus on
mental health following graduation.
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4.3.2 Assessment
The Nursing Council is responsible for setting the
competencies against which the school programs assess students. The
Council also prescribes the minimum number of hours that students should
experience in practice and theory. A number of submissions had reported
that clinical assessment was in some cases an ad hoc arrangement, and the
Report recommended that approval of undergraduate nursing curricula needs
to be contingent upon evidence of clinicians and educators having jointly
developed assessment strategies for the program. Further, it recommended
that education and service providers work together to establish joint
arrangements for undertaking clinical assessment, whereby accountability
is shared.
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4.3.3 Clinical Teaching and Learning
The effective management of clinical teaching and
learning is a major challenge for both nurse educators and service
providers. In New Zealand the restructuring of health services, and the
unbundling of funding for clinical placements had contributed to reduced
clinical experiences being available for students. The current requirement
for 1500 hours for each of clinical and theory in the program was based on
the original decision to move nursing education into the polytechnic
environment. Submissions to the review were overwhelmingly in favour of
retaining the current clinical allocation of hours, but needed to address
more appropriate and better management placements.
In Australia there is considerably flexibility and as a
result greater diversity in models of clinical teaching. It also noted
that there has been considerable debate in the literature since the
transfer of education to the higher education sector in Australia in
respect of the relationship between competency outcomes of students and
hours of clinical experience. The report recommended that the Nursing
Council develop, with education and service providers, an approach to
achieving entry to practice competencies that does not rely on an
assumption of prescribed hours of clinical experience, and that nursing
education providers include quality clinical experience in the first year
of the undergraduate program.
The report noted that as the strong message from
overseas evaluation of undergraduate programs is that the clinical
component needs to be emphasised, and as feedback to the Review strongly
suggested maintaining or increasing, not reducing, clinical experience, it
was appropriate to use the opportunity of the report to demonstrate a
stronger commitment to the clinical practice component. The report
recommended that the prescribing of the 50:50 ratio between theory and
clinical practice cease, and that the Nursing Council requirements focus
on ensuring that education providers demonstrate provision of quality
clinical experience throughout the undergraduate program.
On the subject of supervision, the report recommended
that education providers establish programs for the preparation and
support of clinical facilitators, and strongly encouraged the use of the
preceptorship model during student clinical experience.
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4.3.4 Partnerships
The report noted that effective partnerships between
education and service providers are required if nursing students are going
to have access to an appropriate range of experiences. These are
challenging relationships to manage across a number of institutions,
services and settings. Partnership is an essential tenet of nursing
education and this should be exploited is as many different opportunities
as possible between education and service providers to ensure that
clinical teaching is effective in producing competent registered nurses
for the future.
As undergraduate programs move increasingly to
emphasise competencies that reflect the health system expectations of the
twenty-first century, so too must the modes of delivery. The New Zealand
context lends itself well to flexible learning and a number of submissions
to the Review advocated this approach as one that would meet the needs of
many groups of students. Further, if students are to gain the best quality
educational preparation, then partnerships between educational providers
are necessary.
The report recommended that the New Zealand government
establish incentive schemes for education providers and students to
encourage clinical experience in rural settings. It further recommended
that education providers be encouraged to establish networked arrangements
to ensure provision of distance education and flexible learning approaches
are further developed as a matter of priority, and that investment in
technology to deliver flexible learning options be priorities as a
strategy for increasing access and promoting retention of students.
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4.3.5 Theory and Practice
The theoretical component of undergraduate programs
needs to be structured for the nurse of the future, and it should be
recognised that while clinical experience may be directly related to
theory in some areas of the program, this no longer needs to be based on
medical or system models. The report recommended that flexible learning
and problem based learning approaches be adopted within undergraduate
education programs so as to develop nurses with the skills required for
future practice.
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The decision point for entry to practice is normally
accepted as a point at which professional registration occurs. The notion
of generic practice skills, other than at an initial level of practice, is
becoming increasing unrealistic as the specialisation evident in other
professions is paralleled in nursing. The first year of practice
experience for nurses is increasingly the point at which the entry to
specialty occurs, and first year of practice programs can aptly be
described as entry to specialty practice programs. In the future these
programs will become a critical component of the transition to practice
and provide a mechanism for nurses to achieve and demonstrate registered
nurse competencies.
Nurse educators and service providers need to work
together to address the expectation by many employers that graduates will
immediately take up a work load and a high level of responsibility with
little structural help or support. In reality the undergraduate program
prepares multi-skilled practitioners ready for future education and
consolidation in a chosen practice area. The report recommended that
competency-based, entry to specialty practice programs be established by
District Health Boards in order to promote recruitment and retention of
nurses. It also recommended that undergraduate nursing programs
incorporate arrangements for smooth transition from undergraduate to entry
to specialty practice programs.
There are many variations of current models for support
of graduates in the first year of practice. They range on a continuum from
formally structured programs involving other agencies, to individually
based single graduate or agency programs. There is considerable debate
about the optimal way to provide these initial programs. The report notes
that for over a decade in some Australian States (Victoria and South
Australia) the government provides funding directly to health providers to
enable new graduates to participate in formally structured programs. In
each case the graduate is employed on a full time basis and the funding is
used to support orientation, preceptorship and release for formal
education. The report recommended funding for a similar program in New
Zealand.
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The report identifies some fundamental principles that
should apply to all models for future undergraduate education:
demonstrable linkages between theory and clinical experience; flexibility
and choice within the comprehensive program; partnership between education
and service providers; flexible delivery, and recognition of need for fit
between undergraduate and entry to practice programs.
The report recommended that collaborative relationships
amongst education providers should be a hallmark of the New Zealand
nursing education system, and the such relationships be established to
ensure cost effective, quality, teaching and learning models are developed
for undergraduate nursing programs.
The report recognised that there were some groups in
New Zealand who favour an integrated curriculum for all health disciplines
and there are models overseas in which core components may be taught
across disciplines. There are also groups who favour undergraduate nurse
education programs modular in structure, in which second level programs
can be imbedded as a mechanism for addressing workforce issues and making
access and exit points for undergraduate programs more flexible.
The review favoured an integrated model as the
preferred approach, and most submissions to the review argued for some
degree of focused experience with core modules in the earlier part of the
program. The review recommended that undergraduate nursing programs
incorporate focused experience options during the final year of the
program, and after completion of the core components. It further
recommended that Nursing Council Standards support and encourage
flexibility in focus by education providers in respect of focused
experience and emphasis within the curriculum.
It was noted that in a focused experience model, the
opportunity to complete the undergraduate program and move directly into
an entry to specialty practice program opens up a range of new
opportunities for students. Students can begin to focus on areas of
practice that they are interested in and in so doing prepare themselves
for entry to practice programs. This approach should improve recruitment
to specialty areas and provide an opportunity for students to experience
particular areas of practice prior to registration.
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The significant restructuring of the New Zealand health
and education sectors since the mid 1980s, and the change in patient
profile resulting in increased acuity and complexity and decreased average
length of stay, have both had a major impact on the transition to practice
particularly in respect of the acute care sector where most new graduates
practise initially. Enrolled nurse demand in these areas decreased
accordingly. The result is a nursing workforce under considerable pressure
to both recruit and retain and appropriate mix of staff.
Whilst the review of undergraduate nursing can be
viewed in isolation from some other contexts, it cannot be separated from
the broader health and workforce context. To this ends of the results of
the Review will need to be broadly interpreted and applied if changes in
preparation are to translate to changes in the workplace. One deficit in
the current environment is that there is no formal process by which
education, service, professional and industrial groups work together to
ensure the preparation of nurses is part of a strategic and planned
solution for future requirements.
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Dianne McKenna Hantas
Nursing Education Review Secretariat
June 2001
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