Chapter 5 - Interface between the Education sector and the Health system

Universities are making independent decisions about curriculum development, the states and territories are making independent decisions about the structure of the nursing workforce with relatively weak national coordination of policies...The need for national coordination in this area is self-evident but sadly lacking.[1]

Introduction

5.1        Evidence to the inquiry indicated the need for a much more coordinated approach between the Commonwealth and the States and between the education and the health sectors in relation to the education and training of nurses. The complex division of responsibilities for the education and training of nurses, the registration of nurses and the responsibility for nursing workforce issues and the lack of coordination at the national level in relation to these matters is a continuing problem that needs to be addressed. One commentator highlighted the urgent need for national coordination in these areas:

Responsibility for initial preparation of nurses rests with the universities, loosely coordinated by the Commonwealth government. Each university makes an independent decision about course design, number of entering students, postgraduate course offerings and so on. University decisions have critical consequences for the health and community service sectors in terms of the numbers of entering registered nurses and yet there are no mechanisms at national level and few mechanisms at state level to ensure that these university decisions impact positively on future workforce requirements.[2]

5.2        The Commonwealth Department of Health and Aged Care also alluded to the problem in the following terms:

The Commonwealth Government has an overall interest in the supply, distribution and quality of the health workforce, including nurses. It also provides funding for Registered Nurse education through the Department of Education, Training and Youth Affairs. However, State responsibility for health practitioner registration and the split of responsibility for health service funding and provision in Australia gives the Commonwealth little direct responsibility for the nursing workforce.[3]

5.3        As noted previously, the education and training of nurses is delivered through separate parts of the education and training system – RNs are prepared through the universities which are largely funded by the Commonwealth Government and ENs are prepared in the vocational education and training sector which is largely funded by the States. The Victorian Department of Human Services commented that these funding arrangements can lead to unusual outcomes:

There is something ironic about this. We [the States] are responsible for the training of the work force for aged care facilities and the Commonwealth is responsible for the training of the work force for public hospitals.[4]

5.4        The National Review of Nursing Education (the Education Review) also commented on the effects of the complex interaction of Commonwealth and State Government responsibilities in the areas of education, health and workforce planning and their impact on nurse education. The Education Review stated that:

The initial education of and training of registered and specialist nurses is primarily the responsibility of universities, primarily funded by the Commonwealth education portfolio. The training of Enrolled Nurses...occurs in the Technical and Further Education institutions of the States. State Governments have a direct interest in their role as the dominant employers of nurses. Nursing workforce issues are matters for both the Commonwealth and State health portfolios. These various responsibilities in relation to education policy, funding and employment all impact on nursing education.[5]

5.5        As discussed in previous chapters, the inquiry highlighted the need for better linkages between the workforce requirements of the healthcare sector and the places and programs provided by the education sector; more effective mechanisms for assessing future labour force needs and a nationally coordinated approach to nursing workforce planning; and improved coordination between education and health departments at the Commonwealth and State level. These issues are further discussed in chapter 2.

Improving the interface between the education and health sectors

5.6        As noted previously, evidence to the inquiry emphasised the need for strong links between the education and health sectors in the education and training of nurses. It was noted in evidence that formal, collaborative and effective partnerships between education and healthcare service providers are required to enable nurses to access an appropriate range of experiences to facilitate comprehensive development of nursing skills; produce graduates able to provide competent nursing in an environment of continuing change; and enable cost-effective and appropriate teaching and learning models to be developed for nursing programs.[6]

5.7        Concerns were expressed during the inquiry about the relationship between the education and health sectors both in preparing students and in assisting them to make the transition from the university environment to the workplace.[7] One university noted that:

The move to the higher education sector decoupled the curriculum from service needs allowing Registered Nurses to be educated rather than trained as apprentices. While this has been beneficial in terms of providing Registered Nurses with the theoretical input necessary for a career in modern health care there has been some argument that it has distanced nursing from service priorities.[8]

5.8        Another university also commented that:

Nursing can be strengthened by greater collaboration between clinical practice settings and universities. In Australia the shift of nursing education to the tertiary sector widened the gap between theory and practice. What we are now seeing is a shift back to industry working more closely with nursing-education institutions.[9]

5.9        The 1994 Reid Report into nursing education stated that ‘the outstanding issue’ during that review was the need to encourage closer and more effective relations between the university schools of nursing and the various stakeholders, especially health industry employers, and the profession and the registering authorities, but also consumers of both health services and education services.[10]

5.10      The report commented that:

It is not a question of “restoring” the old health-education relationship that was disrupted by the transfer to higher education. It is a matter of building a new relationship in which education will be more responsive to the needs of the workplace but the relationship with the workplace will take into account educational imperatives...In the emerging environment, education and research will play a more universal, dynamic and higher quality role than before, while at the same time depending for their effectiveness on their relationship with the health sector.[11]

5.11      Evidence to the Committee indicated that while there have been improvements in the linkages between the education and health sectors, they are inconsistent and underdeveloped in many instances.[12] One submission noted that ‘whilst there have been some moves in this direction this remains an area where there is still room for improvement’.[13]

5.12      Evidence suggested an overwhelming degree of support for the development of closer collaboration between educational institutions and health providers.[14]

5.13      A range of measures were suggested in evidence to improve the interface of the education and health sectors, including:

• partnership initiatives;
• joint curriculum development;
• joint appointments/clinical chairs; and
• use of shared facilities.

These measures are discussed below.

Partnership initiatives

5.14      Submissions argued that there should be more partnership models developed between the health sector – both public and private – and the universities and TAFE sectors to facilitate the clinical education and training of nurses.[15]

5.15      Submissions argued that there needs to be better arrangements between the universities and the health sector in clinical planning arrangements, especially to improve the coordination of clinical placements and issues related to the duration and cost of placements. These issues are further discussed in chapter 3.

5.16      A number of successful partnership initiatives were highlighted during the inquiry.[16] As noted previously in chapter 3, Flinders University, in partnership with several hospitals and other health agencies has developed an innovative model for clinical placements through the introduction of Dedicated Education Units.[17] The University of Notre Dame, as previously discussed in chapter 3, has a model of clinical placement that emphasises partnerships with hospitals to enable students to undertake their placements at the same facility for the length of their course.[18] The University of Western Sydney has developed a new ‘industry-responsive’ undergraduate degree program, beginning in 2002, which was developed in close cooperation with clinical service providers in Greater Western Sydney. The University stated that it has developed close liaison with health service provides in planning, implementing and evaluating clinical learning experiences and curricula.[19]

5.17      The University of Technology, Sydney has clinical partnerships with approximately 100 clinical facilities. The University has a large number of partnerships with the public sector and also has strong private sector partnerships, especially in the postgraduate area.[20] UnitingCare noted that agencies had an affiliation agreement with Southern Cross University to provide undergraduate students with practical clinical experience and an effective collaborative partnership with the Queensland University of Technology to develop post-graduate level courses in aged care nursing.[21]

5.18      Submissions argued that private healthcare providers should be encouraged to contribute to the undergraduate and postgraduate education of nurses.[22] The Australian Council of Deans of Nursing (ACDON) noted that the Adelaide Community Health Alliance (the Alliance), a group of five private hospitals, in partnership with several universities ‘is basing its successful recruitment policies on support for continuing education’.[23] The Alliance, has established strong links with Flinders University and the University of South Australia as well as with the Douglas Mawson Institute of TAFE. The Alliance stated that the placement of students in clinical settings over extended periods in its member hospitals has led to the successful recruitment of graduates to work in its hospitals. [24] One submission noted that in Tasmania, a private mental health hospital, in partnership with public sector hospitals, offers paid clinical rotation for students undertaking postgraduate courses in mental health nursing.[25]

5.19      Submissions also noted that partnerships between EN course providers, especially TAFE colleges, and the health system need to be more clearly defined.[26] The National Enrolled Nurse Association (NENA) argued that there was a need to create a more collaborative approach between the education and health sectors and advocated the inclusion of hospital education staff in the teaching process and adequate funding for clinical placements.[27] UnitingCare Australia stated that a number of its organisations at a local facility level ‘do develop relationships with TAFEs to provide on-site training and opportunities for practical experience’.[28]

Recommendation 44: That partnership arrangements be further developed between the public and private health sectors and universities and the vocational education sectors to facilitate the clinical education and training of nurses.

Partnerships between universities

5.20       Submissions also commented on the need for greater collaboration between universities. Monash University stated that it has consortium type arrangements in areas such as community health and development (linked with Deakin University), midwifery (ACU, RMIT and VUT Universities) and emergency nursing (RMIT University). Monash stated that further development and evaluation of such models should result in a more rational use of resources and also meet local industry needs through the use of shared/common course materials and expertise.[29]

5.21      Submissions noted that partnerships should be developed between metropolitan and regional universities to enable students from city campuses to undertake clinical placements in regional hospitals and vice versa. Submissions noted that this was important as the clinical experiences in the two settings are quite different.[30]

5.22      The Australian Catholic University (Sydney) has a partnership arrangement in place that enables students from its regional campus to undertake clinical placements in metropolitan hospitals as well as in regional and rural hospitals. The University is now planning to offer its metropolitan-based students the opportunity of regional placements.[31]

Recommendation 45: That partnerships be developed between universities to facilitate the sharing of resources and expertise; and facilitate undergraduate student clinical placements in a range of metropolitan and regional clinical settings.

Other partnership arrangements

5.23      The Committee received evidence of the involvement of State Governments and Departments in facilitating the interface between universities and the health system. Queensland Health stated that it had implemented strategies identified by the Ministerial Taskforce on the recruitment and retention of nurses to improve this interface. An education standing committee has been established to facilitate the development of partnerships, match postgraduate and enrolment courses to industry needs and address ongoing issues.[32]

5.24      In Tasmania, the Partners in Health initiative between the Tasmanian Department of Health & Human Services and the Faculty of Health Sciences at the University of Tasmania is aimed at developing and maintaining collaborative teaching, research and clinical service delivery activities. The Tasmanian School of Nursing stated that one of the benefits of this program is the establishment of joint appointments that assist in developing linkages between the health and education sectors.[33]

Joint curriculum development

5.25      Submissions argued that there needs to be structured healthcare industry input into curriculum development to ensure that graduates are well prepared for employment in the various practice settings.[34] One submission noted that curricula must not be developed without input from healthcare industry stakeholders.[35] Queensland Health stated that:

Better partnerships between the higher education sector and the health sector in curriculum development and clinical experience planning would reduce gaps between industry needs, improve relevance of curricula content and improve coordination of clinical placement.[36]

5.26      Another submission commented that:

Universities and TAFEs need to develop programs in close consultation with the heath sector agencies so that the programs address both current and emerging health care demands. Currently such programs are developed almost in splendid isolation, or in consultation with the professional bodies only. Hospitals in particular are in a good position to know what the likely needs of their future workforce are to be and thus must be integral to curriculum development as well as implementation.[37]

5.27      The Education Review noted that in some universities clinicians have been appointed to curriculum committees.[38] The Australian Nursing Federation (ANF) stated that more cross membership of key committees such as university curriculum development and health facility education committees would strengthen the relationship between the two sectors.[39] The Australian Healthcare Association suggested that a national industry training authority should be established to ensure a balance of education/training provider, professional and industry input into course content at all levels of nurse education.[40]

Recommendation 46: That improved partnership arrangements be established between the universities and the health sector in relation to curriculum development, including the appointment of clinicians to university curriculum committees.

Joint appointments/clinical chairs

5.28      Many submissions argued that there should be more joint appointments to clinical chairs between universities and health services.[41] Submissions noted that a number of successful initiatives in the area of joint appointments have already been undertaken.[42]

5.29      One submission noted that to enhance partnerships between the universities and the health industry, senior nursing appointments in the health sector could be joint appointments where the incumbent has a university clinical title – similar to that which occurs in the medical field. In addition, a number of joint appointments could be established where salary costs are shared between the sectors.[43] One submission commented on the benefits of joint appointments in the following terms:

This will facilitate cooperative arrangements for organising and sharing the responsibility for clinical supervision and ongoing nursing education at both undergraduate and post-graduate levels. The other obvious benefit, given that nursing is a practice-based discipline, is that it allows academics to engage with the clinical setting and thus maintain their clinical currency.[44]

5.30      The ANF argued that joint appointments could be extended to include all levels, for example, clinical nurses as tutors or mentors, clinical nurse educators as clinical teachers; and professorships. The Federation noted, however, that issues of professional accountability and responsibility can cause dilemmas for nurses who work across the two environments and these issues would need to be addressed.[45] Submissions also argued that joint appointments should be promoted with both public and private sector facilities.[46]

5.31      Submissions also argued that funding should be provided to enable more clinical chairs of nursing at major hospitals to be established.[47] One submission noted that the advent of clinical chairs ‘has done much to cement the relationship between industry and academia. Clinical chairs and joint appointments provide leadership and facilitate collaborative practices between the two parties’.[48] One witness noted that:

Clinical chairs are extremely important and very successful in raising the profile and status of nurses and nursing, facilitating nurses’ contribution to policy development, improving the collaboration between the service and education providers, promoting research in nursing and providing role models for the profession.[49]

5.32      For example, Flinders University stated that the Clinical Chair in Nursing funded by both the School of Nursing and Flinders Medical Centre is ‘highly effective’ in developing that partnership.[50]

Recommendation 47: That the Commonwealth provide funding for the establishment of more joint appointments between universities and health services.

Recommendation 48: That the Commonwealth provide funding for the establishment of additional clinical chairs of nursing.

Shared facilities

5.33      The ANF argued that health facilities should host university nursing campuses on their sites, including tutorial rooms and offices, and encourage staff to be more involved in educational activities. The shared arrangements could cover all levels of education, from formal programs to continuing education programs. The arrangements should also include rural health facilities.[51]

Conclusion

5.34      Evidence to the inquiry indicates a need for a more coordinated approach between the Commonwealth and the States and between the education and health sectors in the education of training of nurses. This requires a national approach and national leadership with more effective interaction between the different levels of government, the universities and healthcare service providers. As the Commonwealth and the States each have a role in the education of nurses and in workforce planning issues, a nationally coordinated approach is required to ensure that the supply of nurses meets current and future needs.

5.35      The Committee notes that while there have been improvements in the linkages between the education and health sectors in relation to the education and training of nurses there are still areas where improvements could be made. The Committee believes that closer and more effective links could be developed through the implementation of partnership initiatives between the health sector and the universities and the TAFE sector, such as in the area of clinical placements, to facilitate the training of nurses. Other areas highlighted during the inquiry to improve the interface between the two sectors were the need for greater healthcare industry input into curriculum development, more joint appointments to clinical chairs between universities and health services, and the establishment of more clinical chairs of nursing at major hospitals.

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