Historically, nursing and midwifery education in Australia was predominantly public hospital–based, with an apprenticeship style system, lasting three or more years, whereby the students were paid and had conditions which included full board and lodging. 155
Nursing has a long tradition and history and change has been incremental in terms of nursing and midwifery training schemes over the years, despite more rapid change in other segments of the workforce. During the 1970s, there were efforts to change the way nursing education was delivered and to introduce a more theoretical component. During the mid-1980s, nursing education commenced a period of change from being hospital-based to being conducted in tertiary settings, with practical clinical experience components. By 1993, all registered nursing students in Australia were entering the profession via the university education pathway. Note the enrolled nursing pathway is discussed later in the chapter.
In 2001 the National Review of Nursing Education was initiated by the then Department of Education, Science and Training and the final report, titled Our Duty of Care, was released in 2002. This report highlighted a future shortfall in the nursing workforce. A number of strategies were implemented to ameliorate this concern, including the provision of scholarships and other financial assistance, an increase in the number of fully funded university places, increased infrastructure spending and a range of incentives to encourage regional and rurally based nurse education programs.
Entry level registered nursing courses are now demand-driven courses at university, but have been oversubscribed. In 2011, 21,937 applications were made for university nursing in Australia and 16,338 people were offered positions.156 Even if all applicants were accepted and completed their studies, this would fall well short of the 18,953 additional places/applicants which HW2025 suggests will be necessary to meet health care needs on “as is” policy settings. The tables below represent the registered nurse enrolments and course completion data over recent years.
Figure 7.1: Nursing student commencements, 2007 to 2011D
Source: Department of Innovation, Industry, Science, Research and Tertiary Education, Higher Education Statistics Data Cube (uCube), 2012
(Given the complexity of education pathways, there is no national data collection of commencements and completion of courses for midwifery.)
Figure 7.2: Nursing student completions, 2001 to 2011D
Source: Department of Innovation, Industry, Science, Research and Tertiary Education, Higher Education Statistics Data Cube (uCube), 2012
Prior to 2009, the Government controlled the number of funded university places for nursing students. However, as a response to the Bradley Review, in 2009, universities moved to a demand-driven system for nursing students. Therefore, it is most likely a function of university and clinical training capacity that nursing enrolments are smaller than applications. Clinical facilities can only cater to a finite number of students and the numbers of supervisors for clinical placements is also limited.
Increasing the supply of registered nurses is not necessarily a question of increasing demand, as university nursing courses are oversubscribed. However, there have been some suggestions during the course of this review that the standard of students applying for nursing has declined. Some universities have been criticised for reducing their minimum tertiary entrance scores to attract more nursing applicants, with some minimum entrance scores falling below 50. The fundamental issue is one of sustainable expansion of nurse education capacity to meet forecast demand while continuing to ensure quality educational delivery, when it is clear on current demographic trends that nurses will need to be trained to work in a diverse range of settings, including aged care, acute care and disability services.
In this regard the Department and HWA have provided support for clinical training facilities through various capital works and recurrent funding programs, including initiatives such as the University Departments of Rural Health (UDRH) and HWA clinical training grants.
The UDRH program supports and promotes nursing and midwifery practice, education and research in rural and remote areas. This program represents the Australian Government’s primary investment in rural nursing and midwifery and allied health education and training under a multidisciplinary focus (within the Health portfolio).
Feedback from stakeholders, as well as the analysis of program performance to date, suggests that the network of eleven multidisciplinary UDRHs has significant potential to provide enhanced education services including re-entry courses for rural and remote nurses seeking to resume their career as well as in other postgraduate education fields. The UDRH program has been discussed in more detail in Chapter 4.
Until recently, midwifery in Australia was a post-basic certificate or a postgraduate degree. That is, all registered midwives were registered nurses who held additional qualifications related to midwifery practice. However, in 2000, the first direct entry courses for midwives were established. Graduates from these courses practise only midwifery, unlike their predecessors.
This newer, more specialised model of midwifery education is demand driven, with some students choosing to pursue this specific career path rather than first completing a nursing degree. It has however, had a mixed reaction among the profession itself and employers. It has also complicated the reliability of workforce data modeling and planning processes, as under the National Registration and Accreditation Scheme (NRAS) there were previously not separate categories for these two professional groups. In future, data from NRAS will be able to separate nurses and midwives.
For the midwifery profession, tracking of students is difficult. There are three education and registration pathways by which midwives can enter the profession: Direct entry midwifery (Bachelor of Midwifery); Double degree (Bachelor of Nursing/Bachelor of Midwifery) or postgraduate qualification in midwifery following a nursing degree (Graduate Diploma and Masters level). Given these complex education pathways, there is no national data collection of commencements and completion of courses for midwifery. Improved data is expected to become available with the 2013 national registration survey. This will give a clearer picture of the ‘status’ of the midwifery workforce into the future.
During the course of this review, stakeholders noted that controversy exists in respect of the multiple education pathways for midwifery registration. While there is some support for direct entry midwifery as the optimum educational pathway, it is also acknowledged that employment options for the graduates of these programs may be limited.
In rural areas, for example, some employers are seeking employees who can provide both nursing and midwifery services due to the variable workloads of smaller facilities. Additionally, in the smaller rural and remote areas, safety issues with the single midwifery qualification are often raised. A single degree (direct entry) midwife will not be trained to manage some emergency situations that a nurse with a double degree qualification (registered nurse and midwife) may be able to respond to. Additionally, a single degree midwife is unable be utilised in other areas of the hospital, should the maternity area be quiet, which is counter to the wider attempt in the health professions, including medicine, to promote a rural generalist model.
Enrolled nurse training takes place in the vocational education and training (VET) sector rather than the university sector. Prospective enrolled nurses undertake a Diploma qualification. In 2010, 3,794 students completed such a course.157
Enrolled nurses provide nursing care within the limits specified by education and the regulatory authority’s license to practise.158 Enrolled nurses retain responsibility for their own actions whilst remaining accountable to a registered nurse for delegated nursing functions. Enrolled nurses are an integral part of the nursing profession, delivering nursing care that is complementary to that delivered by registered nurses. Enrolled nurses work under the supervision of registered nurses: supervision is defined as including oversight, direction, guidance or support (whether directly or indirectly).
The lack of support for vocational education courses for enrolled nurses has been raised as a challenge during this review process, especially when the predicted nursing shortage may drive the need for utilising different models of care and innovative workforce arrangements, including increasing the role of enrolled nurses. (This issue is more fully discussed later in this chapter.)
Despite the existence of around 150 accredited enrolled nursing courses, participation levels in these courses are low, and the level of state government support for the continuation of these places has declined over the last decade. Stakeholders raised the issue of the cost of enrolled nursing courses in the VET sector as a reason for reduced enrolment (an enrolled nurse diploma costs approximately $16,000, in comparison to a registered nurse degree of approximately $23,000).
Submissions were made to this review that the Commonwealth agencies involved in nursing education should investigate the availability and cost of VET sector education as it relates to enrolled nurses. It was also argued that enrolled nursing students should also be eligible for scholarship support, provided it is targeted towards increasing enrolments in this section of the training pathway rather than simply supporting current students.
In recent times, it appears that many acute care hospitals have reduced or removed the enrolled nurse role, preferring to have registered nurses deliver patient care. It is likely that many VET sector providers are no longer offering places in their accredited programs due to a decrease in student demand as a result of reduced job prospects. If demand for new enrolled nursing positions begins to increase in the future, this may flow through to a reinvigoration of support for enrolled nurse education.
During the nursing workforce roundtable consultations, key stakeholder groups including the Australian College of Nursing, the Coalition of National Nursing Organisations and the Nursing and Midwifery Board of Australia all raised issues and concerns regarding the perceived lack of acknowledgement of the enrolled nurse role. Stakeholders agreed that there is a need to acknowledge the enrolled nurse and value and support their role. Stakeholders agreed that more research into the enrolled nurse scope of practice should be undertaken.
As noted above, the enrolled nurse role appears to have been diminishing due to lack of support and employment opportunities, particularly in the acute care sector. International experience in both the United Kingdom159 and New Zealand,160 where enrolled nurse positions and courses were phased out during the early 1990s, indicates that there is a workforce need for enrolled nurses. While the UK still has enrolled nurses working in its health care system, they have not yet reintroduced an accredited educational course that leads to this qualification. They are however, investigating options to recommence enrolled nursing education. New Zealand reintroduced enrolled nursing courses in 2002.
It is important to learn from the international experience of the removal and reintroduction of the enrolled nursing role in these countries, which have recently revised the enrolled nurse role in response to community needs and workforce pressures.
An analysis of the outcomes of the reintroduction of enrolled nurse education overseas and their role within the nursing workforce should be undertaken. This work could then inform policy development in Australia.
Some action is taking place in Australia and in 2010 an additional 600 enrolled nurse training places were funded through the More Nurses in Aged Care Program. This program also provides funds for aged care workers to upgrade their qualifications and provides scholarships for study. This is aimed at enhancing skill development and retention rather than increasing student numbers in the enrolled nursing courses. Nursing scholarships, including those relating to the aged care workforce are discussed in detail in Chapter 3.
Scholarships and distribution
Several scholarships, described elsewhere, exist to support nursing and midwifery students. However, it appears likely that these programs have limited effects on increasing the size of the nursing and midwifery workforce by attracting additional student demand. Scholarships are certainly useful in providing financial support to individual students who have already decided to pursue a nursing or midwifery career.
Broad scholarship funding at the undergraduate level, while clearly a popular measure, will have limited impact on enrolments or workforce retention and is not a solution to meeting the looming workforce shortages identified in HW2025. This is primarily because the offer of a scholarship only occurs once a student has already applied for a university place and nominated their preferences for a particular course of study.
What limited evidence exists, suggests that the prospect of securing relatively modest financial support through scholarship funding is unlikely to be the determining factor in student career choice. It will have an impact in some cases and is certainly likely to assist with completion rates for students undertaking nursing courses. However, with nursing courses currently oversubscribed, the need to encourage more applications by offering broad and un-targeted scholarships appears to be minimal. There are risks that an over-reliance on providing broad undergraduate scholarships will distract attention (and divert resources) from potentially more effective mechanisms for influencing future workforce supply.
During the consultation phase of this review, key stakeholders noted that nursing and midwifery students seeking to undertake courses including re-entry to the profession, enrolled, registered, postgraduate and specialty studies, and nurse practitioner candidates, should be considered eligible to apply for a range of scholarships providing financial and/or non-financial assistance. Scholarships, including nursing and midwifery scholarships, are discussed in detail in Chapter 3.
Nursing and midwifery education does not face the same issues as medicine in terms of the need for additional rural training programs and longer rural educational experiences at the undergraduate level. Compared to medical education there are more numerous existing rurally based nursing schools that have been providing full undergraduate nursing courses for many years.
The substantial level of rural nursing education is likely to be one of the reasons for the better distribution of the nursing workforce when compared to medicine. Rural nursing students have the opportunity to transition straight from university training into employment at rural hospitals and other settings. This avoids the need to complete large sections of their training in the city, which in other disciplines tends to impact upon the life choices of new graduates.
The more even distribution of nurses and midwives is also of course likely to be heavily influenced by employment arrangements in rural district hospitals and other settings (as discussed elsewhere). It is obvious that the continued availability of rural employment opportunities, particularly in the public sector, is the key issue in rural workforce distribution for the majority of nurses and midwives.
In comparison medical practitioners and, more recently, nurse practitioners in private practice are required to set up a practice, with associated costs and the need to develop business management capability. Additionally in some smaller rural communities there may not be a large enough population to support an additional medical or nurse practitioner practice. It may be possible to consider developing alternative arrangements, including allowing these health practitioners access to rooms in rural hospitals and community health centres, or assist them to participate in “easy entry – gracious exit” business arrangements which are discussed in more detail in Chapter 4. This would need to be developed in close consultation with all stakeholders, including all Australian governments.
Stakeholders agreed that access to appropriate clinical placement opportunities was critical to producing work ready graduates. It was noted that access to clinical practice experience opportunities has been under considerable pressure in recent years. Under NRAS there is a requirement for nursing students to complete a minimum of 800 hours of supervised clinical experience placements to qualify and therefore register. Particular education providers require higher levels of clinical placement hours.
Some stakeholders have postulated that, with the increase in student numbers, the capacity of the health system to provide sufficient high quality clinical experience places has been compromised. While clinical training funding through HWA has assisted with this situation, some concerns were raised about the sustainability of these arrangements.
The impact that differential prices for clinical training supervision is having on the system was also raised in the Health Education Roundtable discussion. There was some suggestion that the rollout of HWA funding has inflated the costs that some settings are seeking to recover in supporting training and that this has impacted negatively on training arrangements not funded directly by HWA. This issue appears to have particular relevance for nursing and midwifery education.
The level of work readiness of registered nurse graduates was also raised as a key issue during the roundtable stakeholder consultations. Private sector stakeholders in particular argued that there is considerable variability in the quality of graduates from the various nursing schools and that anywhere up to 50% of new graduates are not fully work ready. This position was refuted by representatives of the Council of Deans of Nursing and Midwifery who pointed to the accreditation of undergraduate nursing courses against national standards set by the Nursing and Midwifery Board of Australia.
Nursing stakeholders did, however, agree that newly registered nurses need enhanced support as they enter the workforce. During the consultation undertaken as part of this review, virtually all the medical, nursing, and allied health professional groups noted that all new entrants to a work area require some transitional support. This is something unlikely to be limited to health graduates.
Considerable concern was raised about the perceived lack of support for graduate nursing positions within the jurisdictions. Key nursing stakeholders stated that the term “work readiness” had negative connotations and should be avoided. Stakeholders noted that the United Kingdom has developed a “fit for practice” model and that it may be useful to investigate that model for its ability to transfer to the Australian health care setting.
While there is no registration requirement for nursing graduates to undertake a transition to practice program, there is a perception that the inability to undertake a structured position of this nature was likely to have negative impacts on a graduate’s employment prospects. However, there is no evidence that the completion of a transition to practice program results in better clinical practice compared to a new graduate who commences practice through the direct employment pathway with the normal supervision support any new entrant to the workforce could be expected to need.
Most newly graduated employees will need to be supported and mentored by organisational structures and day-to-day managers, to assist these new staff to adjust to the realities of the workforce. As is the case for other professions, nurses and midwives need well structured and well resourced recruitment, induction and orientation programs on commencement of their employment.
The role of the nurse practitioner is relatively new, and its development in Australia began to be discussed in the early 1990s. In 2001 the NSW Minister for Health announced the first nurse practitioner to be appointed into a position in remote NSW. Nurse practitioner roles were introduced in Australia with a range of objectives including improved access to health care services via a flexible, innovative, integrated care strategy, and increased continuity of nursing care at an advanced practice level.
The development of the nurse practitioner role has been a strong component of Commonwealth health workforce policy in recent years. In 2008 the Australian Government announced funding for Nurse Practitioner Scholarships to help build the nation’s nurse practitioner workforce. Under a 2010 Budget measure, these nurses gained access to the Medicare and Pharmaceutical Benefits Schemes (MBS and PBS) for their patients. These measures provide opportunities for nurse practitioners to offer a solution to workforce shortages in more remote areas, particularly if interested members of the existing rural and remote nursing workforce can be supported to undertake the necessary educational programs for this role.
According to the Australian Health Practitioner Regulation Agency (AHPRA), as at May 2012, there are 731 nurse practitioners registered in Australia. Although the number of nurse practitioners working in primary care is currently small, numbers are growing in response to recent policies. However, barriers (both perceived and real) remain to the wider adoption of this role within the health system. These may include:
- Resistance from doctors’ groups to this new role, limiting effective partnerships at the practice level between doctors and nurse practitioners. Groups like the Australian Medical Association have expressed strong concerns about any service model that involves independent practice for other health professionals outside of a doctor-led health care team.
- Length of the training pathway for nurse practitioners, which can take up to nine years from the point of entry into a nursing degree. This includes the need to complete a Masters qualification (with associated costs and lack of opportunities to complete this study in rural and remote areas).
- Inadequate remuneration for nurse practitioners working in primary care, particularly in terms of access to the highest level of Medicare rebate (A1 items compared to A2 of the Medicare Benefits Schedule).
- Potential community resistance to being treated independently by nurses and a reluctance to pay for a service which they may perceive to be of lower quality.
The Australian Government encourages primary care practices to consider working with nurse practitioners to improve the effectiveness and efficiency of the health care system. Policy has supported the progression and promotion of nurses in general practice working at advanced levels, including that of nurse practitioners.
A significant barrier to achieving this outcome is access to appropriate clinical supervision, as well as the ability to source locum support while undertaking necessary training. Training modeled on the Remote Vocational Training Scheme (RVTS) model, discussed below, may be a potential solution in this regard, as the program offers an effective approach to remote supervision and support which could be extended beyond medicine to cover the needs of more isolated nurse practitioner candidates.
The Remote Vocational Training Scheme
The RVTS is a is a vocational training program for medical practitioners which is designed to meet the requirements for fellowship of both Australian College of Rural and Remote Medicine and Royal Australian College of General Practitioners. The program delivers structured distance education and supervision to doctors while they continue to provide general medical services to a remote and/or isolated community. It also funds locum relief to allow doctors to attend face-to-face training.
This ensures that solo doctor towns or small communities are not affected by doctors leaving to complete vocational training requirements. The training includes weekly tutorials through video and teleconferences, twice yearly education workshops, remote supervision and individualised training advice.
During consultations undertaken as part of this review it was suggested that the RVTS program, which is designed around distance education and a remote supervision model, could be adapted to include nurse practitioner candidates or nurses who may wish to undertake specific procedures and work to an extended scope of practice.
The Commonwealth should therefore consider the development of a model similar to the RVTS, combining distance education and remote supervision, and access to nurse practitioner locums in conjunction with the nursing and midwifery education and accreditation bodies. This would allow highly qualified rural nurses working in the primary care setting to undertake this advanced training, while still delivering services to the community.
Nursing and midwifery education summary
Increasing nurse student numbers is clearly not achievable at a level which would enable projected supply to meet forecast “as is” demand by 2025. Effort is required to enhance workforce retention, particularly offering nurses and midwives the opportunity to upskill and take on more senior and diverse roles. This should include a greater role for nurse practitioners, and roles commensurate with the skills for registered nurses, enrolled nurses and the care workforce. Access to education to enable easier re-entry to the nursing profession is also of high importance.
An integrated approach that examines factors affecting the retention of nurses within the health workforce, as well as productivity and workplace innovation, is required. These should include issues such as the use of alternative workforces and skill mixes and measures to improve the efficiency and consistency of nurse education, including the question of “work readiness”.
Educational investment also has implications for future workforce mix. In particular it appears that current limitations on the education of enrolled nurses will need to be addressed to ensure this is not an inhibiting factor in greater use of this workforce.
Achieving appropriate distribution of the nursing workforce is not as challenging an issue as predicted future national supply, in remote areas there is continuing demand for better access to education opportunities for nurses to enhance and maintain their expertise and play a greater role in service delivery. Greater investment in postgraduate nursing and midwifery education appears to offer the best value for money to address the workforce shortages identified by HWA.
In order to develop a more strategic and coherent approach to all aspects of nursing and midwifery education, the Commonwealth should work with the profession and across jurisdictions to establish a National Nursing and Midwifery Educational Advisory Network (NNMEAN). The NNMEAN would liaise closely with HWA to ensure that the respective activities are complementary and that plans are developed using the best available evidence and data. The membership of this group would need to be considered, but should be drawn from the profession, chief nursing officers, the university and VET sector, regulatory bodies and the Government. The role of this group may include consideration of matters such as supply planning, education and employment, new and/or extended roles, scholarship priorities, inter-professional collaboration and undertaking or commissioning research.
155 Extract from L Russell (1990). From Nightingale to Now: Nurse Education in Australia, 2005
156 Department of Health and Ageing, analysis of data from Department of Education, Employment and Workplace Relations 2011, February 2012
157 Department of Health and Ageing, Analysis of data from the Department of Education, Employment and Workplace Relations 2011, February 2012.
158 Royal College of Nursing Australia. Position Statement,2004, accessed at www.rcna.org.au.
159 Francis, Becky; John Humphreys (August 1999). "Enrolled nurses and the professionalisation of nursing: a comparison of nurse education and skill-mix in Australia and the UK". International Journal of Nursing Studies 36 (2): 127–135
160 Nursing Council of New Zealand, Scope of Practice for Enrolled Nurses, 2010. Accessed at www.nursingcouncil.org.nz