Council of Deans of Nursing and Midwifery (Australia and New Zealand) (CDNM)
Submission to Productivity Commission Health Workforce Study (29 July 2005)

Introduction

The Council of Deans of Nursing and Midwifery (Australia and New Zealand) (CDNM) is the peak body for Australian and New Zealand universities that provide undergraduate and postgraduate education in nursing. The Council is made up of all Deans of Nursing   or their equivalent across universities that offer nursing programs. This submission emphasises the items in the Issues paper of relevance to the group

Key issues
.	There is a significant undersupply of registered nurses in Australia and the recent moves to address this have been inadequate;

.	The findings of the two recent reviews of nursing education that have been largely ignored, both came out in favour of nursing education remaining as it is currently. That is, registered nurse education should remain within the university system and be funded appropriately at that level.

.	The current funding for nursing education within the university sector is inadequate. In particular, the schools of nursing struggle to cover the costs associated with the clinical component of the course.

Workforce supply
Shortages in the supply of nurses are an international trend, and Australia is not unique. However, given the current concerns about the shortage of nurses and the number required to meet the needs of the health workforce for the future, it is important that the number of funded places for students in undergraduate nursing courses is sufficient to meet these needs. In 2003 there were 23,547 domestic students undertaking a course of study leading to registration as a nurse. In 2004 there were 210 new ‘regional nursing places’ announced and these will grow to 574 by 2007. In 2005 there will be 440 new aged care nursing places (growing to 1,203 by 2008) and 1,054 new nursing places from the 9,100 new university places funded under the Higher Education Support Act that will grow to 2,882 by 2008. In 2005 there will also be 122 ‘National Priority’ nursing places at private higher education providers and in 2006 a further 60 new nursing places at the University of Notre Dame, Sydney, growing to 139 by 2008. The total graduations for 2005 will be approximately 6,110, for 2006 6,776, for 2007 7661 and for 2008 8,769. Whilst the growth in nursing places is recognised, we do not believe these figures represent the growth required to meet the projected needs of the nursing workforce for the future.

Three national reports recently completed have attempted to predict future requirements for nursing and all recommended that substantial increases in supply are necessary to meet future needs. The following is a breakdown of their findings:

1.	The Australian Nurse Supply and Demand (Preston 2002) (commissioned by the Australian Council of Deans of Nursing)
-	nurse shortfall of 2.2% by 2006
-	projected 2006 requirement for graduates was 10,182 but supply is projected to be 6,131
-	this represents a shortfall of 4,051 graduates or 39.8%.

2.	The Nursing Workforce 2010 (Karmel & Li 2002) ( commissioned by the National Review of Nursing Education)
-	projected annual increase in demand for registered nurses of 2.56%
-	by 2010 180,522 registered nurses will be required in Australia
-	projected short fall in 2010 of 40,000
-	increase in nursing graduates of 120% projected to balance the workforce need in 2020.

3.	Job Growth and Replacement Need in Nursing Occupations (Shah & Burke 2001) (commissioned by the National Review of Nursing Education)
-	projected shortfall of 2.2% by 2006
-	annual growth rate of 2.5% required

A further report produced in 2002 by the Australian Health Workforce Committee (AHWAC) which examined midwifery nursing workforce in Australia identified a shortage of 1,847 midwifery positions. It appears that Australia has gone from a position where we educated approximately 3,000 student midwives each year to around 300.

Problems with existing funding and administration arrangements for undergraduate education of registered nurses
Nursing is currently designated as a National Priority and funded at $9,316 per EFTSL yet when this is compared to the funding received by universities for medical students, $14,738 per EFTSL, it hardly represents a significant amount for an area designated as a priority. The problem for schools of nursing is primarily related to accessing and funding quality clinical placements for undergraduate students within the current inadequate funding model. The clinical funding allocated by the Department in 2004 to schools of nursing was an important and welcomed outcome of the recent National Review of Nursing Education. It is considered a timely and appropriate recognition of the costs associated with the provision of quality clinical placements to nursing students. The burden of costs associated with clinical placement has resulted in high student-teacher ratios across schools, lack of funding for staff development, and relatively little or nothing for nursing research. However, whilst the release of the clinical funding was greeted with excitement by schools of nursing, we are concerned that the strategy may not have achieved the expected outcome. In fact, the release of the funds has probably made little if any difference for many schools of nursing, and only a small difference for others because of the policies of universities in their internal distribution of funds. As the clinical money is included in the new funding model from 2005, we recommend:
That DEST ensure that universities make adequate provision for funding of clinical education of nurses.

Students enrolled in undergraduate nursing degrees are required to undertake up to 1,000 hours of clinical practice. In many cases these placements are undertaken away from the university and often at a significant distance from the student’s usual place of abode. The need to travel large distances and find accommodation in rural and regional settings is almost always at the student’s expense. 

The proposal to move the funding for university education to State and Territory level could pose a significant threat to the future of registered nurse education and goes against the recommendations of the recent reviews of nursing. The CDNM does not support this proposal. The CDNM does however support the notion of a funded period of transition where the new graduate is provided with a supportive environment for the first 6 months. If an approach such as this was funded at a State level then the transition to practice as a registered nurse should be much less problematic and as a result, retention of new graduates should increase.

Flexible workforce options
The CDNM is in favour of the development of flexible workforce options for the future and recognises the problems inherent in rigid role demarcation. However, this must not occur at the expense of quality and unfortunately one of the risks associated with flexibility is ultimately the loss of identity and responsibility. This has the potential to lead to a health system where consumers are at risk of poor quality outcomes such as those exposed in the recent Bundaberg Enquiry. Rather than develop a generic health care professional the CDNM supports an extended role for nurses. In this situation nurses could be prepared for procedural roles in areas such as gastroenterology and anaesthetics, or more advanced practice roles such as the Nurse Practitioner. Nurse Practitioners, if funded under the MBS payment, could offer an alternative to medical officers in many areas of current demand. The NP is educated to an advanced level, usually at Masters level, to offer advanced clinical care in specialised areas in both urban and rural settings. Evidence from other countries such as the United States and Fiji clearly demonstrates how this expanded role can provide a useful service that complements medicine.

Competency based rather than time based courses
The CDNM does not support the implementation of competency-based training modules for registered nurse education. Competency based training is based upon the development of psychomotor skills and whilst this has some place in registered nurse education, it is quite inadequate to be the only means of delivering education to undergraduate nurses. Whilst this might be appropriate for some levels of health care providers, it is not considered sufficient for the registered nurse level where nurses are required to make decisions about the care of patients, be capable of reflection on care delivered, and make sound ethical judgments. As a competency based system would not be suitable for medicine, it is not appropriate for registered nurse education. If a competency based education system was introduced for all health professionals we would end up with a health workforce able to deliver on skills but nothing else. Surely this flies in the face of the push for evidence-based practice as a means of ensuring quality in health service delivery.

Lack of sufficient clinical placements for undergraduate nursing students
Schools of nursing currently struggle to ensure an adequate supply of quality clinical placements to offer students the required clinical hours to adequately prepare them for registration. The current system is untenable where schools of nursing are at the mercy of the health system who have no mandate or inducement to offer the placements. Competition between schools of nursing for the placements perpetuates this problem. What is required is a fresh look at the ways that universities and health facilities might work together to ensure the availability and viability of placements. Perhaps a new partnership model for nursing, based on that of medicine would be appropriate if nursing was funded at a similar level to medicine. Alternatively, the government should consider investing in simulated clinical teaching laboratories that would be available for the clinical education of all health professionals in the future.