Editorial

The Changing Skill Mix and Scope of Practice of Health Care Workers in New South Wales: Implications of education and training reforms for registered nurse practice, performance, and education

Jane Conway
School of Nursing and Midwifery, University of Newcastle, Newcastle NSW

PP: 221 - 224

Article Text

In Australia, as in much of the rest of the Western world, a number of political, social and technical factors have resulted in a need for the aged care sector and the nursing profession more broadly to modify their skill mix in order to better respond to changes in the needs of older Australians.

In particular, Residential Aged Care Facilities (RACFs) in Australia face a number of significant issues including:

• the need to respond to policy changes emphasising efficiency in RACFs
• the nature of the needs of residents with increasing acuity
• the impact of decreasing numbers of Registered Nurses working in the RAC environment
• the aging of the workforce
• the changing composition of the residential care team and changing roles within that team.

In contrast to the more ‘high tech' trademarks of health care work so often depicted through the media, aged care services are largely hidden from both the public and the professional view (Bellchambers, McMiIllan & Conway 2007) Despite this, the aged care industry has had significant influence in prompting a reconsideration of the nursing profession's skill mix requirements in Australia. Specifically, there is now recognition that the aspirations of some for an all Registered (Level 1) Nurse (RN) workforce were, perhaps inevitably, unsustainable. The role of the Enrolled (Level 2) Nurse (EN) has been under considerable scrutiny for the last decade. In particular, A Review of the Current Role of Enrolled Nurses in the Aged Care Sector: Future Directions (National Aged Care Forum 2001) illuminated the changing demands within the aged care industry and its associated workforce needs.

Since the 2001 review and a period of extensive consultation, there have been a number of changes in the EN's scope of practice in New South Wales (NSW), perhaps most notably the 2004 amendment to legislation and education that enabled ENs to administer medication. This changed scope of enrolled nurse practice in NSW resulted in Level 2 nurses in NSW being supported through education and legislation to have a scope of practice which their counterparts in other parts of Australia have had for some time. In turn, this has necessitated further examination of the roles, functions and responsibilities of all members of the health care team, reconsider work practices, and establish education and training programs that are consistent with the contemporary health environment across Australia.

Despite the endorsement of ENs, many of the factors that prompted the changed scope of practice for ENs continue to impact upon RAC sector at this time including:

• a decline in numbers of regulated (both enrolled and registered) nurses seeking employment in aged care
• case-mix changes
• skill-mix deficiencies
• changes in the profile and expectations of care recipients
• changes in economic and political imperatives of both government and industry
  (Hunter, Conway & McMillan 2007).

In response to this, there will continue to be an expansion of an increasingly certified yet unlicensed workforce in aged care and health service delivery (Conway & Kearin 2007). The recently released Health Training Package offers a nationally recognised framework for health worker training and assessment of competence. It includes a range of qualifications that are reflective of the skills escalation and articulation pathways in health care work. The Training Package provides pathways from high school into health careers for both unregulated and regulated workers. The inclusion of enrolled nursing in this has resulted in a well articulated education pathway from generic and unregulated health worker to Advanced Diploma qualifications in nursing in a range of practice areas such as aged care, diabetes management, acute care, mental health and perioperative care. Given this, it is imperative that the RN workforce to be adequately prepared for a role that has knowledge of standards for direct care but may not necessarily deliver that care.

A review of nursing education over the past five decades highlights the extent to which nursing education practice has changed in response to the changing role of nurses. There has been a marked change from the 1950s model in which nurses received biomedical knowledge largely through lectures from medical officers or texts written by medical officers to contemporary times in which nursing knowledge is created by nurses, is informed by other disciplines, and is transmitted and co-created through a range of teaching, learning and research strategies framed by an increasing consciousness of the uniqueness of the knowledge, skills and attitudes that constitute the practice of nursing. The challenge is now for RNs to be prepared to practice in ways that enact the full potential of a degree qualified workforce.

According to the Nurses and Midwives Board of New South Wales (NMB NSW) higher education at ‘degree or higher, develops students' intellectual, reasoning and decision making- skills' (2007: 15).

While there has been considerable restructure within the nursing profession in Australia, there has been little recognition of the potential for this restructure to lead to role confusion and overlap among those who are required to facilitate change.

The intent of education in contemporary nursing is to achieve increased capacity in the profession to respond to complexities in client needs and enhance the professions' ability to address these needs. It is now time that the education of RNs in Australia recognises the implications of a nursing and non-nursing health care workforce that has unprecedented educational preparation and qualification and focuses on the complex issues of responsibility, accountability, delegation and supervision that accompanies changing scopes of practice within the nursing workforce. Moreover, as clinical safety and quality is dependent upon safe, knowledgeable and competent practitioners who are not only effective practitioners within their own discipline but who can guide and work with others from a range of other groups to promote patient outcomes. Despite the structural reforms that have occurred in health care delivery, there has been limited impact on the operation of health care teams as intra and interprofessional partnerships (Cooper, Braye & Geyer 2004). RNs in particular have an obligation to change the interprofessional isolation and tribalism that other health workers report experiencing when interacting with nurses.

Change involves creating and realising new behaviours, symbols and activities (Schein 1992) through leadership activity.

The role of the RN has, at least in theory, changed from being a person who practised modified medicine to a person who appreciates the dynamic and evolving nature of nursing and is able to use the skills of inquiry, critical thinking, problem solving, reflective practice and plays a leading role in the coordination and interaction of the health care team.

Leadership has emerged as a key concept in the contemporary health care environment. Development activities, including formal learning opportunities, mentorship, and experience are required to build effective leadership skills. Therefore, clinical education and professional development must be viewed not only as essential to the development of leadership skills in nursing, but as leadership activities in and of themselves. This has a number of implications for not only what is taught but how it is taught.

In times of significant change such as the reforms that are occurring in Australian health sectors at the moment, there is heightened potential for the identity of specific groups to become lost or to fail to capitalise on the opportunities afforded by change to establish new benchmarks for practice. While individual members of a professional group may be well aware of the need to reshape their individual and collective identity, they frequently fail to invest in articulation of their practice and their contribution to the organisation and profession. I would contend that, as a group, RNs have yet to recognise the professional expectations of their role to participate in, respond to, and indeed, lead change as part of systemic reform. In referring to overseas trained nurses, the NSW NMB (2007: 17) has recently noted that ‘Where a person has competed a course lower than the level of an Australian diploma, for example, in a hospital-based course similar to those which existed in New South Wales 25 or 30 years ago, an applicant's qualification will not be considered adequate for registration'.

Personally, I am unclear about the extent to which the RN workforce educated in Australia has come to terms with, acknowledges the need for, and is prepared to lead the re-creation of its professional identity to be one commensurate with the expectations of contemporary health service delivery of a degree qualified profession. This will necessitate that the educational preparation of RNs focus on their role in managing care processes - and managing these differently to how they might have done traditionally (Conway, McMillan & Solman 2006). The nursing workforce continues to move from its traditional industrial mindset towards an increasingly professional paradigm for practice. Moreover, the RN workforce, degree qualified or not, needs to resist a tendency to perform at a standard that is congruent with an educational preparation less than that of Australian diploma.

The aged care sector will continue to be instrumental in differentiating the scope of practice for those in the health care workforce and in delineating expectations of health workers, including nurses, educated to a range of qualifications. Perhaps now, more than 20 years after the transfer of registered nurse education to the university sector in Australia, the profession's aspirations for enacting the capacity to lead and reform practice promised by degree qualifications for RNs will come to fruition.

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