Response to: Australia’s Health Workforce – 
Productivity Commission Position Paper 

November 2005

Background 

The Australian Nursing and Midwifery Council (ANMC) is the peak national body established for the purpose of bringing a national approach to the regulation of the disciplines of nursing and midwifery.  The ANMC works in collaboration with the state and territory nursing and midwifery regulatory authorities (NMRA) in the development of national standards for statutory nursing and midwifery regulation.  The goal is to establish standards that are flexible, effective and responsive to the health care requirements of the Australian population. Standards developed include competencies for registered and enrolled nurses, midwives and nurse practitioners, codes of professional conduct and ethics, and national guidelines and policies for the profession. ANMC works closely with other peak nursing and midwifery organisations in developing these standards, examples of this collaboration being the development of the Code of Ethics which was jointly produced with the Australian Nursing Federation and the Royal College of Nursing, Australia.

The resulting standards are broad and principle based so that they are sufficiently dynamic for nurses, midwives and NMRAs to use as a benchmark for the assessment of competence in all areas of nursing and midwifery practice from beginning practitioner and beyond. They are utilised in various ways, including by educators to assess the competence of undergraduates as beginning practitioners, by registered nurses, midwives and employers to assess competence as part of the annual renewal of registration process and by NMRAs to assess both the competence to practice of midwives from other countries and professional conduct matters.

General Comments to the Position Paper

The ANMC congratulates the Productivity Commission on a position paper which has identified the key issues affecting the health workforce in Australia, and which proposes options for improvement. 

Whilst the ANMC does not endorse all the recommendations detailed in the report, it supports the objective of achieving national consistency for the regulation of the nursing and midwifery professions, and educational processes which are simplified and responsive to changing health care and community needs. It also supports the premise that healthcare services provided by the nursing, midwifery and medical professions are already world class. However, the ANMC is concerned that whatever changes are implemented should not dilute the standards which have been responsible for the professions reaching the current levels. The ANMC is also supportive of the need for effective collaboration between the various health professions and government agencies, and is keen to work with the various groups to progress nursing and midwifery specific issues. It also believes that the processes of regulation, education and accreditation are inextricably linked, and therefore should be considered together within each professional group, rather than as separate programs.

The ANMC is also keen to emphasise that within the health professions, ‘one size’ does not fit all, and it does not support any processes which may result in a generic healthcare worker at this time. It does, however, recognize that there may be a range of skills and core competencies across the health workforce which could be incorporated into tertiary health programs. 

The Productivity Commission position paper has not discussed retention and re-entry issues in detail. The ANMC is concerned that this omission should be addressed in the final report, as retention of nurses in particular, is currently a major issue within the profession.

ANMC provides the following responses in relation to nursing and midwifery issues raised by each draft proposal:

Draft Proposal 3.1

ANMC supports the proposal for The Council of Australian Governments (CoAG) to endorse the majority of the principles of the National Health Workforce Strategic Framework (NHWSF). It believes that the Framework provides the basis for a long term approach to managing the issues surrounding the health workforce.

ANMC also supports the view expressed in the Commission’s position paper that the self sufficiency principle limits recognition of the important contribution made by health professionals employed from overseas, and the transient nature and rights of many health professionals seeking to work and travel internationally. From a nursing and midwifery perspective, the ethical issues surrounding migration of health professionals has been widely debated, resulting in the development of national and international principles for ethical recruitment of nurses and midwives. Such principles include the Commonwealth Code of Practice for International Recruitment of Health Workers, and the codes established by international professional groups such as the International Council of Nurses and the International Confederation of Midwives. In addition, the ANMC has developed its own position statement on ethical recruitment, drawing on the international principles noted above. This is available on its website at www.anmc.org.au. 

The ANMC believes that nurses and midwives have the right to practice and travel in other countries, and as such ethical recruitment of health workers should be included in any future health workforce planning - both in the short and long term.  However, the ANMC also recognises the importance of protecting the public by ensuring all people have access to the highest standards of nursing and midwifery care, and to this end has worked with the state and territory nurse and midwifery regulatory authorities (NMRAs) to develop processes which assess and maintain nationally consistent standards within the nursing and midwifery professions. These processes, such as the national competency standards and codes of conduct and ethics, and decision making frameworks are already well established within the nursing and midwifery professions – but may need to be developed in consultation with all states and territories where gaps exist within other health professional groups.

 Draft Proposal 3.2

The ANMC supports the need to regularly review the implementation process of the NHWSF, and encourages such reviews to seek feedback from the nursing and midwifery professions. The ANMC also urges that evaluation of the outcomes expected of the framework should also be undertaken. It also emphasises the need for review to be sought nationally.

Draft Proposal 4.1

The ANMC supports the establishment of an advisory health workforce improvement agency – with the proviso that the agency includes appropriate representation from the nursing and midwifery professions, including representatives from regulatory authorities with national and international regulatory expertise.

Draft Proposal 5.1

Identification by the Commission of the need for a shift in responsibility for funding allocation for the education and training of heath workers to the Department of Health and Ageing is welcomed by the ANMC as a possible means of streamlining funding within the health sector. ANMC therefore supports this proposal, subject to appropriate quarantining of funds to meet the shortfalls in nursing and midwifery places in the university sector and nursing places in the VET sector.  It does, however, raise the concern that shifting of funding responsibility in itself will not be enough to overcome issues relating to insufficient places allocated to health care courses, and the potential risk of creating ‘health silos’ within the tertiary sector. The ANMC agrees that a major focus of DoHA has been on the medical workforce in the past – so a refocus on the needs of other health care professionals, especially nurses, would be required.

In the event of this proposal not being actioned, then ANMC considers that there needs to be agreement between DoHA and the Department of Education, Science and Training (DEST) on the distribution of funding for the education of the health workforce.

Draft Proposal 5.2

The ANMC supports in principle the establishment of an advisory health workforce education and training council. The ANMC, however, is very concerned that workforce shortages should not be used as reasons by this council to alter or potentially lower professional practice standards.

 Whilst the focus of the council would be as an evaluation body, ANMC believes that the council should be independent, and with a clear governance focus. Its composition should be made up of broad representational membership across the health and business sectors, including a consumer. In light of the number of nurses as a representational group within the health care sector, the ANMC, does, however, strongly support the inclusion of one nurse and/or midwife from the current regulatory authorities and one senior nurse or midwife clinician with additional skills in the education sector. 

Draft Proposal 5.3

The ANMC is concerned about the lack of access to clinical education due to funding inconsistencies and splitting of responsibilities at state/territory and Commonwealth levels.  In order for nurses and midwives to meet the national competencies for registration or enrolment, appropriate clinical experience is essential, so reallocation or additional funding which appropriately quarantines allocated funds to meet costs associated with the provision of clinical education for undergraduate nurses and midwives would be welcomed by the ANMC. However, there is currently work being undertaken in this area following up on Recommendation 24 of the National Review of Nursing Education (2002) Our Duty of Care which stated that additional support and resourcing should be directed to the clinical component of undergraduate curricula, and that there should be an evaluation of outcomes of funding. This recommendation is currently being addressed by the National Nursing and Nursing Education Taskforce (N3ET), with details of the various projects surrounding this recommendation available on their website:  http://www.nnnet.gov.au/work/rec24.htm

Nurse and midwifery education programs which are accredited by the NMRAs in Australia must meet the respective state/territory requirements relating to hours, type of clinical experience for the respective courses and competency achievement. This is currently provided in a range of clinical settings across the health care sector. In order for nurses and midwives to meet the requirements for registration or enrolment, the course providers frequently negotiate with the public and private health sectors to offer a range of learning opportunities for students. Since these arrangements may or may not be provided pro bono, the ANMC is unaware of impediments to competition.

Draft Proposal 6.1

The ANMC does not support this proposal in its current form as it contradicts Recommendation 19 of the National Review of Nursing Education (2002) report ‘Our Duty of Care ‘(2002) which explicitly states that nursing and midwifery programs should continue to be accredited by State and Territory registration boards in accordance with national principles developed by the ANMC.   

The ANMC believes that the nursing and midwifery professions already have well established national competency standards which have been accepted by all nursing and midwifery regulatory authorities and by the professions, and are embedded in the curricula of accredited tertiary and VET nursing and midwifery programs. These standards include core competency standards for registered nurses, midwives, and enrolled nurses, and generic competency standards for nurse practitioners.  

Currently, the NMRAs accredit education programs using accreditation standards and criteria developed in consultation with ANMC and each NMRA. In January 2004 the discussion paper, ‘Action on National Direction for Accreditation of Nursing & Midwifery Courses Conducted in Australia’, was disseminated widely by the then ANC, seeking comment from key stakeholders.  Wide interest in the discussion paper was generated with submissions received from the NMRAs, Commonwealth and state governments, the education sector and other key stakeholder groups including peak nursing and midwifery organisations.  The overall analysis of findings from the consultation revealed support for a national framework for accreditation of courses leading to registration and enrolment to practice with the provision for administration of the framework by the state and territory nursing and midwifery regulatory authorities.  
 In accordance with a principal function of the ANMC to establish, review and promote nationally consistent standards and regulatory framework for nursing and midwifery practice in Australia, the concluding phase of this important national initiative is soon to commence in collaboration with key stakeholders.
Whilst the ANMC acknowledges that some other health professional groups have a less streamlined process, the implementation of an agency which would take over these established processes would not be acceptable to the ANMC, or to the nursing and midwifery regulatory authorities.  

Draft Proposal 6.2

The ANMC supports the establishment of a national approach for the assessment of overseas trained health professionals. However, the nursing and midwifery professions have well developed evidence based processes to ensure that overseas trained nurses and midwives meet the criteria for practice in Australia. 
The ANMC is recognised under the Migration Act (Cth) for the purposes of assessing nurses and midwives who seek to migrate to Australia under the skilled migration program, and has authority under the Act to undertake assessments to determine whether the qualifications of the nurses and midwives meet the requirements for migration or whether they may need to undertake further education in order to be eligible for migration. Other applications from overseas trained nurses and midwives seeking registration to work in Australia on a temporary basis may be dealt with at state and territory level by the appropriate regulatory authority. The ANMC also provides an advisory service for these authorities, and co-ordinates research activities to enhance the NMRA’s understanding of nursing and midwifery education and practice in different countries. Examples of this include two recent projects to gather information about nurses educated in China and the former Yugoslavia. Both these projects were managed by the Collaborative Advisory Panel of the ANMC. The research for the China project has been conducted by the Nurses Board of Victoria and the research for the Yugoslavia project has been carried out by the Queensland Nursing Council. Following completion of these projects the ANMC Council has in principle approved the recommendations from both reports. The Executive Summary and the recommendations from these projects are available on the ANMC website. 
The ANMC therefore believes that the establishment of an agency to develop a national approach for all health professionals should consider the model used within the nursing and midwifery professions, and should seek input from the ANMC.

Draft Proposal 7.1

In principle, the ANMC supports the view that registration boards should focus activities in accordance with uniform national standards – but by using, in the case of the nursing and midwifery professions, existing national processes rather than through establishment of a new body for this purpose.  The ANMC whose members are the state and territory nursing and midwifery regulatory authorities, is the peak body which facilitates a national approach to nursing and midwifery regulation.  The ANMC supports a nursing and midwifery workforce sufficient in size, and able to demonstrate the competencies required in an increasingly complex healthcare system. The contribution of a national nursing and midwifery regulatory perspective to health policy concerning nursing and midwifery workforce planning and development is integral to effective health outcomes for the community.

The nursing and midwifery professions in Australia have well established regulatory processes supported in legislation in each state and territory which compare favourably with regulatory best practice standards worldwide. The ANMC works in partnership with the State and Territory Nursing and Midwifery Regulatory Authorities to attain the goal of national consistency in regulation.  In accordance with the mission, vision and values of the ANMC and its commitment to ensuring an evidence basis informs the ongoing development of the regulatory framework in Australia, ANMC strongly supports uniform national standards within nursing and midwifery, and has already in consultation with the broader nursing and midwifery communities, developed national competencies for both enrolled and registered nurses and midwives, generic competencies for nurse practitioners, and national codes of conduct and ethical codes. The core ANMC competencies articulate the contemporary nursing and midwifery roles, identifying the knowledge, skills and attitudes expected of nurses and midwives nationally. Developing standards from a national perspective also facilitates the principle of mutual recognition. 

Competence to practice is monitored in most states and territories through processes such as audits which require nurses to provide evidence of activities undertaken to demonstrate maintenance of continuing competence.

The ANMC also believes that national accreditation standards, the processes of implementing accreditation standards, and the regulatory processes for registering nurses should not be undertaken by the same body. Standard setting nationally, with implementation locally is seen as a transparent process which is well accepted within the nursing and midwifery professions.

 Draft Proposal 7.2

Whilst there are well documented issues relating to some health professional groups moving and working between states, we believe that the nursing and midwifery authorities have already taken steps to address issues relating to registration in more than one state.  In particular, ANMC has recognised the costs experienced by nurses working in more than one jurisdiction.  To assist the professions and individual nurses and midwives, ANMC and the state and territory regulatory bodies have a cross border policy (which may be viewed on the ANMC website, (www.anmc.org.au) relating to waiver of fees.  Regulatory authorities in all states and territories (except the ACT) have the capacity to waiver fees in certain circumstances, but this is implemented at the discretion of each individual registration board – not as indicated in the Productivity Commission’s position paper, page 107. 
An additional issue relating to cross border practice, concerns the uniformity of standards of practice. The introduction of telenursing in particular has required nurse/midwife regulatory bodies to review policies relating to nurses and midwives who may be treating or providing advice to patients/clients in other states and practicing under other jurisdictions. In response to this, the ANMC has produced guidelines to assist health professionals, which may also be viewed on the ANMC website, www.anmc.org.au.   The guidelines identify the need for nurses and midwives to practice within the framework of the national competency standards and codes as well as other relevant national requirements. 
The ANMC supports the need for consistency of skills and qualifications in specific roles and is working with each state and territory regulatory body and professional organisations to develop national frameworks for specialist nurses. An example of this is the recent work undertaken, with contributions from the Nursing Council of New Zealand, to investigate the scope and role of nurse practitioners and develop national standards for nurse practitioners.  The research initiative is now complete having drawn on leading professional nursing, midwifery and educational expertise across Australia and New Zealand. The research undertaken for the ANMC Nurse Practitioner Standards Project has generated wide interest nationally and internationally and will provide a valuable foundation on which to establish essential educational and practice standards for the newly evolving role of the nurse practitioner for the Australian and New Zealand contexts.  
Draft  Proposal 7.3

This proposal is not relevant to the nursing and midwifery professions since the state and territory regulatory authorities have already endorsed the ANMC codes of conduct and ethics, the ANMC national competencies, and national and state/territory based scope of practice documents.  These standards provide a framework for practice which operates effectively within the existing legislation in the various jurisdictions.

In addition, the regulatory authorities through the ANMC are currently developing a national decision making framework in which issues such as task delegation, supervision and professional responsibilities are clearly articulated. The project will draw upon an existing decision making framework which is currently adopted by four states including the Queensland Nursing Council, the Nurses Board of Western Australia, the Nurses Board of South Australia and the Nursing Board of Tasmania to ensure national acceptance.  This framework will also operate within the existing legislation in the various jurisdictions. 

Draft  Proposal 8.1

The ANMC supports this proposal, as there are currently limitations imposed by the existing services covered under the Medical Benefits Schedule. Over the last 12 months, the addition of MBS item numbers for practice nurses to undertake specific activities has been positively received by the medical and nursing professions. The ANMC believes that such additions to the schedule ultimately enable health professionals to provide a more comprehensive range of quality services to the community, and so applauds restructuring of referral and reimbursement processes to facilitate this. However, it also supports the belief that existing systems whereby a doctor claims the MBS item number on behalf of the nurse undertaking the procedure should be revised to enable the nurse to claim directly for the activity. Expansion of the item numbers to the nursing profession would enable nurses working in many primary health care settings to provide a more expansive range of services to the community in their own right, complimentary to the services provided by the medical profession.

Expansion of prescribing rights under the Pharmaceutical Benefits scheme would also be of benefit to many nurse practitioners, whose ability to practice within their full scope of practice is currently limited in areas such as ordering pathology and diagnostic tests by the PBS as well as by legislation in their local jurisdiction.  MBS and PBS item numbers for nurse practitioners and midwife practitioners would enable them to truly embrace their intended scope of practice. It should also be noted that nurse practitioners and midwife practitioners are usually salaried workers, so the requirement of these numbers is not for their personal reimbursement, but to facilitate equity for their clients to claim rebates that clients treated by health practitioners with these numbers are entitled to do. 

Draft  Proposal 8.2

The ANMC supports improvements to the rebatable processes currently provided through the MBS. In 2004/2005 the addition of MBS item numbers for practice nurses (who are different to Nurse Practitioners) to undertake specific activities has enabled practice nurses to undertake important health promotion and chronic disease management activities, and ANMC believes that additional item numbers should be introduced enabling nurses to undertake further delegated health promotion/education/clinical roles in health settings.  ANMC supports such developments as this provides a broader range of quality services available to the community and is therefore consistent with its vision ‘The Council aims to achieve consistent high quality nursing and midwifery practice which meets and responds to the needs of the Australian community…’  Such changes would also create additional opportunities for midwives to provide services in their own right such as ante and post natal care which is frequently provided by obstetricians under current MBS arrangements.  

Draft  Proposal 9.1

The ANMC supports the rationalisation of workforce planning, with the proviso that any new committee should have high level representation from the nursing and midwifery professions.

Draft Proposal 9.2

The ANMC supports the inclusion of workforce projections as part of the role of the secretariat discussed in Draft Proposal 9.1, and agrees that undergraduate entry should be given priority, with nursing and midwifery included as one of the key health workforce target groups. The ANMC, however, reiterates that it is concerned that workforce shortages should not be used as reasons to alter or potentially lower professional practice standards.

Draft Proposals 10.1, 10.2, 10.3 

The ANMC recognises the specific challenges facing workforce issues for nurses, midwives and other health professionals in rural and remote areas, and supports the AHMC explicitly considering the requirements in these areas.  There are key specialist nursing organisations such as the Council of Remote Area Nurses of Australia Inc (www.crana.org.au), and the Association of Australian Rural Nurses (www.aarn.asn.au) who should be consulted when undertaking this work. 

Draft 11.1

The ANMC supports the need for any health workforce frameworks to include flexibility to consider the needs of special groups. In particular, the aged care sector and the needs of indigenous and culturally diverse groups should be addressed.