Editorial

Tilting at windmills: A look at policy and workforce drivers that influence contemporary nurse education in Australia

Wendy Cross
School of Nursing and Midwifery, Monash University, Melbourne VIC

PP: 55 - 58

Article Text

As I contemplated writing this editorial, I posed a series of questions to myself about the factors that shape contemporary nursing education. I then tried to explore them in greater depth within the parameters of the pre-service preparation domain, the postgraduate preparation for specialty practice domain, ongoing professional development and advanced practice domains. In the end I settled on these:

What are the influential policy and political drivers?

What are the workforce issues that must be addressed?

In recent times, there have been numerous government reviews and discussion papers about nursing education or that make reference to nursing education. In 2002 the National Review of Nursing Education [Department of Education, Science and Technology (DEST) 2002] made 36 recommendations that included activities such as establishing the national council, consistent scope of practice, national registration, national standards for accreditation and nurse practitioners, nursing education and workforce forums, articulation pathways, workforce planning clinical practice and competency. Shortly after this review the Commonwealth government announced that nursing was a national priority area. There was an increase in financial allocations to nursing courses and additional places were offered. The additional funding was meant to be directed towards the costs associated with clinical practice. To date, clinical placements not only continue to be under-funded, but as universities increase their student numbers, competition for limited placements is soaring [National Health Workforce Taskforce (NHWT) 2009].

Since 2002 we have seen the establishment of the national council and other initiatives that were recommended in that review. However, not much has yet changed. A NHWT discussion paper focusing on clinical training governance and organisation is currently available for comment. Among various issues, the paper observes the current challenges facing education providers in securing sufficient high quality clinical placements including a raft of models for securing and maintaining placements, the inability of the system to identify and explore options for underutilised capacity, the barriers to new providers and health services 'gazumping' some educational providers based on 'premium pricing' offered by others.

The NHWT suggests the system could be improved by centrally managing clinical placements for all disciplines, not just nursing. It also supports a shift in focus to competency based rather than time-based learning and claims that this would facilitate interdisciplinary learning. Importantly, NHWT declares that funding should be explicit and flexible and that incentives to health services and education providers would encourage more clinical placements that were conveyed in efficient and effective ways. Most of this is not new and although it acknowledges the positive aspects of current inter-sectoral relationships and models for clinical learning it still advocates for centralisation without clear indications as to the roles for either health services or education providers. The NHWT has called for submissions, so I note that these may be developed in time. My grave concern is that the best models currently being employed will be lost.

Meanwhile, despite the increased numbers of student nurses, workforce shortages remain as local governments and health services have not adequately addressed the high attrition rate of nurses from the workforce. The Commonwealth emphasised the responsibility of State and Territory governments to ensure that nursing graduates remain in the system, effectively washing its hands of the matter (Australian Health Ministers' Conference 2004). Continuing to focus on the supply whilst ignoring the leakage has put added pressure on nursing schools which are now also grappling with enormous class sizes and a stream of sessional tutors that need support and guidance from already overloaded and exhausted academics.

I noted earlier the entry into the nursing education marketplace of new providers. Last year, the Nurses Board of Victoria (NBV) approved for accreditation a Bachelor of Nursing course from Holmesglen TAFE. Despite vigorous opposition from Australia's peak nursing organisations, the approval went ahead. This move is in direct contradiction to recommendation 22 of the 2002 review that clearly stated that 'the minimum level of qualification for entry to practice as a registered nurse should remain a university-based bachelor degree, with a minimum length equivalent to six full-time semesters'. The responsibility for ensuring this recommendation was adhered to was placed on DEST and each jurisdiction's nursing registration board. Not only has the NBV failed to remain faithful to the recommendation, it has placed itself above Australia's peak nursing organisations. With the introduction of national registration and accreditation for nursing courses, where other jurisdictions will produce university graduates of nursing, where will graduates of TAFE programs find themselves? Issues of fairness and equity will demand robust interrogation.

This week, The National Health and Hospitals Reform Commission (NHHRC) Interim Report was launched. Again, issues around the health workforce preparation were targeted. Of particular note was the proposal to adopt a competency based framework, greater interdisciplinary learning opportunities, establishing broad-based clinical training infrastructure with dedicated funding, a focus on rural and remote health workers and in particular, Aboriginal and Torres Strait Islander health workers. So far, so good. However, the interim report supports a national agency for clinical training that would advise on the 'adequacy' of health professional education and promote innovation in education. This agency would report on the 'appropriateness' of accreditation standards with regard to ensuring that curricula meet emerging health needs. Unfortunately, the report does not provide a definition of adequacy. Does it refer to graduating numbers for the workforce? Curriculum content? Interprofessional learning activities? Work-readiness? Employability?

Further, whilst it claims that such an agency would promote innovation, it does not refer to the nature of the potential innovations (pedagogy or substance) nor how the agency would actually do it. As for accreditation standards, they are wide-ranging statements of intent where individual education institutions have the obligation to comply using an array of learning opportunities. Each curriculum is accredited for a number of years and is not static. To assume that changes in health needs (or other changes such as technology) will be addressed in current curricula through an accreditation standard rather than internal review is erroneous.

I made comments before regarding workforce numbers but focused on the supply and retention of nurses. I didn't broach the subject of workforce re-design, role substitution, role expansion or interdisciplinary learning. As we move toward greater role diffusion, the need for interdisciplinary learning opportunities expands. Yet health professionals are still being taught independently of each other. Though there are some shared activities they are not integrated across multiple professional curricula.

Whilst we see more combined degrees emerging, for example, Bachelor of Nursing/Bachelor of Emergency Health or Bachelor of Nursing/ Bachelor of Early Childhood Education have not concurrently developed the employment roles that graduates could work in when they have multiple skills sets. Role diffusion also affects the relationship within and between professional groups. We note the expanded duties of the enrolled nurse and the work of the nurse practitioner and the proliferation of 'technical' support roles such as ECG technicians. Each of these examples reflects changes within professional groups and the substitution of workers into professional areas that had not previously been their responsibility.

I have referred to work readiness and employability. Criticisms have been leveled at education providers regarding the ability of graduates to enter the workforce and adapt quickly to the demands placed on them. In other words, to 'hit the ground running'. These criticisms relate to cognitive issues of knowledge acquisition, knowledge transfer, problem-solving and clinical decision-making as well as performance issues around time management, technical skill and interpersonal relations. To enable new graduates to make the conversion from student to worker, health services are funded to assist in the transition to working nurse and current curricula devote considerable effort to transition, yet the criticisms remain despite representation by health services on external advisory boards to schools of nursing. I suspect that the limiting factors in transition programs in nursing courses are the focus on theory rather than on practical scenarios and the silos in which this education takes place. So we continue to challenge students intellectually but do not create the environment where they can safely explore practice dimensions within defined work-like parameters. Interprofessional simulation activities would enhance these outcomes and lift the pressure on newly graduated nurses.

Quality and risk are strong drivers of health services yet nurse education continues to give scant attention to them. Some innovative programs exist but largely, pre-service curricula tend to focus on disease and clinical competency despite making best efforts to respond to directives from various statutory authorities that demand certain other inclusions. The Australian Commission on Safety and Quality in Healthcare (2008) released the Australian Charter of Healthcare Rights. It focuses on access, safety, respect, communication, participation privacy and comment and will have a key role in shaping safety and quality improvements in healthcare. Building on this, the NHHRC advises that health workers are educated in quality and risk including methods based on a national curriculum that is embedded in accreditation requirements. It is imperative that contemporary nurse education includes these notions at all levels. Quality addresses the issues pertaining to the 'right care in the right place at the right time by the right professional' (NHHRC 2009). It cuts across both practice and research as it seeks continuous improvement of best practice informed by the best evidence. Academic programs must reflect this in all curricula to demonstrate the application of evidence to practice. This then clearly leads us to research and how nurses inform their work and ensure it is justifiable. The NHHRC notes the 'biggest failure in healthcare is to implement what we already know' (p.26) and proposes that the gap between research and practice be bridged through increased numbers of clinical research fellowships across all professional groups, a priority on health services research that translates research into practice and funding for the indirect costs. It also supports initiatives by the National Health and Medical Research Council (NHMRC) regarding Centres of Clinical Research Excellence and advises that the National Institute of Clinical Studies have a broadened remit. Nurses must share in these opportunities and be researching in collaboration with other health professionals. Education regarding quality, safety and research must link directly with practice and be integrated throughout academic programs.

Practice directions for nurses are changing. The NHHRC (2009) places great emphasis on population health perspectives and consumer empowerment; primary care and health promotion; sub-acute care; end-of-life care; disadvantaged groups such as Aboriginal and Torres Strait Islanders, those in rural and remote areas and those living with mental illness. Further, chronic and complex illness profiles will be more important as the population ages. These prospects create far reaching openings for health education providers to develop new and innovative academic programs that link professional groups, are informed by users of health services and connect primary, secondary and tertiary health services. They also afford the opportunity to develop new models of care and professional roles. Both undergraduate and post graduate curricula as well as ongoing professional education programs must reflect these changes.

Australia is a world leader in nursing education. Professor John Daly, Chair of the Council of Deans of Nursing and Midwifery (Australia & New Zealand), also chairs The Global Alliance for Nursing Education and Scholarship (GANES) which was formed in 2005 between four of the world's leading nursing education organisations (US, UK, Canada) to improve healthcare outcomes and ensure a healthy global supply of highly educated nurses. GANES provides worldwide strategic- level expertise in the education and professional development of nurses. To quote Professor Daly:

There is an urgent need for us to work globally with governments and key non-governmental organisations to assist in scaling up the global health workforce. We are excited about implementing and extending our agenda for improving health care for all. Investment in quality nursing and health education will be crucial to this aspiration. (NSW Nurses' Association 2008)

With some sketchy brush strokes, I have attempted to review a few of the factors that are influencing contemporary nurse education with an emphasis on policy and political drivers and workforce needs. In an editorial such as this it is impossible to attend to all the issues thoroughly, but I hope I have made some interesting observations and critical points. I have incorporated numerous policy documents though I acknowledge there are many others. I also acknowledge that I have focused on nursing and have not dealt with midwifery. That requires a paper in itself due to the plethora of literature regarding the education of midwives. There is a lot of work being undertaken at local and national levels with regard to the health workforce and because nurses and midwives are the greatest in number we have the most to lose. However, we also have the most to gain and we must be in for the wins. Nurse and midwife education in both sectors must reflect the intent of these policy directions and lead workforce change.

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