Editorial
Developing the health workforce: What constitutes clinical education?
Wendy M Cross
School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton VIC
PP: 056 - 058
Article Text
A couple of years ago (Cross, 2009) I wrote about some of the policy directions influencing nurse education and what I saw as the response needed by universities and health services in addressing them. One of the important policy changes was related to health workforce. When I wrote in 2009, the National Health Workforce Taskforce (NHWT) was coming to an end and transitioning to Health Workforce Australia (HWA, 2010). HWA's remit involves:
national workforce planning, policy and research advice; access to quality clinical education placements across all health sectors through extended capacity, improved quality and variety in learning opportunities; a national network of simulated learning environments (SLEs); a national program of health workforce innovation and reform; interprofessional practice and a nationally consistent approach to international recruitment of health professionals to Australia.
In recent times there again have been initiatives affecting universities and health services as they work toward educating the future health workforce. These schemes include the many HWA calls for submissions related to clinical placements, simulated learning environments, scoping/mapping data and inter-professional education.
Moreover, in Victoria we have also seen the introduction of clinical placement networks (CPN) that have the objective of 'streamlining' and 'equalising' the placement of health workforce students within public health services. Networks of this type will be rolled out across all states in due course. Funding has fl owed as a result. However, the funding that has been attached to these initiatives does not address the fundamental underfunding of clinical-based courses. Moreover, the assumptions underpinning average clinical hours and the dollar value attached as a 'subsidy' to universities has been seen by many health services as the yardstick by which additional charges will be made based on the assumption that this is the standard amount per student per day. Previously 'free' or 'low-cost' placements are now being paid for out of already stretched clinical budgets.
Despite long-term relationships between universities and health services, the real possibility of having these relationships destabilized exists as the market players jostle for their share of the places and the funds available.
Important work being undertaken involves workforce training. HWA will develop a national training plan specifically for the dominant professions of medicine, nursing and midwifery practice proposing the most advantageous entry numbers for each professional group over the next 14 years. This will be undertaken to achieve self-sufficiency in health professional supply by 2025. HWA acknowledges that Australia is part of a global market for health professionals and continues to investigate the recruitment of overseas trained health professionals (HWA Workplan December 2010).
A statistical resource (database) is being compiled to amass a range of national data relevant to workforce planning, including data from the Australian Health Practitioner Regulation Authority (AHPRA). Further, a National Health Workforce Planning Tool is also in development whereby high-level simulation modeling will permit supply and demand projections of the health workforce into the future to be calculated, concurrently providing a facility to analyse various supply and demand scenarios (HWA Workplan December 2010).
Using the numbers modeled, HWA will develop a training plan for each profession signifying the number of undergraduate, post-graduate and specialist training positions required each year until 2025 that will be required to meet the goal of self-sufficiency across various geographical locations. Importantly, HWA will also need to address the retention issues of the health workforce and these also need to be modeled.
One assumes that funding will follow though this is not overtly stated. Given the scramble for funds during the last round by both education providers and health services, it is understandable that as scenarios are modeled and tested, there will need to be 'testing stations' that are adequately resourced to either confi rm or negate the model. How will these funds be applied and to what extent are other agencies that contribute to the training of health professionals factored into the model? How will unregulated health workers be counted and utilized? Given that many come under the auspices of the nursing workforce, nurses must have significant input into any projected scenario that accounts for this group.
It is laudable that projections for health workforce are being undertaken. However, there are other pertinent matters to be considered when examining the nursing workforce. For example, roles and role design must be examined. Bloomer and Cross (2011) describe the inconsistent role expectations and descriptions within Clinical Nurse Consultant and Clinical Nurse Specialist groups that reflect ad hoc manner in which these roles have emerged and developed. They account for sizeable numbers of nurses in a service so need to be clearly defined.
Furthermore, there are many nurses that will be on the AHPRA database who do not provide direct patient care. They count in the overall nursing numbers but not at the bedside. They are drawn away from direct patient care and whilst they contribute to the health service overall in many other ways, additional health workers (regulated and unregulated) are needed to provide this care.
Another major area of interest for HWA is simulated learning environments (SLEs) with the aim of substituting clinical placement time with a simulated experience. A study undertaken by McKenna, Newton, French, and Cross (2007) showed that simulation was already used widely in the education of nurses at both undergraduate and post-graduate levels employing a range of activities and media from part-task trainers, high fidelity mannequins to actors and role play. There was widespread agreement that simulation provided a safe learning environment. However, we found that without exception, that there was a preference for the 'real' to the simulated patient stating that actual clinical learning was not directly replaceable with simulation. Most agreed that where students had passed a clinical placement but had time to make up due to illness or other problem, a simulated experience would suffice, saving clinical costs as well. The accreditation of health professional curricula must take into account the nexus between competence and time (hours) spent in clinical because funding for clinical placements based on hours will continue to shrink and we must be ready with adaptable curricula to enable competence to be demonstrated.
Once again I have skimmed some of the issues we are confronting in clinical education for nurses at present. Despite a raft of projects, initiatives and funding models we are not really significantly advanced when it comes to minimum hours, competence and its measurement, role design and expectations, skill mix and the core concerns of supply and demand. Scenarios, mapping, modeling and statistical resources will be futile if the professions cannot come to an approved position regarding what constitutes clinical.
References
Bloomer, M. J., & Cross, W. M. (2011). An exploration of the role and scope of the clinical nurse consultant in a metropolitan health service. Collegian, 18(2), 61-69.
Cross, W. M. (2009). Tilting at windmills: A look at policy and workforce drivers that influence contemporary nurse education in Australia. Contemporary Nurse (Advances in Contemporary Nursing), 32(1-2), 55-59.
Health Workforce Australia. (2010). Workplan. Accessed March 3, 2011, from http://www.hwa.org.au
McKenna, L., Newton, J., French, J., & Cross, W. M. (2007). Identify use of simulation, and more appropriate and timely clinical placement to increase clinical competence and undergraduate positions. Report for the Department of Human Services, Prepare Nurses for the Future Submission to recommendation 2 Work Group.
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