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
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.
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.
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’.
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.
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.
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.
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.
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. 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.
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
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
Current models of nurse education and
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).
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.
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.
Overview of models of education and training related to nursing and midwifery
Models of Education and
Doctor of Philosophy/Professional Doctorate
Midwife (on completion of Diploma or Masters)
- Masters by
research or course work
embedded - Cert/Diploma/Masters with exit points at each level if desired
standing courses at each level
Nurse/Division 1 Nurse
Midwife (program commenced in 2002)
degrees (nursing plus another degree)
semester courses (2-3 years)
semester courses (with or without honours)
Nurse entry programs
- One year
entry for registered hospital trained nurses with lapsed registration
upgrade (1 semester)
contract with TAFE course (eg NSW traineeship)
- VET Course
with clinical placement (TAFE or private provider)
Apprenticeship - on and off job training
Level V Certificate (Advanced Certificate)
Enrolled Nurse (Advanced Certificate)
Nurse/Division 2 Nurse
for school students
with clinical placement (full or part-time)
Source: National Review of Nursing Education, Discussion
Paper, December 2001, p.113.
As noted above,
RNs undertake a minimum of three years undergraduate preparation in the higher
education sector at the Bachelor degree level.
programs comprise the following undergraduate nursing courses:
- Three-year Bachelor degrees
- 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
- One-year conversion programs
for overseas-qualified nurses seeking registration in Australia.
nursing programs are offered at 28 universities as well as Avondale
In total, full or part nursing programs are delivered at 58 campuses
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.
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
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
Number of courses
Percentage of total number of
Total number of graduates
Note: Does not include non-university sector (NSW
College of Nursing)
Source: National Review of Nursing
Education, Discussion Paper, December 2001, p.119.
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.
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
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
Certificate IV in Health (Nursing)
Certificate IV in Community Services (Enrolled
Certificate IV in Nursing (Enrolled Nurse)
Diploma in Enrolled Nursing
Certificate IV in Health (Nursing)
Certificate IV in Health (Enrolled Nursing)
Certificate IV in Health (Nursing)
Certificate IV in Enrolled Nursing
Source: National Review of Nursing Education, Discussion
Paper, December 2001, p.115.
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
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.
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.
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. The Committee has made recommendations
relating to the regulation of these workers in chapter 4.
Improving undergraduate education and training programs
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
Provision and funding of additional
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.
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.
The main features of the current funding
- provision of operating resources as a single block operating
- 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.
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.
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.
Submissions argued that there is a shortage of
Commonwealth funded undergraduate positions. The Victorian Government,
reflecting much of the evidence from State Governments/Departments, commented
Efforts to increase the number of HECS funded places in nursing
are being severely hampered by the inadequate level of Commonwealth funding
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.
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.
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.
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
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
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.
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.
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.
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’.
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’.
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.
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.
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
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. 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.
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.
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’.
The Committee notes, however, that this was the expectation for
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
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
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
6 weeks + 4 week block
University of Tasmania4
None, 2 weeks in 2003
(+ units taught at clinical sites)
Queensland University of
50 per cent off-campus
- small proportion
in 1st year;
- in 3rd
year - last semester - 8 weeks out of 13 in direct clinical placements
50 per cent clinical placements - clinical
hours reduced from 1 200 to 900 hours in current curriculum
University of Southern
45 per cent clinical placements
Source: 1 Committee Hansard, p.682. 5 Committee Hansard, p.595.
2 Committee Hansard, p.698. 6
3 Committee Hansard, p.482. 7
Committee Hansard, pp.290-293.
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. However, as the above table
indicates, for some courses the clinical component is less than this average.
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.
One hospital noted that in Victoria, undergraduates have between 600-700 hours
of clinical practice over their three-year courses.
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’. 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.
Evidence to the Committee indicated that there
needs to be earlier placement of students in hospitals and other healthcare
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’. 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’.
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.
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
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,
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.
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.
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.
One witness commented that the DEU is a ‘very sound model’ with the hospital
receiving ‘good feedback’ from clinicians regarding its operation.
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
Another witness noted that University of Technology, Sydney (UTS) and a number
of other universities in Victoria are examining the Notre Dame model.
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’. 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.
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.
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.
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.
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. 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’.
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
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
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’.
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.
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.
A number of options were suggested to address
the problem of the availability of placements.
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.
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.
Some hospitals already provide employment for
second year student nurses with pay rates equivalent to assistants in nursing
Evidence suggests that this approach has positive results. One witness noted
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.
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.
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. This would, however, increase
the costs of clinical education.
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’.
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
This issue is discussed later in the chapter.
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.
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
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. The Education Review also
noted that there is general satisfaction with the theoretical background of new
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. Other areas identified as
requiring more attention were leadership, negotiation skills, research,
information technology, and pharmacology.
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.
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
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
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
New South Wales
Australian Capital Territory
NB: Clinical experience hours exclude elective
Source: M. Clinton, Scoping Study of
the Australian Mental Health Nursing Workforce 1999, Canberra: Department
of Health and Aged Care, 2001, p.32.
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.
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
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’.
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.
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
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
Duration of undergraduate courses
Several submissions argued that the current
three-year undergraduate degree course is too short and should be increased to
a four-year degree program.
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.
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.
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’.
Options for a fourth year
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.
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’. Royal Perth Hospital added
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.
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. Queensland Health suggested
that the trial of paid employment for undergraduate nurses ‘could assist
transition to the clinical environment’. 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.
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
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.
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. 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.
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’.
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.
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
Submissions and other evidence argued that the
current funding model does not adequately support the clinical practice
requirements of undergraduate nursing programs.
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
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.
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. 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.
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. One submission noted that
many Schools of Nursing are required to meet annual clinical budgets of $1
QUT indicated that its projected clinical costs will be $1.3 million for
Submissions argued that additional funding
specifically earmarked for improving the programs of clinical placement for
student nurses should be provided by the Commonwealth. 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.
The Education Review further argued that ‘it is obvious that dedicated funding
of clinical education is needed, outside the operating grant model’.
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
Submissions argued that improved teacher/student ratios enhance the learning
opportunities of undergraduate students.
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’. 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.
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
Students generally pay a Higher Education
Contribution Scheme (HECS) contribution for their nursing courses.
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. 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. 
While there are some scholarships available,
most target Indigenous students and students from rural and remote areas.
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. Rural nursing scholarships
are also available through some State Governments, universities and nursing
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. The ANF suggested that
nursing should be HECS exempt in the immediate short term.
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. Some submissions recognised,
however, that providing special HECS arrangements for nursing students would
create precedents for the Commonwealth regarding other fields of study.
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.
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. 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.
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.
Other submissions argued that scholarships
should be available.
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.
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). 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
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.
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
Other support measures
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
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. 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.
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.
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.
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
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.
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
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
Recommendation 19: That the Commonwealth Government provide
general scholarships for undergraduate nursing students based on merit.
Transition from university to practice
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. 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.
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
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.
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
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.
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.
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.
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. In Western Australia, one
witness stated that hospitals only get ‘a few hundred dollars per student’
under the program.
The hospitals have positions for graduate nurses and their employment costs are
paid for in their budget allocations. 
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
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’.
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’.
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.
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.
In respect of payment, Tasmania’s recently negotiated Nurses Enterprise
Bargaining Agreement includes the introduction of a preceptor allowance.
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
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.
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.
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.
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’.
The ANF argued that clinical nurse educator positions should be widely
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.
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. 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
The Association pointed to the need for quality
preceptorship and orientation programs for newly graduated ENs. 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.
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.
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
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.
The types of articulation pathways currently
available are illustrated in the figure below.
Figure 3.1:Articulation pathways for those currently involved in nursing
Source: National Review of Nursing Education, Discussion
Paper, December 2001, p.121.
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.
Submissions generally supported the need for a
range of academic pathways for entry to, and exit from, various courses.
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’. 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.
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
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. 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
During the inquiry issues were raised in
relation to articulation pathways for ENs, nursing and personal care
assistants, ATSI health workers and midwives.
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. 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’.
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
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.
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.
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. 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’.
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. 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.
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.
Currently, entry to practice as a midwife requires completion of a postgraduate
course, following initial registration as a nurse.
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.
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
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
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’. 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.
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
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’.
Some witnesses did not support the introduction
of a national curriculum emphasising the need to maintain diversity in course
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.
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
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’.
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’. 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.
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
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
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