Chapter 3 - Undergraduate Education

The demand for intelligent, imaginative nurses capable of navigating and delivering a complex course of care cannot be overstated. Nurses are the largest part of the professional health workforce, and for them to do what is required of them today and in the future will take tremendous practical, political, organisational and technical abilities – skills of the highest order.[1]

Introduction

3.1 The ability of nurse education programs to produce nurses capable of operating in an increasingly complex health system is one of the most important issues facing the profession, the healthcare system and the community generally. The delivery of healthcare in Australia continues to undergo rapid transformation. Nurses practice in this highly complex system, characterised by increased demands for healthcare services, high levels of technology, increased patient acuity, shorter length of stay and increased levels of consumer knowledge and expectations. These processes impact on how healthcare is delivered and the role of healthcare professionals in this system.[2]

3.2 The Australian Nursing Council (ANCI) stated that to provide realistic expectations of the nursing role, the most important principles underlying a program of nurse education should include:

linkages between theory and practice;
collaboration between education and service providers;
flexible delivery of content; and
consistency between content of education and ANCI competencies.[3]

3.3 The Australian Council of Deans of Nursing (ACDON) stated that the nurse of the future will become a ‘knowledge worker’, rather than ‘knowledge holder’, acting in partnership with the healthcare system, clients and the community – ‘the skill development and experience for this life-long work are...very different from those of the traditional hospital-type curriculum. The “new” work necessitates new relationships between theory and practice and new understandings of the term “competency” given that nursing is a practice-based discipline regulated through demonstration of competencies to State authorities’.[4]

3.4 This chapter and chapter 4 discusses the Inquiry’s terms of reference (b) relating to opportunities to improve current arrangements for the education and training of nurses, encompassing enrolled, registered and postgraduate nurses and makes recommendations on nurse education and training to meet future labour force needs. This chapter specifically focuses on issues related to the undergraduate education of RNs. The terms of reference relating to the interface between universities and the health system are discussed in chapter 5.

3.5 The Committee notes that there is some cross-over in these terms of reference with the current National Review of Nursing Education (the Education Review) which was jointly announced by the Commonwealth Ministers for Education, Training and Youth Affairs and for Health and Aged Care in April 2001. The Education Review, which is expected to report in July 2002 is, inter alia, examining the effectiveness of current arrangements for the education and training of nurses encompassing enrolled, registered and specialist nurses.[5]

3.6 There are two levels of licensed nurse in Australia – registered nurses (RNs) (Division 1 in Victoria), who undertake a minimum of three years undergraduate preparation in the higher education sector at a Bachelor degree level, and enrolled nurses (ENs) (Division 2 in Victoria), who generally undertake their education in the vocational education/TAFE sector at a Certificate IV or Diploma level. Both levels are regulated by State regulatory bodies. Australia is one of the few countries whose RNs are all prepared to the same educational standard – the Bachelor degree level. Of the total number of employed licensed nurses, 78.7 per cent are RNs and 21.3 per cent are ENs.[6]

3.7 Within Australia, each State and Territory has its own nursing legislation (Nurses Act or Nursing Act), which provides for the accreditation of courses, registration, professional conduct and practice standards. Acknowledging the differences between the various Australian State/Territory nursing legislation and practice standards, the ANCI has developed ANCI National Competency Standards for the Registered Nurse and the Enrolled Nurse. They identify the minimum competency standards for nurses to practice in Australia and have been adopted by all the nurse regulatory authorities.[7]

3.8 Submissions and other evidence to the inquiry indicated comprehensive and widespread support for the retention of RN education in the university sector at the Bachelor level.[8] The Australian Nursing Federation (ANF), reflecting much of the evidence, stated that:

Entry to practice as a registered nurse should continue at the Australian Qualifications Framework level of Bachelor degree, offered in the higher education sector. We cite the increasing complexity of health care; the higher acuity and greater dependency of patients/clients accessing health services; the need for evidence based nursing and health care; the increasing use of complex technology; the increased expectations of patients/clients; and the expansion of advanced nursing role, as reasons for this position.[9]

3.9 The Committee strongly supports the current university based system for the training of RNs. The Committee notes that the National Review of Nursing Education also indicated their support for this position.[10] The Committee, however, believes that there are aspects of the current education and training programs for RNs and ENs that could be improved and these issues are discussed in this chapter and in chapter 4.

Recommendation 10: That the current university-based system for the undergraduate education of Registered Nurses be continued.

Current models of nurse education and training

3.10 The table below provides a summary of the current arrangements for nurse education and training in Australia and their links to the Australian Qualifications Framework (AQF).

3.11 The AQF establishes a framework for nationally consistent recognition of educational qualifications from the school, vocational education and training (VET) and university sectors. The AQF is a nationally agreed framework which identifies the qualifications available in these three educational sectors. Currently, ENs complete Certificate IV or a Diploma in the VET sector and RNs gain Bachelor degrees and other qualifications from universities.[11]

3.12 Certificate I courses teach introductory skills for certain occupations. Certificate II courses include traineeships with an on-the-job component. Certificate III courses provide a range of well developed skills in a variety of occupational areas. In the area of aged care, Certificate III courses provide the skills and knowledge required by workers who support and assist people with their daily living and personal care in community or residential settings. Certificate IV courses teach supervisory skills and advanced technical skills.[12]

Table 3.1: Overview of models of education and training related to nursing and midwifery

Australian Qualifications Framework	Title	Models of Education and Training
Doctorate		Research
Doctor of Philosophy/Professional Doctorate	Doctor of Philosophy Doctor of Nursing
Postgraduate Masters Diploma Certificate	Registered Midwife (on completion of Diploma or Masters)	Masters by research or course work Courses embedded - Cert/Diploma/Masters with exit points at each level if desired Free standing courses at each level
Bachelor	Registered Nurse/Division 1 Nurse Registered Midwife (program commenced in 2002)	Double degrees (nursing plus another degree) Six semester courses (2-3 years) Eight semester courses (with or without honours) Graduate entry programs Enrolled Nurse entry programs One year entry for registered hospital trained nurses with lapsed registration Hospital-trained (1 year) Diploma upgrade (1 semester)
Diploma	Enrolled Nurse (Queensland)	Employment contract with TAFE course (eg NSW traineeship) VET Course with clinical placement (TAFE or private provider) New Apprenticeship - on and off job training
Level V Certificate (Advanced Certificate)	Enrolled Nurse (Advanced Certificate)
Level IV Certificate	Enrolled Nurse/Division 2 Nurse
Level III Certificate	Healthcare worker Assistant in nursing Personal care worker Aged carers Disability carers	Traineeships for school students Traineeships post-school On the job training Course with clinical placement (full or part-time)

Source: National Review of Nursing Education, Discussion Paper, December 2001, p.113.

Registered nurses

3.13 As noted above, RNs undertake a minimum of three years undergraduate preparation in the higher education sector at the Bachelor degree level.

3.14 Pre-registration programs comprise the following undergraduate nursing courses:

Three-year Bachelor degrees in nursing.
Four to five-year combined degrees, which either consist of a Bachelor degree in Nursing with a Bachelor degree in another field of study such as Psychology, Commerce or Arts, or a Bachelor degree in Nursing with a Bachelor degree in another nursing discipline, such as Midwifery or Rural Health.
Two-year Bachelor degrees in Nursing for graduates from another discipline or students with previous nursing studies, such as Enrolled Nurse (Division 2) nurses. (These students are usually admitted into the three-year pre-registration Bachelor of Nursing program and are given credit equivalent to one year's full-time study).
One-year re-entry programs (Bachelor degree or Certificate in Nursing) for nurses whose registration had lapsed.
One-year conversion programs for overseas-qualified nurses seeking registration in Australia.[13]

3.15 Undergraduate nursing programs are offered at 28 universities as well as Avondale College.[14] In total, full or part nursing programs are delivered at 58 campuses across Australia.[15]

Midwifery

3.16 Under present arrangements midwifery registration usually follows registration as a nurse and study is at the postgraduate level. Midwifery courses are available in all States and Territories. A new four year double degree program integrates preparation to become a RN and undergraduate midwife as part of an undergraduate program. In addition, direct entry midwifery courses were introduced in 2002 in Victoria and South Australia.[16]

Specialist nurses

3.17 Specialist nursing courses may range from Graduate Certificates through to Masters degrees in any given specialisation. Courses preparing for specialisation can attract the same level of qualification but show considerable variation in length, the mix of clinical and theory and the level of involvement of the health sector in their delivery.[17] Table 3.2 shows a profile of university courses by speciality and the number of graduates expected in 2001. This profile includes Postgraduate Certificate, Diplomas and Masters Degrees by coursework. Graduate Certificate courses are usually equivalent to six months of full-time study, while courses offered at the Graduate Diploma level are equivalent to one year of full-time study. Masters courses range from one to two years of full-time study, and Doctorate courses range from two to three years of full-time study.

Table 3.2: Number of postgraduate courses and expected domestic graduates in 2001 by nursing speciality across Australia

Speciality	Number of courses	Percentage of total number of courses	Total number of graduates
Family and child	34	6	282
Generic	84	14.7	743
Research	69	12.1	146
Functional	20	3.5	100
Community health	52	9.1	329
Midwifery	56	9.8	772
High dependency	114	20	1 036
Mental health	37	6.5	428
Rehabilitation/habilitation	37	6.5	128
Medical/surgical	67	11.8	294

Note: Does not include non-university sector (NSW College of Nursing)

Source: National Review of Nursing Education, Discussion Paper, December 2001, p.119.

3.18 Postgraduate courses are predominantly offered part-time, using flexible modes of delivery and are both up-front fee-paying and HECS funded. Postgraduate nursing data displays a trend toward courses within the specialties of midwifery and high dependency. States varied in the number of specialties that they offered, and the number of students projected to complete these courses in 2001. The Education Review noted that while there appears to be a trend toward an overall increase in postgraduate student enrolments into specialty courses, this trend may reflect the tail end of the transfer of postgraduate nurse education into the tertiary sector.[18]

Enrolled nurses

3.19 In most cases, EN courses are determined through the agreements of TAFE institutes and nurse registering authorities. The development of courses within the various States and Territories has resulted in considerable variation in the educational programs. Courses are offered through 22 capital city and 32 regional providers.

3.20 Table 3.3 shows details of courses offered for Enrolled Nurses across the States and Territories. Most courses are offered at AQF Level IV, except in the case of Queensland. The Level IV courses are predominantly offered over 12 months or equivalent full-time study, except in the case of Western Australia where the course is offered over 18 months.

Table 3.3: Enrolled Nurse courses by State or Territory

State/Territory	Course Title	Course length (months)	AQF level
Australian Capital Territory	Certificate IV in Health (Nursing)	12	4
Northern Territory	Certificate IV in Community Services (Enrolled Nurse)	12	4
New South Wales	Certificate IV in Nursing (Enrolled Nurse)	12	4
Queensland	Diploma in Enrolled Nursing	18	5
South Australia	Certificate IV in Health (Nursing)	12	4
Tasmania	Certificate IV in Health (Enrolled Nursing)	12	4
Victoria	Certificate IV in Health (Nursing)	12	4
Western Australia	Certificate IV in Enrolled Nursing	18	4

Source: National Review of Nursing Education, Discussion Paper, December 2001, p.115.

3.21 The flexibility of EN courses varies considerably around Australia. In New South Wales all students undertake a full-time employment model. Currently, there is no option available for part-time studies in that State. Western Australia also offers only full-time programs. In a hospital-based program to be offered in South Australia in 2002, students will undertake an employment-based program, available by full-time mode only. Within the other States and Territories, there is greater flexibility for students to study either full-time or part-time.

3.22 Hours of course contact are determined within the curricula set at State and Territory levels. Variations exist in the various States and Territories in relation to the amount of contact hours in courses, with total course contact hours varying between 756 hours (Northern Territory) and 1 200 hours (Western Australia). A new curriculum is being introduced in the Northern Territory from 2002 that consists of a significant increase in classroom and clinical hours. In Victoria and the ACT total course hours are set at 850 hours generally with 610 hours allocated to classroom teaching. Within the majority of courses students spend four full days per week on campus engaged in classroom learning.

3.23 Enrolled nurse students usually undertake block placements in health and community settings throughout their courses. The emphasis in courses on clinical practice experiences vary from State and Territory. This is discussed further in chapter 4. All courses expose students to significant amounts of aged care and rehabilitation nursing. Furthermore, all courses provide students with exposure to acute care areas, mainly medical surgical nursing.[19]

Unregulated care workers

3.24 Unregulated healthcare workers are employed predominantly in the aged care sector. While there is no requirement for these workers to have formal training, industry training packages provide the framework for competencies for the Level II and III Certificates. The Community Services and Health Industry Training Advisory Body, has developed two training packages that provide skills training in related fields of health. While this level of qualification does not encompass nurses, it does prepare a range of workers whose work involves care and is often done under the supervision of a nurse.[20] The Committee has made recommendations relating to the regulation of these workers in chapter 4.

Improving undergraduate education and training programs

3.25 Evidence received during the inquiry indicated that there is a need to improve the education and training available to RNs. Issues related to the education and training needs of these nurses are discussed below.

Provision and funding of additional undergraduate places

3.26 The level of Commonwealth funding is fundamental to the viability of public universities – it determines the number of HECS-liable places for domestic students and provides the overwhelming majority of the resources available for teaching and research.

3.27 Commonwealth operating and research grants form a large part of universities’ revenue. Universities, however, also generate a large proportion of their revenue from fees, particularly from postgraduate courses and overseas students, consultancies, donations and investments.

3.28 The main features of the current funding framework are:

provision of operating resources as a single block operating grant;
allocation of resources in the context of a rolling triennium which ensures that institutions have a secure level of funding on which to base their planning for at least three years;
allocation of research funding primarily on a competitive basis ($460.8 million in 2001);
special capital funding ($40.3 million in 2001); and
an accountability framework provided essentially by the yearly submission of educational profiles.[21]

3.29 While the Commonwealth provides the bulk of university funds ($5.86 billion, including HECS, in 2001), higher education institutions are essentially autonomous organisations that are responsible for the distribution of funds between faculties and schools based on their own assessment of priorities and needs. Universities are responsible for the allocation of places across various fields, although the allocations are discussed with the Department of Education, Science and Training (DEST) during the annual profiles consultations. Universities are expected to take into account the extent of student demand, and the needs of the labour market.

3.30 Operating grants consist of four components:

a teaching related component;
Indigenous Support Funding;
a research component; and
a capital component.

The teaching related component forms the largest part of the operating grant. It provides funds for the general operating purposes of the institution. This includes academic and non-academic staff salaries, minor works and equipment, etc. The teaching related component is primarily determined by the agreed number of fully subsidised places measured in Equivalent Full-Time Student Units (EFTSUs) for a given year in the triennium and specified undergraduate fully subsidised minimum places for the year.[22]

3.31 Submissions argued that there is a shortage of Commonwealth funded undergraduate positions.[23] The Victorian Government, reflecting much of the evidence from State Governments/Departments, commented that:

Efforts to increase the number of HECS funded places in nursing are being severely hampered by the inadequate level of Commonwealth funding provided.[24]

3.32 Evidence from State Governments and Departments indicated the seriousness of the problem. The Victorian Government stated that despite an increase of over 12 per cent in the first preference for university nursing places, the total number of nursing places available in 2001 actually declined by 250 places from the previous year.[25]

3.33 The NSW Health Department noted that, based on workforce requirements, the State requires a steady state of 2 490 EFTSU undergraduate first year enrolments per annum. The Department noted that the universities have consistently been unable to meet this target of 2 490 enrolments. The Department indicated that a problem is that the universities emphasise their autonomous status and ‘determine numbers’ on a year to year basis without reference to State workforce requirements.[26]

3.34 The South Australian Department of Human Services noted that current forecasting indicates that to maintain the South Australian RN workforce at its current size, the number of new graduates completing undergraduate nursing programs each year need to be between 650 and 1 350. A total of 389 students graduated at the end of 2000 and 430 graduated at the end of 2001. The Department stated that these numbers are ‘significantly below’ the range required to balance and meet current and future requirements.[27]

3.35 The Western Australian Department of Health stated that Western Australia requires more HECS funded positions for undergraduate nurses because the State’s population is increasing. The Department noted that 1 669 students listed nursing as their first preference in 2002. As there were only 558 places available to students in Western Australian universities, 668 applicants failed to get into a nursing program.[28]

3.36 Queensland Health stated that over the last eight years, the number of pre-registration nursing commencements in the State has averaged approximately 1 200 per annum, and rose to 1 500 in 2001. The Department indicated that this number needs to rise to 1 700 within the next two years to maintain an adequate long term supply of nurses in Queensland.[29]

3.37 The Deans of Nursing stated that in 2000 and 2001 each State had more applicants for the undergraduate nursing degree courses than they had places available in the universities.[30]

3.38 The Deans of Nursing also emphasised that the number of nurses produced by universities is directly related to the funding of universities. The Council noted that:

Within each university funds are distributed to the various faculties and schools in accordance with the broad policies and priorities of the university. However, nursing is in competition with every other component of the university for funding, and in a situation where the Government itself has recognised that funding for universities is inadequate, it is not surprising that faculties/schools of nursing are constrained in the numbers they can take in. Indeed, most faculties and schools of nursing are over-enrolled, taking more students than they are funded for, in recognition of their social responsibilities.[31]

3.39 The Committee questioned the Department of Education, Training and Youth Affairs (DETYA) as to whether the Department has mechanisms in place to determine the adequacy of undergraduate nursing places in universities. DETYA responded that:

We have an annual discussion with each university around what we call the profile of their enrolments. When nursing was transferred to the university sector, numbers were notionally agreed. Often there is pressure from the state health authorities to see where those numbers are trending. I think it is fair to say that some universities have within their mission retained a strong emphasis on nursing as part of the range of their offerings and have given attention to quality of provision. Others have responded more to student demand in other areas, as a result of which there has been variable performance in the total number of places that are around.[32]

3.40 The Committee further questioned the Department as to whether the lack of funding was due to Government funding decisions or the choice of universities not to provide places in nursing. The Departmental representative conceded that ‘one can argue either way, I suppose. But I think there are discretions that the universities have within the funding that is made available to them, and some have exercised that discretion in favour of nursing and others in favour of other fields’.[33]

3.41 Witnesses argued that there needs to be more effective mechanisms in place between the Commonwealth, States and the universities so that funding issues and the question of university places can be assessed, especially as there is a common perception of a nursing ‘shortage’ yet courses continue to be oversubscribed. One witness noted that ‘there absolutely has to be some kind of better dialogue that enables that funding to flow more effectively and be used more effectively’.[34]

3.42 Funding issues for undergraduate places are also related to the question of national nursing workforce planning and the mechanisms in place for assessing future nursing labour force needs. These issues are discussed in chapter 2.

Conclusion

3.43 The Committee considers that improved mechanisms need to be put in place, in consultation with the States and universities, to determine the numbers of nurses needed – both in the short and longer term – and effective allocation of places between the States. The Committee believes that issues of supply and demand need to be considered in conjunction with improved mechanisms for assessing future nurse labour force needs.

3.44 The Committee also believes that there is an urgent need for the Commonwealth to increase the number of undergraduate university places for nurses and that consultations with State Governments, nursing organisations, unions and other key stakeholders in relation to this issue needs to be given priority. As discussed in chapter 2, there is a serious shortage of nurses in Australia and increasingly that shortage is now threatening the maintenance of our hospitals and health services.

Recommendation 11: That the Commonwealth, in conjunction with the States and universities, implement improved mechanisms to determine the supply and demand for nursing places at universities and in determining how these targets are set.

Recommendation 12: That the Commonwealth Government provide funding for additional undergraduate nursing places to universities offering nurse education courses to meet the workforce requirements set by the States.

Clinical component of undergraduate courses

3.45 During the inquiry the Committee received a considerable amount of evidence, especially from the healthcare sector, suggesting that the clinical education component of university courses is not sufficient to prepare new graduate nurses for work as nurses.[35] The Australian Healthcare Association (AHA), summarising much of the evidence, stated that:

The level of practical preparation of graduates for entry-level practice is variable across universities and across graduates, and in many instances, insufficient to meet organisational requirements.[36]

3.46 Women’s Hospitals Australasia & Children’s Hospitals Australasia (WHA & CHA) also argued that:

The clinical component of education programs needs to be increased so that, in addition to developing clinical skills, the students gain a real appreciation of what working as a nurse entails.[37]

3.47 The universities and others argued, however, that it was an unrealistic expectation to expect new graduate nurses to have this level of skill and therefore to be able to ‘hit the ground running’. The Deans of Nursing stated that ‘in no other profession is the newly qualified graduate expected to perform to the standard of the experienced professional’.[38] The Committee notes, however, that this was the expectation for hospital-trained nurses.

3.48 Table 3.4 shows the clinical component of undergraduate courses in selected universities. The table indicates considerable variation in the clinical component of courses both in duration and clinical time allocated over the length of courses.

Table 3.4: Clinical Component in Undergraduate Courses - Selected Universities

	1^st Year	2^nd Year	3^rd Year
*Flinders University¹*	2 days per week for 13 weeks	2 days per week for 13 weeks	3 days per week for 15 weeks (+ practicum in area of choice)
*University of Adelaide ²* (proposed undergraduate course)	2 days per week for 42 weeks	3 days per week for 42 weeks	5 blocks of 6 weeks at a time
*University of Western Sydney - Macarthur campus ³*	4 weeks	6 weeks	6 weeks + 4 week block elective
*University of Tasmania⁴*	None, 2 weeks in 2003	3 weeks	Predominantly clinical placements (+ units taught at clinical sites)
*Queensland University of Technology⁵*	50 per cent off-campus clinical placements: small proportion in 1^st year; increases in 2^nd year; in 3^rd year - last semester - 8 weeks out of 13 in direct clinical placements
*Griffith University⁶*	50 per cent clinical placements - clinical hours reduced from 1 200 to 900 hours in current curriculum
*University of Southern Queensland ⁷*	45 per cent clinical placements

Source: ¹ Committee Hansard, p.682. ⁵ Committee Hansard, p.595.

² Committee Hansard, p.698. ⁶ Committee Hansard, p.595.

³ Committee Hansard, p.482. ⁷ Committee Hansard, p.595.

⁴ Committee Hansard, pp.290-293.

3.49 The Deans of Nursing stated that for most courses, approximately 40-50 per cent of the degree program is comprised of clinical practice that is undertaken in healthcare agencies.[39] However, as the above table indicates, for some courses the clinical component is less than this average.

3.50 The Committee received evidence that the total clinical component varied considerably between States. The WA Department of Health indicated that in that State there are 1 000 hours of clinical practice provided in undergraduate degrees, while other States have between 500 and 900 hours.[40] One hospital noted that in Victoria, undergraduates have between 600-700 hours of clinical practice over their three-year courses.[41]

3.51 The National Review of Nursing Education (the Education Review) noted that the issue of adequate clinical preparation ‘is clearly a complex, multifaceted and difficult issue partly because it involves different perceptions of what is important and because its resolution involves very different players with different agendas’.[42] The Education Review noted that placements for students are not always easy to obtain even when educators recognise the value of exposure to particular clinical settings; there is a high level of competition for placements; and the costs of delivering adequately supervised programs are high.[43]

3.52 Evidence to the Committee indicated that there needs to be earlier placement of students in hospitals and other healthcare settings.[44] One witness noted that ‘there could be improvements to the practical clinical preparedness of newly graduating staff by increased opportunities for clinical training placements [and] exposure to practice at an earlier stage in the registered nurse education program’.[45] Another submission noted the need for ‘some improvements in the current tertiary preparation of students including the establishment of a clinical focus early in the training’.[46]

3.53 Evidence also indicated a need for longer blocks of clinical placements and better coordination and planning in these placements. The Austin and Repatriation Medical Centre stated that:

Many of the university students we deal with at the moment, who have three-year degrees, have very limited clinical experience. They often have 600 or 700 hours in their total three-year degree. They often come for clinical placements to our hospital for one or two weeks at a time. We feel those clinical experiences are fairly meaningless because they never get really socialised or accepted into the work force...We believe that clinical experiences need to be more like six or eight weeks long. There needs so be some sort of continuity with them as well and they need to be planned and involve our staff.[47]

3.54 A number of universities have developed new and innovative ways of approaching clinical placements, such as those operating at Flinders University in South Australia and the University of Notre Dame in Western Australia.

Flinders University, South Australia

In an effort to ensure that students are oriented to the realities of nursing and equipped with the necessary clinical skills the School of Nursing and Midwifery at Flinders University, in partnership with several hospitals and with other health agencies, has developed an innovative model for clinical placement called the Dedicated Education Unit (DEU). The philosophy underpinning a DEU is one of collaboration between service and education based on mutual respect and trust. In summary, a DEU is an area which may be a ward in an acute or aged care institution, a mental health facility or a community site such as Royal District Nursing Service which is set up collaboratively to provide a consistent learning environment for students. The establishment of a DEU is a negotiated enterprise between the health care site and the University and ensures that both parties are keen for students to be placed at that institution. Students spend protracted periods of time (ie. 2-3 days per week per semester) in the DEU and clinicians and academics work together in fostering the provision of quality student teaching and learning.

Collaboration between academics and clinicians in clinical teaching means that the differing foci of each sector are brought together for the benefit of students. Clinicians, students and academics receive specific preparation prior to the DEU placement so that all are clear about the expectations for student achievement. A clinical liaison position is attached to the DEU and allows for a Level 1 Registered Nurse to be upgraded to Clinical Registered Nurse level. The clinical liaison Registered Nurse works closely with the academic assigned to the DEU to monitor the students’ progress and generally facilitate and foster student learning and problem solve any issues that may arise. Students in the DEU are involved in an active exploration of experience and are encouraged to reflect on their experiences in critical ways. Peer teaching is encouraged and students are ‘buddied’ with more senior students as well as experienced Registered Nurse clinicians who have been fully briefed about the program and its intent. At present the university funds this model with ‘in kind’ support from the clinical agency.

Source: Submission No.740, pp.6-7 (Flinders University of SA, School of Nursing and Midwifery).

University of Notre Dame, Western Australia

The model of clinical placement at Notre Dame University emphasises partnerships with hospitals so that students can undertake their placements at the same facility for the length of their course. This allows students to familiarise themselves and be comfortable with the uniqueness of a particular hospital or healthcare setting. It also gives the student a sense of belonging and for the assigned Hospital or healthcare group a sense of ownership of the student. Placements are also made with either hospitals or healthcare agencies close by so that the amount of travelling time for students is limited.

The university uses the whole of the academic year, with a summer term in January (4 weeks), first semester (14 weeks), a winter term (7 weeks), and then second semester (14 weeks). Nursing students use the 7 weeks of winter term for practicum and the last 6 weeks of second semester. Students commence clinical placements are the end of their first semester. Clinical placements are ‘reality based’, with students working the same shift across the week as their mentor, for a minimum of 32 hours a week in preparation for the reality of shift work during their working life as a nurse. It is expected that students undertake a patient case load of up to three patients by the end of their clinical placements. Also students are mentored by a Registered Nurse from the area in which they are assigned, and where possible have the same mentor for the whole of their clinical placement. The university seeks mentors voluntarily from each work place and provides them with an education program that not only identifies the level of competency they can expect from the student but gives them skills in teaching at the bedside.

Source: National Review of Nursing Education, Discussion Paper, December 2001, p.143.

3.55 As noted above, Flinders University has developed an innovative model for clinical placements called the Dedicated Education Unit (DEU). A DEU is an area such as a ward in an acute or aged care institution which is set up collaboratively to provide a consistent learning environment for students. The model provides for students to spend protracted periods of time – 2-3 days per week per semester – in the DEU and clinicians and academics work together to provide quality student teaching and learning.[48]

3.56 An evaluation of Flinders University DEU model has shown it to be extremely effective in producing graduates with beginning competence in clinical settings. The evaluation report concluded that the major strength of the DEU was that it enhanced the transfer of theory into practice for students more effectively than previous models of clinical placement used by the university.[49] One witness commented that the DEU is a ‘very sound model’ with the hospital receiving ‘good feedback’ from clinicians regarding its operation.[50]

3.57 As indicated above, the University of Notre Dame uses the whole of the academic year for teaching and students commence clinical placements early in their courses – at the end of their first semester. Several witnesses cited this model of nurse preparation as being particularly effective. One witness noted that Notre Dame was a ‘best practice example’ – ‘it is able to solve the problem...which is lack of clinical preparedness in undergraduates and also provide some opportunities for earlier entry into the work force’.[51] Another witness noted that University of Technology, Sydney (UTS) and a number of other universities in Victoria are examining the Notre Dame model.[52]

3.58 Another witness, however, cautioned that that it was ‘far too early’ to assess the effectiveness of the model offered at Notre Dame –‘it is also a very selective school of a very small size – a “boutique” school of nursing if you like – where they can obviously try different approaches in a very much less structured fashion than a school of nursing which has to accommodate up to a thousand students’.[53] The Education Review found that the model at Notre Dame University ‘appears to be working well with students’, although the first small group of nursing students were only enrolled in the program in February 2000.[54]

3.59 Other models, such as courses at the University of Wollongong were also referred to in evidence as best practice examples in relation to clinical placements.[55] The University of Western Sydney (UWS) has also developed a new, innovative, and ‘industry responsive’ undergraduate program which was introduced from 2002. It has a strong emphasis on clinical application in response to changes that have occurred in the clinical service area, for example, in models of care and staffing levels. The university has developed close liaison with health service providers in planning, implementing and evaluating clinical learning experiences and curricula.[56] The UTS referred to the use of clinical development units in the third year of their undergraduate degree – ‘where almost all of the third year of our program is now spent in the clinical facilities’. The university noted the positive response of the area health service to this development.[57]

3.60 Some witnesses saw merit in students undertaking their placements at the same facility for the duration of their course, such as occurs at the University of Notre Dame. This was seen as important as it builds in students a sense of attachment and loyalty to the healthcare facility.[58] Other witnesses did not, however, support this concept arguing that it is not always possible to obtain all types of placements within the one facility and that a diversity of clinical placements was important for students. One witness noted that this diversity is a ‘plus’ – ‘our students are actually placed in a variety of venues...I do not think there is an identification with one particular area’.[59]

Conclusion

3.61 The Committee considers that there should be greater clinical exposure earlier in courses and that it should be of a longer duration than that which is available in many courses at present. Evidence indicates that greater clinical exposure is better than less exposure. The Committee notes that there have been significant improvements in many university courses over recent years that have led to an increase in the duration of clinical placements. This demonstrates an acknowledgment by universities of the need to increase the clinical exposure of students during undergraduate courses and a recognition that this will lead to improved retention of nurses once in the workforce.

Recommendation 13: That, while maintaining a balance between theoretical and practical training, undergraduate courses be structured to provide for more clinical exposure in the early years of the course and that clinical placements be of longer duration.

Clinical placements in undergraduate courses

3.62 Concerns were raised in relation to the availability and cost of clinical placements available to undergraduates. It was emphasised during the inquiry that quality clinical placements in a variety of health services are vital to the achievement of fitness to practice as a professional nurse.[60]

3.63 Evidence indicated that placements in clinical settings are increasingly difficult to obtain. The Deans of Nursing indicated that each dean or head of school has to find hospitals and other healthcare facilities which are able and willing to accept students and offer them supervised practice – ‘it is becoming increasingly difficult to make such arrangements because hospitals and other organisations are themselves short of resources; they are less and less able to spare the time of hard- pressed nurses to assist in the training of students, and some clinical nurses...resent this extra load’.[61]

3.64 One witness graphically illustrated the problem faced by the UWS:

We have a lot of trouble finding enough adequate and quality clinical places. It is very hard to find clinical places in the drug and alcohol area in our region of Sydney. It is very hard to find in-hospital placements in mental health...It is hard to find opportunities to give students experience in working with community mental health nurses, because they are thin on the ground and we have a large number of students. Some facilities have very good intentions. They might be small private surgical hospitals or small private psychiatric hospitals, but they limit the number of students they can take over time...because they have restructured and downsized.[62]

3.65 It was emphasised in evidence that the cost of undergraduate clinical education is high because hospitals, and other healthcare providers, charge for providing this service, or the universities have to employ clinical teachers to supervise students.[63]

3.66 A number of options were suggested to address the problem of the availability of placements.

3.67 Some witnesses suggested that ‘sandwich’ courses should be piloted. These programs would provide that a large part of the undergraduate course – up to half of each year of the course – would be spent in the clinical environment as a salaried member of the workforce. It was recognised that quality clinical teachers would need to be available in the healthcare settings and industrial relations issues related to pay and conditions would need to be negotiated.[64]

3.68 Some evidence suggested that part-time employment for nursing students should be provided, especially during student vacations so that they are exposed to hospital settings and get a ‘feel’ for nursing and the ‘culture’ of the hospital environment.

3.69 Some hospitals already provide employment for second year student nurses with pay rates equivalent to assistants in nursing rates.[65] Evidence suggests that this approach has positive results. One witness noted that:

While there have been some teething problems with it, the actual undergraduate students who are working at this post-second year level of their program are anecdotally saying that they are starting to feel part of what is going on; they know what the hospital is like; they know who these people are.[66]

3.70 A difficulty with this approach is that the pay rates offered by hospitals are lower than equivalent pay that can be obtained with outside casual employment. One witness noted that the pay rates for assistants in nursing is about $11.50 an hour, and $13-14 hour in the acute sector, compared with approximately $20 an hour for casual work with outside employers, such as KFC or McDonalds.[67]

3.71 Other witnesses suggested that clinical education should be available across the entire year. Currently, most universities run their clinical education programs within two narrow 14-15 week semesters each year. Invariably this means that clinical agencies are ‘overloaded’ with students at certain times of year. Access to agencies therefore has to be rationed and not all students have access to the widest range of clinical experiences. Submissions suggested that universities should use the entire year for clinical education thus affording more students the opportunity to access a range of clinical placements.[68] This would, however, increase the costs of clinical education.

3.72 Other witnesses suggested that the quality of the clinical placements, and not necessarily the duration of the placements needed to be maximised but that this would require additional resources – ‘resourcing into units, adequate staffing of units, would be an enormous step forward to having a better clinical environment for the students to learn in’.[69]

3.73 Other witnesses suggested that a fourth year of supervised clinical practice was a better option than trying to find extra undergraduate placements given the difficulties in obtaining placements in the current environment.[70] This issue is discussed later in the chapter.

Conclusion

3.74 The Committee believes that issues related to the availability of clinical placements need to be addressed. As previously discussed, the Committee believes that students should have more clinical exposure during courses. Questions related to clinical placements are also bound up with issues related to the duration of undergraduate courses and the cost of clinical education. These issues are discussed later in the chapter.

3.75 The Committee believes that students need to spend more time in clinical practice under the supervision of experienced clinicians so that they are exposed to work in hospitals and related settings. The Committee considers that hospitals should be encouraged to provide for paid, part-time employment for nursing students during their undergraduate courses, which from evidence has proved to be a good learning experience for the students. The Committee also believes that clinical education programs in universities should be available across the entire year rather than within two narrow 14-15 week semesters per year as occurs in most courses at present.

Recommendation 14: That hospitals and other healthcare agencies be encouraged to provide part-time paid employment for student nurses from the second year of undergraduate courses.

Recommendation 15: That universities, as far as practicable, operate their clinical education programs across the entire year.

Content of undergraduate courses

3.76 Evidence to the inquiry indicated that the theoretical aspects of undergraduate courses were generally satisfactory. The ANF cited the results of a survey undertaken by the ANF (SA Branch) which indicated that newly graduated nurses, experienced nurses and Directors of Nursing considered that the undergraduate programs were providing a sound theoretical base for students to enter the nursing workforce.[71] The Education Review also noted that there is general satisfaction with the theoretical background of new graduates.[72]

3.77 Concerns were, however, raised that some areas such as mental health, aged care and cross-cultural nursing are not adequately covered in existing undergraduate programs.[73] Other areas identified as requiring more attention were leadership, negotiation skills, research, information technology, and pharmacology.[74]

3.78 The ANF stated that:

The curriculae...must prepare nurses for practice in the current environment in which health services are provided eg mental health, aged care, community and primary health care, and not just focus on preparation for practice in the acute care sector.[75]

3.79 In relation to mental health, the WA Branch of the Australian & New Zealand College of Mental Health Nurses noted the relatively small amount of teaching time devoted to mental health in undergraduate courses in Western Australia, especially compared to the previous hospital-based courses. The College noted that more teaching time needed to be devoted to mental health nursing in courses and also more time spent in clinical areas.[76]

3.80 Research commissioned for the Education Review found that in relation to mental health nursing, current programs preparing general nurses ‘contain too little, and inadequate, preparation for mental health nursing practice. Specialist preparation, of higher quality, and of greater intensity in both theory and clinical practice, is therefore needed to meet workforce demands of quality and quantity of the mental health nursing workforce’.[77]

3.81 The table below provides information on the number of hours of classroom instruction and of clinical experience in undergraduate mental health nursing courses offered by Australian universities. The table shows that both classroom hours and clinical experience varied markedly across States.

Table 3.5: Average number of hours of classroom instruction and clinical experience in mental health nursing in Australian universities - 1999

State/Territory	Classroom Instruction (hours)	Clinical Experience (hours)
New South Wales	63	86
Victoria	69.75	140
Queensland	71.6	106
Western Australia	116	260
South Australia	35	95
Tasmania	18	116
Australian Capital Territory	78	120
Northern Territory	24	40
Australia	59.4	120

NB: Clinical experience hours exclude elective clinical placements.

Source: M. Clinton, Scoping Study of the Australian Mental Health Nursing Workforce 1999, Canberra: Department of Health and Aged Care, 2001, p.32.

3.82 The research report for the Education Review reviewed a variety of possible models for mental health nursing education. These focus on undergraduate programs including generalist programs which provide initial exposure to mental health nursing, and programs offering an initial period of specialist training within a three or four year degree. On the basis of the models reviewed, it was found that there were advantages in adopting a four-year model, based on generalist preparation in the first two years, followed by specialist theoretical and clinical placement components in at least the last year. Initial registration as a nurse would be possible after the third year, but specialist registration as a mental health nurse would not occur until after the fourth year.[78]

3.83 With regard to aged care, some submissions suggested that that there was insufficient time devoted in undergraduate programs to issues on ageing and insufficient clinical placements in aged care facilities.[79]

3.84 Commissioned research for the Education Review found that undergraduate nursing programs currently offer ‘too little specialised theoretical work and clinical practice in aged care. As a consequence, newly Registered Nurses are often inadequately prepared for work in the area’.[80] The researchers suggest that undergraduate courses be extended from three to four years. They argue that the current three years does not allow sufficient time for the development of general knowledge and clinical competencies and for the development of specific knowledge and skills for clinical practice in a particular area of specialisation – whether in aged care or other settings. The fourth year would allow students to develop the particular knowledge and clinical skills for work in different specialised settings.[81]

3.85 Submissions also noted that courses need to promote culturally sensitive programs. Such programs ‘will assist nurses maximise health outcomes and provide appropriate care within Australia’s multicultural society’.[82]

Conclusion

3.86 The Committee notes that evidence to the inquiry indicated that the theoretical aspects of undergraduate courses were generally satisfactory. However, concerns were raised during the inquiry that certain areas, such as mental health, aged care and cross-cultural nursing are not adequately covered in many undergraduate programs. The Committee believes that more attention should be devoted to these areas in relation to both theory and clinical practice in undergraduate courses.

Recommendation 16: That undergraduate courses provide additional theory and clinical experience in mental health, aged care and cross-cultural nursing.

Duration of undergraduate courses

3.87 Several submissions argued that the current three-year undergraduate degree course is too short and should be increased to a four-year degree program.[83] As noted above, it was argued that the current three-year course does not allow adequate time to be devoted to certain areas of nursing such as mental health and aged care.

3.88 Submissions argued that a four-year course is necessary to ensure that students are sufficiently exposed to the burgeoning knowledge base required for professional nursing practice.[84]

3.89 Submissions also pointed out that nurses are the only health care professionals who receive a three-year degree: all others require a 4-year degree, including physiotherapists and occupational therapists – ‘this makes nursing unattractive to many potential applicants as its status is automatically reduced’.[85]

Options for a fourth year

3.90 Some submissions argued that a three year degree program could be followed by a fourth year as an intern year with full registration at the end of the fourth year. The student would be paid during the internship at special student award rates.[86]

3.91 Royal Perth Hospital, in arguing that the fourth year of the undergraduate nursing course should be spent in the practice setting as paid employees –‘students of nursing’ – noted that ‘this would help alleviate the staff shortage issue as well as reduce the reality shock that currently confronts new graduate nurses’.[87] Royal Perth Hospital added that:

I would draw a parallel with those in the medical system, whereby five years of their time is spent largely in academic preparation and then they have a compulsory internship year if they are going to practice clinically...Unfortunately, at this stage the graduate year placements are not compulsory...our preferred position now from an industry perspective, is to see a compulsory fourth year offered and for there to be sufficient positions to accommodate all newly graduating nurses in that.[88]

3.92 A number of submissions argued that a system of paid employment for both student ENs and student RNs would increase the exposure of student nurses to the healthcare system.[89] Queensland Health suggested that the trial of paid employment for undergraduate nurses ‘could assist transition to the clinical environment’.[90] The Education Review stated that individual arrangements already exist and some other formal arrangements for both RNs and ENs are being developed or are in place in some States.[91]

3.93 The Education Review noted that while such arrangements may increase the exposure of nursing students to the healthcare system, employers are often too inflexible to use the students to best advantage and often the student nurse will not carry out any ‘real’ nursing tasks.[92]

3.94 One witness noted that the graduate nurse program – a one-year supervised clinical program in a health facility – is similar to the concept of an intern year and nurses have the advantage under the program of being paid as RNs.[93]

3.95 The University of South Australia also suggested that the Bachelor of Nursing degree should be awarded after four years, that is, at the conclusion of the 3-year undergraduate nursing course and after the one year graduate nurse program – as the majority of nurses undertake a fourth year in the form of a graduate nurse program.[94] The University proposed that an undergraduate nursing program of four years duration could include an exit point at which a student would be eligible for enrolment as a nurse as well as inclusion of the graduate program or internship as the fourth year, after which the student would gain a degree and be eligible for registration.[95]

3.96 The Tasmanian School of Nursing argued that a four-year undergraduate program is preferable to the option of an internship because ‘it allows a better blend of clinical practice and the fostering of higher level conceptual development necessary for practice in contemporary healthcare settings. It also enables the preparation of nurses who are exposed to clinical practice in a variety of clinical settings’.[96]

Conclusion

3.97 The Committee is not persuaded that the undergraduate degree program should be increased from three to four years. The Committee considers that the cost to the Commonwealth Government of this change would be substantial. The Committee believes that the focus of reform in this area should be on improving the structure of the current three-year undergraduate program, especially in relation to greater clinical exposure of undergraduates and support for first year graduate nurses in their workplaces.

3.98 The Committee also believes that a four-year program would not address the problem of the retention of nurses, indeed lengthening of the undergraduate degree program may act as a disincentive to many students contemplating a nursing career. The Committee further believes that resources in the area of nurse education would be better directed towards support for first year graduate nurses in the workplace by improving education outcomes through the graduate nurse transition programs, and by encouraging continuing education and the provision of additional postgraduate places for specialist nurse education. These issues are discussed later in this chapter and in chapter 4.

Funding of the clinical education component of courses

3.99 Submissions and other evidence argued that the current funding model does not adequately support the clinical practice requirements of undergraduate nursing programs.[97]

3.100 As noted previously, the universities receive the bulk of their funds as a one line operating grant. The funding rate per student received by each university depends on the distribution of students across levels and fields of study. The funding rate is based on the Relative Funding Model (RFM). The model comprises a teaching related component designed to reflect the relative costs of teaching in different discipline cost clusters at different levels, and a research related component to support research activities.

3.101 A relative teaching costs index was developed to distribute the teaching component of the model’s allocations on the basis of an institution’s particular mix of disciplines and levels. Nursing is placed in cost cluster 3 (out of five possible clusters). This means that the notional funding for undergraduate nursing is 1.6 times the funding of the base cost cluster (undergraduate accounting/economics/law/other humanities). For a postgraduate coursework award it is 1.8 times the base cost cluster funding.[98]

3.102 Several submissions argued that the weightings in the RFM do not reflect actual teaching costs. One submission noted that in the model nursing was allocated a weight of 1.6 for the undergraduate program, 1.8 for the postgraduate program, and 2.0 for research degrees which was very low in comparison with other healthcare disciplines. For example, medicine and dentistry are allocated weights of 2.7 for undergraduate programs, 3.0 for postgraduate programs, and 4.7 for research degrees.[99] It was argued that universities were therefore not being adequately compensated for the costs associated with courses, resulting in further cost pressures, or a failure to provide appropriate standards of training, or both.

3.103 The cost of undergraduate clinical education is high. RMIT University stated that it employed clinical teachers at approximately $35 an hour, and the Education Review noted that the costs of supervision are as high as $50 an hour.[100] One submission noted that many Schools of Nursing are required to meet annual clinical budgets of $1 million.[101] QUT indicated that its projected clinical costs will be $1.3 million for 2002.[102]

3.104 Submissions argued that additional funding specifically earmarked for improving the programs of clinical placement for student nurses should be provided by the Commonwealth.[103] The funding for undergraduate nursing courses does not at present include particular funding to accommodate for the costs of clinical education. The Education Review stated that these costs are high due to the need for the clinical supervision of students.[104] The Education Review further argued that ‘it is obvious that dedicated funding of clinical education is needed, outside the operating grant model’.[105]

3.105 One university stated that funding should be increased to a level that would allow the clinical teacher/student ratio to be decreased from the current ratio of 1:8 to a ratio of 1:4 or 1:6 at the maximum.[106] Submissions argued that improved teacher/student ratios enhance the learning opportunities of undergraduate students.[107]

3.106 The ANF commented that the inadequate funding for the clinical preparation of nurses ‘means that the quality of their clinical preparation is compromised and they have less opportunity to develop the clinical skills for a confident entry to practice’.[108] The Federation argued that there should be a review of the real costs of the clinical preparation of RNs and that funding should be allocated accordingly.

Conclusion

3.107 The Committee believes that the current funding arrangements fail to adequately support the clinical education requirements of undergraduate courses. The Committee considers that the Commonwealth should provide additional funding specifically directed to the undergraduate clinical education component of nursing courses.

Recommendation 17: That the Commonwealth Government provide specific funding to support the clinical education component of undergraduate nursing courses; and that this funding provide that the clinical teacher/student be maintained at a ratio of 1:4.

Cost of undergraduate courses for students

3.108 Students generally pay a Higher Education Contribution Scheme (HECS) contribution for their nursing courses.[109] The HECS debt will depend on the length of the course and the combination of subjects within the course. Most nursing courses are in HECS Band 1 (contribution of $3 521 per year in 2001), which is the lowest level of contribution, although some components of the course are in Band 2 ($5 015 in 2001). This means that nursing students will pay HECS at a higher level than that defined for Band 1 courses.[110] Student ENs pay course fees in most States and Territories, except in NSW where the Area Health Services meet these costs. Course fees vary between the States – from no fees payable in the case of NSW to between $3 000-$4 500 in the case of Tasmania. Added to HECS payments or fees for ENs are the costs of travel to clinical placements, uniforms and accommodation (often both for their usual residence and the one near the clinical site). Many also have childcare costs. [111]

3.109 While there are some scholarships available, most target Indigenous students and students from rural and remote areas.[112] The Commonwealth Government in the 2001-02 Budget introduced the Commonwealth Undergraduate Remote and Rural Nursing Scholarship Scheme. The scheme provides funding for 110 annual undergraduate rural nursing scholarships at a cost of $10.9 million over four years. Funding is provided for 100 scholarships valued at $10 000 per annum for undergraduate nursing students from rural and remote areas and 10 scholarships valued at $10 000 per year for ATSI nursing students undertaking a full-time undergraduate nursing degree. Financial assistance of up to $5 000 is also available for scholarship recipients suffering exceptional financial hardship.[113] Rural nursing scholarships are also available through some State Governments, universities and nursing organisations.[114]

HECS exemptions

3.110 Many submissions argued that undergraduate nursing courses should be HECS exempt as the cost of such courses provide a disincentive to students undertaking these courses.[115] The ANF suggested that nursing should be HECS exempt in the immediate short term.[116]

3.111 Other submissions suggested that HECS contributions should be waived for certain nursing students, for example, from rural and remote backgrounds or ATSI students or that the HECS debt should be waived for nursing students who undertake a specified period of nursing in rural or remote areas upon completion of their studies.[117] Some submissions recognised, however, that providing special HECS arrangements for nursing students would create precedents for the Commonwealth regarding other fields of study.[118]

3.112 DEST advised the Committee that an average HECS liability for a full time undergraduate nursing degree completed in 2002 would be $10 582 and the Department estimated that it would take 8.5 years to repay this HECS debt.[119]

3.113 The Education Review stated that HECS does not appear to be a disincentive to students from lower socioeconomic (SES) backgrounds undertaking nursing courses, and that it is unlikely that the removal of HECS would encourage more students into nursing.[120] Data on the SES backgrounds of nursing students in undergraduate courses from 1994 to 2000, indicate that those from low-and middle-SES backgrounds increased marginally over the period.[121]

3.114 Reports on the impact of HECS on participation in higher education generally found that HECS is not a major factor influencing the higher education participation of students from low SES backgrounds. Reports by the Higher Education Council on the impact of HECS concluded that HECS was not deterring students from participating in higher education. A Higher Education Council 1991 attitudinal survey, which specifically targeted disadvantaged groups, found that for school leavers, HECS was a low ranking factor in their decision not to go onto higher education, while for those intending to undertake higher education or those undecided about whether to do so, HECS ranked behind academic factors and more pressing economic factors in their decision making. Another report on this issue by DETYA concluded that HECS is a very minor factor in the low participation rates in higher education by students from lower SES backgrounds.[122]

Scholarships

3.115 Other submissions argued that scholarships should be available.[123] There are no general Commonwealth Government scholarships currently available for undergraduate nursing students except, as noted above, for Indigenous students and students from rural and remote areas. Some groups argued that these scholarships should particularly target students from disadvantaged backgrounds, non-English speaking backgrounds, ATSI students and students from rural and remote areas or students who undertake to practice in areas of need or shortage after graduation.[124]

3.116 The ANF, while welcoming the recent allocation of scholarships for undergraduate rural and remote nursing students noted that there is a significant disparity between the nursing scholarship allocation and the medical scholarship scheme (with 500 medical scholarships for 1 200 commencing students, compared to 100 nursing scholarships for more than 7 000 nursing students commencements each year).[125] One submission suggested that the number of nursing scholarships should be available on a pro-rata equivalent basis to the number of Commonwealth-funded scholarships available to medical students.[126]

3.117 The ANF argued that there should be additional scholarships provided for nursing students as well as the inclusion of a ‘support component’ to assist students in completing their courses, such as the provision of bridging courses, mentoring and extra tutorials.[127]

3.118 The National Rural Health Alliance (NRHA) argued that the Commonwealth should establish a scholarship scheme for student nurses similar to the John Flynn Scholarship Scheme for medical undergraduates. The Alliance argued that this Scheme when fully operational should provide at least 300 nursing scholarships per year. This would be in addition to the undergraduate rural nursing scholarship scheme. The Alliance stated that the John Flynn Scheme has proved a popular way to enable medical undergraduates to gain some experience of working in rural and remote communities The scholarships provide medical undergraduates with a two-week placement once a year for four consecutive years during their medical training. This is in addition to any rural placement that occurs as part of their clinical education.[128]

Other support measures

3.119 Submissions suggested that measures that assist students with the costs associated with clinical placements should be a priority. Submissions noted that the cost of undergraduate education, including accommodation and travel to clinical placements, is an increasing burden on students.[129]

3.120 Submissions commented especially on the high cost of clinical placements for students who choose to undertake clinical experience in rural or remote areas. Submissions argued that the housing and travel costs for these students should be subsidised.[130] Submissions noted that students who are exposed to rural nursing/midwifery during their undergraduate education are more likely to return to work in rural areas after graduation.[131] An example cited in evidence was the situation in Tasmania where the School of Nursing is located outside the capital city in Launceston which means that students coming from elsewhere in the State may incur considerable accommodation and travel costs in completing their studies.[132]

3.121 One submission noted that problems with encouraging nursing students to take up rural and remote clinical placements will continue until there is a sustainable funding source similar to that available for medical students undertaking rural placements through the RUSC funding from the Commonwealth.[133]

3.122 The Education Review also noted that the provision of some support during the undergraduate course may be a better incentive to retain those students who are struggling to meet living costs than HECS exemptions. This could take the form of scholarships or allowances to meet daily living expenses, especially the costs associated with clinical placements.[134]

Conclusion

3.123 The Committee does not consider that undergraduate nursing courses should be HECS exempt. The Committee believes that as nurse education properly belongs in the university sector and that undergraduate courses generally require a HECS contribution from students, nursing undergraduates should be treated no differently than other undergraduates in relation to the payment of HECS. Apart from such a practice creating a precedent for other courses, evidence indicates that HECS does not appear to be deterring students from selecting nursing courses. The Committee notes that nursing courses continue to be oversubscribed.

3.124 The Committee believes that support measures such as scholarships are a more practical approach to assist with the costs students face in undertaking undergraduate courses, rather than HECS exemptions. The Committee believes that general scholarships as well as specific targeted scholarships should be provided by the Commonwealth and State Governments.

Recommendation 18: That the Commonwealth and State Governments provide additional targeted scholarships for undergraduate nursing students based on merit directed at students from economically and socially disadvantaged backgrounds, NESB and ATSI backgrounds, and from rural and regional areas.

Recommendation 19: That the Commonwealth Government provide general scholarships for undergraduate nursing students based on merit.

Transition from university to practice

3.125 A large percentage of new graduates leave nursing within twelve months of graduation. Many submissions argued that programs of support for new graduates during this transitional year need to be improved.[135] A number of persistent transition issues from university to workplace have been identified that include: preparedness for practice; skill mix in clinical settings; new graduates practicing without support and beyond their level of expertise; and conflict between the demands of the situation and the skills of the beginning practitioner.[136]

3.126 Evidence to the inquiry indicated that adjusting to the transition from university to the practice setting, from student to nurse, is difficult and stressful for many graduates. The Committee was told that new graduates entering the workforce suffer a serious reality shock when faced with working expectations and conditions, and the usual stresses associated with hospital and other healthcare work environments. There is a strong expectation that new graduates should ‘hit the decks running’. The transition process from student, with little responsibility and accountability, to RN with full responsibility and accountability, is difficult enough without this expectation.

3.127 In many hospitals a hierarchy operates based on the old ‘apprentice’ system. The reality shock is compounded for some graduates who believe they are highly trained and should not be required to perform many of the ‘traditional’ routine or manual nursing duties.

3.128 From the hospitals’ perspective there are reports that graduates lack practical key clinical and supervisory skills to easily survive the daily demands of a busy acute hospital with patients with high levels of acuity and short length of stays. Tensions arise when overworked senior nurses regard themselves as having to carry the extra work of their inexperienced new colleagues. The education sector is then criticised for producing graduates with insufficient clinical training and expertise.

Graduate nurse programs

3.129 The main mechanisms for facilitating the transition from university to nursing work for new graduates are graduate nurse programs, orientation programs and periods of preceptorship/mentorship or other forms of supervision or assistance by an experienced nurse. Graduate nurse programs provide a broad framework in which activities such as orientation programs, preceptorships and other forms of assistance may be provided. The graduate programs vary considerably in scope and may consist of, for example, placements in three or four wards or units or the provision of an educator and an education program with the provision of time off for study.[137]

3.130 Orientation programs and preceptorships may also be used outside the framework of a formal graduate nurse program, as new graduates require preceptorship and orientation to specific work environments. Some undergraduate courses include a form of preceptorship during clinical placements, in which students work on a one-to-one basis with an experienced RN as preceptor. Students often return as graduates to clinical areas that had provided good learning environments. Transition to practice programs are affected by the shortage of nurses, especially RNs.

3.131 The inadequacies of current graduate nurse programs were summarised:

The programs offered to support new graduates into their first year of practice are inconsistent from one health care organisation to another. There is no consistent amount of funding in Australia to hospitals for these programs. These programs may consist of formal and informal preceptorship, mentoring and orientation that vary in quality and length of time. There have been increasing instances of graduates who have been employed on a casual basis with an agency or an emergency ‘pool’ where they are expected to practice in a range of clinical settings without having any appropriate orientation process.[138]

3.132 Graduate nurse programs are not compulsory in the States and Territories. Evidence also indicated that some graduates do not get into these programs and there are few programs in the private and aged care sectors. While most State governments contribute some funds to the program there are different levels of funding between the States and Territories. The Victorian Government provides $10-11 000 per graduate under its graduate nurse program. In 2001, 223 graduates were funded under this program.[139] In Western Australia, one witness stated that hospitals only get ‘a few hundred dollars per student’ under the program.[140] The hospitals have positions for graduate nurses and their employment costs are paid for in their budget allocations. [141]

3.133 The ANF argued that graduate nurse programs should be offered in all environments where nursing is provided – ‘these should be tailored to the needs of the individual and incorporate the use of mentors or preceptors’.[142] One witness noted that ‘I certainly feel that nurses are ready to work in practice at the end of three years, but they need continued support in that transition to practice. Not all nurses are offered that opportunity or are able to take that opportunity up. Those that do not maybe practice in areas outside of their level of expertise’.[143] Another witness emphasised the need to support nurses’ transition into the workforce ‘with some well-structured programs that are effectively managed and are monitored on the outcomes that they are able to achieve...in the first six months graduates are essentially finding their feet, and in the second six months they are consolidating their experience as a new registered nurse and they begin to fly’.[144]

3.134 The Committee also received some evidence that the funds allocated by State Governments for graduate nurse programs are not being spent for the purposes for which they are intended. The Deans of Nursing suggested that State Governments should carefully audit these programs.[145]

Preceptorship programs

3.135 Much evidence referred to the need to develop nationally formal mentoring and preceptorship programs and that such programs should include competency and individualised development plans for all nurses. There is a need to expand the provision of training and payment for those nurses chosen to become preceptors to compensate them for providing supervision to new graduates and nurses returning to the profession. As examples, Queensland Health has developed Preceptor Training Modules designed to assist trainers when providing preceptors with the preparatory knowledge and skills necessary to fulfil their role.[146] In respect of payment, Tasmania’s recently negotiated Nurses Enterprise Bargaining Agreement includes the introduction of a preceptor allowance.[147]

Recommendation 20: That formal mentoring and preceptorship programs be developed nationally, with enhanced training and the payment of allowances for nurses chosen to become preceptors.

The role of nurse educators

3.136 Submissions noted that the role and functions of nurse educators in both educational and clinical settings had been abolished or absorbed. Nurse educators can be clinical educators – teaching and working in a ward or they may have a wider role in education and they may be organising new graduate education, including short courses and working with students.[148]

3.137 In universities, positions for clinical teachers are predominantly sessional positions – for many competent clinicians the seasonal nature of these positions are therefore unattractive, as they offer little financial security and few opportunities for career advancement.[149] The Education Review also noted that in universities, staff find that the time and effort required to remain current and clinically competent competes with other academic priorities.[150]

3.138 In healthcare settings, the ANF argued that the demise of nurse educator positions or their absorption into the nursing care delivery workforce in times of shortage is adversely impacting on new graduates – ‘these positions provide an enormous amount of support and have an important role in continuing education, competency assessment, managing change etc’.[151] The ANF argued that clinical nurse educator positions should be widely re-introduced.

3.139 The ANF also noted that nurses are constantly engaged in supervising, supporting and educating new staff, both new graduates and other employees new to the workplace, in addition to their normal workloads, without any acknowledgment or monetary reward.[152]

Enrolled nurses

3.140 Transition to practice is also an issue for ENs and many of the same support programs are required. The ANF argued that similar strategies to those for RNs are needed for ENs, that is, peer support, mentorship and clinical educators.[153] The National Enrolled Nurse Association (NENA) argued that there should be a fully funded post registration/graduation year program in line with the current RN graduate year program.[154]

3.141 The Association pointed to the need for quality preceptorship and orientation programs for newly graduated ENs.[155] NENA noted that there are no formal graduate or preceptorship programs in the States or Territories for ENs. In the Northern Territory a graduate program for ENs is being introduced. Some States have hospital based preceptorship programs for ENs.[156]

Conclusion

3.142 The Committee notes the concerns expressed in evidence that support programs for new graduates – both RNs and ENs – need to be improved to address difficulties that these graduates may face in adjusting to the hospital environment.

3.143 The Committee believes that graduate nurse programs should be available for all nursing graduates and that the emphasis of the programs needs to focus on the provision of a period of supervised practice to consolidate clinical and decision-making skills and to provide orientation to the workforce.

Recommendation 21: That graduate nurse programs be available for all nursing graduates and that these programs:

concentrate on skills consolidation through a structured program to enable professional development,
be provided with appropriate supervision and support, and
be jointly funded by Commonwealth and State Governments.

Articulation between nursing levels

3.144 A number of different articulation pathways between different nursing education levels operate at present. Evidence indicated the need for innovative, flexible and multiple models of enrolled nurse, registered nurse and postgraduate education within an articulated framework that enables multiple entry and exit points, all of which should include competency based outcomes.[157]

3.145 The types of articulation pathways currently available are illustrated in the figure below.

Figure 3.1:Articulation pathways for those currently involved in nursing work

Source: National Review of Nursing Education, Discussion Paper, December 2001, p.121.

3.146 The Education Review noted that currently students are undertaking Certificate III courses with a view to going onto Enrolled Nursing – in some places, agreements with employers exist to support this arrangement. Student ENs are beginning Certificate IV intending to use it to move into an undergraduate nursing course. Bridging courses exist or are being developed in various forms to assist students to make this transition. There are also EN programs that are designed to lead directly into undergraduate entry programs. Graduate entry programs also operate in universities. These allow students who graduate with a degree from another discipline to accelerate their completion of a nursing degree.[158]

3.147 Submissions generally supported the need for a range of academic pathways for entry to, and exit from, various courses.[159] One witness noted that multiple entry and exit points are important to ensure that ‘if for some reason somebody cannot complete a training program, the training is not wasted and they can perform a useful role within the profession’.[160] Some submissions stated that students should be able to exit at one, two or three years with a specific qualification that will enable them to work in the health sector, instead of having to undertake a standard three or four year university program.[161]

3.148 Some universities are developing flexible programs. La Trobe University stated that it has developed a flexible EN/RN conversion course to be offered to experienced ENs and a flexible midwifery education course.[162] Charles Sturt University offers ENs with an Advanced EN Certificate from TAFE admission to their Bachelor of Nursing degree courses. The University also provides nursing studies through distance education to some 470 students – out of a total of 650 students enrolled in the nursing undergraduate course. Most of the distance education students are ENs who are converting their current qualifications to RN status. Some 70 per cent of the distance education students live in rural or remote areas. Although most live in NSW, a significant number reside in Victoria and Queensland. The University stated that there is a ‘very high demand’ for the course.[163] UTS stated that it has multiple entry programs – ‘possibilities into the Bachelor of Nursing program. ENs can come in with a certificate IV...It is a special program designed to the same exit point as the other [programs], but to meet the needs of enrolled nurses’.[164]

3.149 During the inquiry issues were raised in relation to articulation pathways for ENs, nursing and personal care assistants, ATSI health workers and midwives.

3.150 In relation to ENs, NENA argued that there needs to be national consensus in recognising prior learning and experience for those ENs wishing to articulate to registered nurse.[165] The NSW Health Department stated that ‘we believe very strongly that there needs to be articulation through all educational pathways and that an institution needs to recognise the prior learning that a nurse has received in a previous course’.[166]

3.151 The Education Review noted, however, that there are difficulties in establishing a system that gives standard credit for education and experience for ENs seeking a university place. These factors are:

standards and qualification requirements for ENs vary across Australia and standards vary within States. Without a common standard it is not possible to identify an appropriate level of credit.
university courses also vary in approach and the order in which materials are covered, so topics an EN has previously completed may be distributed anywhere/widely throughout in the standard university course.
there is no framework that demonstrates that EN competencies are an identifiable subset of those for RNs, or that the theoretical foundations required for a university course are established as part of the EN program. Without this overlap it is difficult to establish a system of credits for ENs at university.[167]

3.152 The Education Review noted that the current situation means that in States like NSW which has a centralised EN curriculum, the development of conversion and bridging courses at TAFE allows students to gain credit at university as well as overcomes some of the problems that automatic credit arrangements might cause.[168]

3.153 The ANF argued that the formal articulation and recognition of prior learning arrangements which have developed between EN courses and RN courses by some universities and EN education providers should be consolidated and extended so that all ENs have access to undergraduate programs if that is their career path choice.[169]

3.154 The TAFE NSW Nursing Unit proposed a single model educational pathway for ENs and RNs. Under this proposal, students would enter the program at the Diploma level and have two optional exit points – exit after 12 months as an EN – after completion of a Diploma in Nursing – or exit after 3 years as a RN after completion of a Bachelor of Nursing degree.[170] TAFE NSW argued that the EN education program ‘needs to be embedded into the first year of the undergraduate nursing program and provide exit points...either exiting as an enrolled nurse or moving into the second year of the program’.[171]

3.155 The ANF argued that formal articulation and recognition of prior leaning arrangements should be developed between Certificate III courses for unlicensed nursing and personal care assistants (however titled) and enrolled nurse courses, and between courses for ATSI health workers and enrolled nurse courses.[172] One submission stated that a possible pathway could include the opportunity for students to enter as personal care assistants through the TAFE sector. These students would then be offered the opportunity to progress into an EN program and from then to a Licensed Practical Nurse program (based on the US model where these nurses have a specific role which is different from that of the RN), and then onto completion of the program as a RN.[173]

3.156 In relation to midwifery, the Australian College of Midwives (ACMI) advocates separate, direct entry undergraduate programs for the preparation of midwives, as a complementary mode of entry to existing programs. On the basis of a cooperative effort between midwifery educators in a number of States, a three year Bachelor of Midwifery has been developed for implementation in 2002. At present, courses are offered in Melbourne and Adelaide.[174] Currently, entry to practice as a midwife requires completion of a postgraduate course, following initial registration as a nurse.

3.157 Some groups expressed concerns that while direct entry midwifery programs may satisfy those who only want to practice as midwives, they may limit the career choices of those who undertake them and reduce their employment potential, particularly in rural, regional and remote areas.[175]

Conclusion

3.158 The Committee notes progress made in the development of articulation and recognition of prior learning between different levels of nursing. The Committee believes that formal articulation and recognition of prior learning should be further extended for ENs, unregulated healthcare workers and ATSI health workers.

Recommendation 22: That formal articulation arrangements and recognition of prior learning between enrolled nurse courses and registered nurse courses by universities and enrolled nurse education providers be further developed nationally.

Recommendation 23: That formal articulation arrangements and recognition of prior learning be developed between Certificate III courses for unregulated healthcare workers and enrolled nurse courses, and between courses for ATSI health workers and enrolled nurse courses.

National nursing curriculum

3.159 Several witnesses argued for the development of a national nursing curriculum to ensure consistency with competency standards. One witness stated that in relation to national consistency in the delivery and development of undergraduate courses –‘I do not think we have articulated our expectations clearly at the national level of what we expect of students who have completed the three-year degree course’.[176] The Education Review noted that there were views expressed during its consultations that a core nursing curriculum that allows for local variation should be developed and applied nationally.[177]

3.160 While all nurse education programs incorporate the ANCI competencies and all graduates are assessed to meet those competencies in order to be registered, there appears to be considerable variation in their interpretation.[178]

3.161 There was some diversity of views as to what a national curriculum would or should entail. One witness noted that ‘for me, when they say, standardised national curriculum, I have the vision of just one type of course. But I think there should be some diversity within the core curriculum’.[179]

3.162 Some witnesses did not support the introduction of a national curriculum emphasising the need to maintain diversity in course structure.[180] The Faculty of Nursing at the University of Technology, Sydney stated that:

The AUTC review clearly says that there is no evidence of the need for a national curriculum. We have ANCI competencies. They are expressed in different ways in different curricula, but they meet the appropriate nursing registration authority standards and there is a real need for university curricula to be able to have local flavour.[181]

3.163 An alternative approach to a national curriculum proposed by some witnesses was the development of a national accreditation system of all education programs for nurses to ensure national consistency in standards. Currently, each nurse regulatory authority is responsible for the accreditation of nursing courses in their jurisdictions. The ANCI stated that when nursing courses are accredited, competency standards are used to identify that the particular course would be able to produce a graduate who would in fact demonstrate those competencies – ‘so, in essence, national standards exist for the development of courses, standards which everybody has adopted for that purpose’.[182] One witness noted that ‘we do have national competency standards to which all universities work. That is a better way [than a national curriculum] because they can be creative, but they have the same outcome standards to meet’.[183]

3.164 The ANCI informed the Committee that it is currently examining the issue of the development of a national system of accreditation. The ANCI stated that a national system ‘would bring a better sense of standards being set across the country’.[184] The Nurses Board of Victoria in supporting a national system of accreditation of nursing courses also argued that the ANCI should examine the establishment of a national accreditation system. The Board suggested that the system could be modelled on the current system in place for accreditation of medical courses conducted by the Australian Medical Council.[185]

Conclusion

3.165 The Committee believes that a national curriculum framework or guidelines for undergraduate nursing courses should be developed and applied across Australia to overcome current variations in the interpretation of ANCI competencies. The Committee believes that this core nursing curriculum should, however, allow for local variation in course design. The Committee does not propose the introduction of the same nursing curriculum nationwide, only that there be consistency in course structure with defined competency standards.

Recommendation 24: That the Australian Nursing Council, in conjunction with key stakeholders, including State regulatory bodies, the universities, professional nursing bodies and nursing unions, develop a national curriculum framework or guidelines for undergraduate nursing courses to ensure greater consistency in the interpretation of the ANCI competencies.

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