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									    Sir Charles Gairdner Hospital
  Education & Development Centre
Hospital Avenue, NEDLANDS WA 6009

SUBMISSION: - NATIONAL REVIEW OF
      NURSING EDUCATION

           August 2001
                                Sir Charles Gairdner Hospital Submission to
                                    National Review of Nursing Education



The following submission is an amalgamation of the views and opinions of the
coordinators from the Centre for Nursing Education at Sir Charles Gairdner
Hospital (SCGH). All three terms of reference have been addressed and the
submission is structured with these TOR used as headings: Models of
Education and Training; Types of Skill and Knowledge; and Recruitment and
Retention. Under models of education and training, the whole gamut of
education from undergraduate education through to postgraduate education
and including continuing education have been addressed. The practices at
SCGH that are considered best practice, such as postgraduate education, are
described wherever appropriate. In regard to the models of education not
directly under the control of SCGH, such as undergraduate education,
properties of the ideal model are described. Under the skills and knowledge
TOR, models of competency based training and vocational education and
training are espoused. Under recruitment and retention, the educational
programs conducted by SCGH that have relevance to recruitment and
retention are described. In addition to these programs, migrant conversion
programs are briefly discussed and the importance of financial incentives for
postgraduate qualifications is emphasised.

Models of Education and Training
Undergraduate Education:
The ideal model of Registered Nurse undergraduate education would include:
• Theory education being provided in universities.
• Clinical experience being provided in hospitals and agencies in block system/s.
• Students returning to same hospital / agency several times so they have
   allegiance to that organisation and a good understanding of the policies,
   protocols and people at that organisation.
• Hospitals/ agencies hosting groups of students from several universities to allow
   for                                                                        cross
   pollination of ideas and a good mix of staff in the hospital / agency.
• Continue the 3 - 3 &1/2 year degree qualifications.
• Negotiate some rewards/ financial incentives for the Registered Nurses whom
   precept students.

Registered Nurse Graduate Year:

The ideal Registered Nurse Graduate Year would include:
• Hospitals/ agencies providing Graduate Support and Development Programs with
   a six months minimum time period. Even with more clinical experience, as an
   undergraduate there is need for a staffing year as for medicine, law or
   physiotherapists.
• Governments to pay hospitals / agencies for providing this support.
• Hospitals/ agencies to recruit own graduates OR use the Victorian model of
   Graduate Consortium ie number of graduates allocated to hospital and hospital
   then interviews those graduates and selects those they want to offer employment
   to.
• Continuing education is essential for graduates.


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Postgraduate Education
Over the past 10 years Sir Charles Gairdner Hospital has responded to the labour
force needs of several specialist areas by developing four specialty specific
postgraduate programs for Registered Nurses. The courses are Graduate Certificate
programs in: Critical Care Nursing; Emergency Nursing; Neuroscience Nursing and
Nephrology Nursing. All four courses are based on competencies for specialist
practice and integrate theory with clinical practice in such a way that graduates have
sound clinical competency and a strong theoretical knowledgebase specific to their
particular specialty area. The courses are formally recognised by both Curtin
University of Technology and Edith Cowan University so that graduates have
advanced standing towards higher degrees should they wish to pursue them.

The graduate certificate programs in Critical Care Nursing and Emergency Nursing
are both in house courses, which are conducted over 54 weeks. The students are
employed by Sir Charles Gairdner Hospital and work in clinical areas at SCGH,
Fremantle Hospital, or Joondalup Health Campus. Rotating the students through
different clinical areas in different hospital provides a richness and diversity of
clinical experience to their education that develops adaptability and flexibility in their
clinical practice. The students work between 64 and 80 hours per fortnight and are
supported by staff development nurses in the clinical context. The theoretical
component of the course is delivered in a study day format. Fifteen study days are
paid study leave and the remaining 27 study days are attended in the student’s own
time. The students are formally assessed through a variety of means including written
assignments, competency based assessment tool, seminar presentations and
worksheets.

The graduate certificate programs in Nephrology Nursing and Neuroscience Nursing
differ to the Critical Care and Emergency Nursing programs in that they are
conducted in a distance learning format and are more open and flexible. All the course
materials are either text based study guides and readers or video or computer based
resources. This enables students to work wherever they want as long as they can
develop the competencies required by the courses and students can also study at their
own pace and in a manner dictated by themselves. Students are given the option of
working at SCGH if they need to work in a metropolitan teaching hospital to gain the
level of competency required by the courses. The Neuroscience course has both
certificate and graduate certificate options available so that students can customise
their level of learning even further.

All four graduate certificate programs articulate with higher degree programs at both
Curtin University of Technology and Edith Cowan University. Curtin University
award 125 credit points toward a 200 credit point postgraduate diploma or they can be
used in gaining credits towards a masters degree in nursing. Edith Cowan University
award half the credits toward a postgraduate diploma and likewise these credits can be
used in a masters program.

The postgraduate programs, described above, serve a recruitment function and also
enable Sir Charles Gairdner Hospital and the other collaborating hospitals to
contribute directly to the training of specialist nurses in specialist areas, which have
experienced chronic shortages over the recent past. The courses serve a recruitment

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function in the sense that they attract nurses to SCGH to undertake training and at the
minimum recruit their labour for the duration of the course and often retain them well
beyond the end of the course of study. By conducting these courses SCGH is
providing the training and education required to ensure a well-educated and highly
competent work force in some of the most demanding and technologically specialised
areas in nursing.




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    Continuing Education - Vocational Educational Training
SCGH is committed to encouraging and providing opportunity for ongoing
professional development of the nursing staff.          A comprehensive continuing
education program is offered at no cost to staff and delivered onsite. Curriculum is
aimed at providing education that is professionally and clinical skills focussed with an
emphasis on industry need and competencies required.

Programs offered are scheduled for staff to attend after hours and during work time
as paid study leave. Programs are centrally coordinated, can be tailored to specific
areas and delivered by subject matter experts.

Short vocational courses include ‘just in time training’ as well as accredited programs
that articulate to higher awards. Programs are provided for all level nurses and the
nursing eduction section collaborates with corporate training department to develop
combined training for professional development.

The clinical staff development nurses are professionally supported by educators in
the central nurse education unit who offer curriculum development skills and an
education consultancy.


     Types of Skill and Knowledge
Today’s highly technological society requires nurses to master not only a great many
skills, but highly complex skills involving very expensive, dangerous and
sophisticated equipment, instruments, devices and processes.

A person who is described as competent in a profession is considered to have a
repertoire of skills, knowledge and understanding which he or she can apply in a
range of contexts.

Nursing as a job demands demonstration of competence in the workforce, and as
such points to the need for work experience to be a component of training which
leads to occupational competence. The experience of work needs to be structured
and varied to ensure there is sufficient coverage of the major components of
competency for the role of nurse.

A competency based approach must be underlined with a belief that training
programs should
   • Spell out exactly what it is that trainees should learn
   • Provide high quality instruction
   • Help students learn one thing before going onto another
   • Require each trainee to demonstrate competency

Skills and knowledge for nursing

Nursing requires a sound knowledge of scientific principles and clinical application of
those principles. Theory provides what can be made explicit and formalised but
clinical practice is always more complex and presents many more realities than can
be explored by theory alone. Theory and research are generated from the practical
world and the practices of the experts in the field. Theory guides clinicians and
enables them to ask the right questions.




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With the demands that new technology brings, it is essential that nurses have well-
developed psychomotor skills to operate equipment and attend to procedures for
patient care. Problem solving skills are required for effective management of
complex patient care and the management of changing environments. Nurses must
be competent and familiar with a wide range of information technology to be able to
document care, access information and operate instruments and devices.

Advanced communication skills are necessary as nurses are subject to a variety of
circumstances with people who are under duress. Numeracy and literacy skills are a
requirement for understanding between colleagues and ensuring patient safety when
delivering clinical care.

Reflective practice advances the development of clinical expertise and ability in
clinical decision making. This skill is introduced during undergraduate training and is
an essential skill that requires ongoing guidance.

Evidence based practice enables nurses to practice in the most effective and efficient
way basing what they do on what the current evidence suggests. This is the means
by which nurses integrate theory, research and clinical practice together



Recruitment and Retention

Educational programs conducted by teaching hospitals have a large part to play in
making individual workplaces attractive to new recruits and in retaining nurses over
the longer term. At Sir Charles Gairdner Hospital there are several educational
programs in place which impact on both recruitment and retention. These educational
programs include: structured workplace learning for school students; clinical support
and development programs for new graduates; postgraduate programs particularly for
second year RNs; refresher and re-registration programs for experienced RNs re-
entering the profession; and continuing education for all ENs and RNs. In addition to
these programs, retention of employees can be enhanced by providing financial
support for education endeavours and by financially recognising the attainment of
postgraduate qualifications. These individual programs and initiatives will now be
described in more detail.

Providing opportunities for high school students to learn about nursing in an
experiential way is very important in making nursing an attractive career choice. High
school students have always been accepted into hospitals for work experience and
with some additional thought and planning this service could be developed into a
potent recruitment tool.

Once newly graduated RNs and ENs are employed by hospitals it is essential that they
be supported by experienced preceptors and staff development nurses. At SCGH two
programs are offered to newly graduated RNs: the first is comprised of rotations to
medical & surgical areas and is of 12 months duration; whereas the other includes
rotations to medical & surgical areas and mental health areas and is of 18 months
duration. Structured education is provided in study days and clinical learning seminars
and clinical support is provided by preceptors and staff development nurses.




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Following on from the new graduate support and development program is the second
year RN program. This provides ongoing development opportunities to RNs and
engenders a commitment to life long learning. Participants of this program rotate to
two specialty areas over a 12-month period. Structured education is provided in a
study day format and clinical support is provided by preceptors and staff development
nurses. This kind of program could easily be extended to ENs.

Complementing the second year RN program are the four postgraduate programs
described previously. These programs allow new graduates to move into some of the
specialty areas and continue to develop themselves in both a professional and an
educational sense.

Short courses which enable ongoing professional development are an essential means
to maintain the commitment to lifelong learning and as such are an important
mechanism for retaining nurses in the workplace. A comprehensive program of
continuing education delivered at no financial expense to the employee and in close
proximity to the workplace is the ideal way to deliver this kind of education. At
SCGH we are developing clinically relevant vocationally oriented continuing
education courses that are modularised to enable the learner to link different courses
together to gain credit towards higher qualifications. These are delivered on campus
and are very easily accessible to all nurses employed by SCGH.

Re-entering the profession of nursing after having a break in a career can be very
daunting. Providing refresher programs aimed at upskilling nurses who have had a
break from work and re-registration for those who have let their registration lapse are
excellent mechanisms for attracting nurses back into the profession. Conducting these
programs at negligible cost to the employee is important in demonstrating the
employer’s commitment to new employees. Making these programs clinically
relevant and providing structured, supported clinical experience is essential to the
success of such programs.

Providing migrant bridging program is another means by which education can
positively influence recruitment of nurses. Such a course should be provided on an
as needs basis and should be separate to re-registration courses because migrants
have different needs and therefore require different learning objectives to nurses who
have trained in Australia but whose registration has lapsed over time.

Although the above mentioned programs have the potential for positively influencing
retention of staff, one of the major problems facing postgraduate education and
continuing education in nursing is the lack of financial incentive to undertake further
studies. The new Enterprise Bargaining Agreement (May 2001) includes a one off
payment to nurses who have completed postgraduate studies provided the courses
meet certain criteria. This will go some of the way to providing an incentive to nurses
to undertake further work related studies but it is already widely perceived as
inadequate because it is only a one off payment. Furthermore it only applies to
courses of 12 months or greater duration. Until nurses are adequately remunerated for
their efforts in further education nurses will continue to look outside nursing for
postgraduate studies to further their career. Likewise study leave and other forms of
financial assistance to undertake further education must be provided if employers
want to encourage nurses to stay in the profession and continue to learn and develop.


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             Sir Charles Gairdner Hospital
             Nursing Executive Committee
         Hospital Avenue, NEDLANDS WA 6009

          SUBMISSION: - NATIONAL REVIEW OF
                NURSING EDUCATION

                                        August 2001




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                               SIR CHARLES GAIRDNER HOSPITAL

        NATIONAL REVIEW OF NURSING EDUCATION


This submission has been prepared by the Nursing Executive at Sir Charles
Gairdner Hospital and reflects the combined opinion of the Nursing Co-
Directors, Co-ordinator Corporate Nursing, and the Executive Director of
Nursing at Sir Charles Gairdner Hospital.

The Nursing Executive have discussed several issues and potential
recommendations under the headings provided in the Terms of Reference for the
Committee. We have identified key areas that represent opportunities for
development and have capacity to influence the future of nursing specifically
addressing nursing education. The identified strategies are provided as specific
options that can be explored, refined and implemented as appropriate to enhance
nursing across Australia.

The Nursing Executive and the 1,100 nurses it represents strongly endorses
tertiary education for all Registered Nurses. All comments made in this
document should be read with this endorsement in mind.

Nurse education and training to meet future labour force needs.

    There is an expectation from industry that preparation of graduates would provide
    nurses who are industry ready and are prepared for a practice base discipline. To
    ensure this, there needs to be some improvements in the current tertiary
    preparation of students including establishment of a clinical focus early in the
    training and recognition of experience, to encourage those who have practiced in
    alternative related disciplines. Undergraduate experience and opportunities to
    prepare nurses for a range of skills should be encouraged at that level.

    Options for increasing the marketing to school leavers may include reflecting a
    program that recognises nursing as a part of a wider health service and therefore
    creates the ability for transition throughout careers rather than providing a single
    career path. This needs to be supplemented by providing increased clinical
    practice time and an alternative model for tertiary education that recognises a
    practice based discipline.

    As the health care system becomes more complex and specialised the need for
    specialty specific postgraduate education becomes more acute. This type of
    education needs to be both clinically relevant and academically rigorous to satisfy
    the professional and vocational aspects of nursing. Collaborative programs,
    which actively involve teaching hospitals and universities in the learning process,
    provide postgraduate education, which is both clinically relevant and
    academically rigorous.




    Strategies



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    •    One suggested strategy is that an alternative path is created through the
         initial undergraduate course. This may include opportunities such as double
         majors or streams of excellence in management, research, education or
         advanced clinical practice, which would provide qualifications to allow
         students to step into future roles within the health sector.
    •    The establishment of adequate funding arrangements with DEETYA for
         nursing through recognition of the undergraduate course as clinical.
    •    Cadetships for nurses with identified career paths after some clinical
         exposure may accelerate nursing leaders in a variety of fields.
    •    Sponsorship of student placements with agreed commitment to institution and
         or department following completion of undergraduate degree.( Similar to
         armed services support).

The interface between universities and the health system


     The ability of nurses to enter the Health system with the confidence, autonomy
     and support to develop expertise within the boundaries of their professional
     practice is essential. This will ensure satisfaction with roles undertaken and
     recognition of their contribution within the health sector for the skills that are
     specific to nursing. A substantial contributor to this will include the development
     of strategies that are reflected across both university and health.

     Strategies

     • Scope of Nursing Practice – A Decision-Making Framework developed by the
       Queensland Nursing Council and currently being reviewed for adoption by
       the Nurses’ Board of WA provides a framework to shift nursing practice at a
       state level to one of professional empowerment within the scope of nursing
       practice. It has the potential to enrich job rewards by enabling professional
       practice rather than excessive regulation.

    •     At a state and national level it is suggested that there is an investment in a
          framework for research and evidence based practice to ensure gaps in
          practice and knowledge deficits in regard to patient care are addressed. The
          opportunity to undertake research that explores alternative models for
          nursing practice requires investment to ensure the link to evidence. This will
          establish evidence based practice and nurse’s clinical responsibilities at the
          unit level, which promotes accountability and continuity of care.
    •    Consideration of a range of models should be explored for ensuring an
         appropriate interface. An example of this is ; the model of postgraduate
         education delivery devised by Sir Charles Gairdner Hospital provides nurses
         with courses with several exit points. The hospital runs certificate (Level 4
         ANF) and Graduate Certificate (Level 8 ANF) courses that articulate with
         higher degrees at Curtin University of Technology and Edith Cowan
         University. Students can exit with a certificate, graduate certificate or go on to
         undertake higher degrees. This model ensures that the hospital guarantees
         clinical relevance and the academic rigour is provided through the articulation
         with university.

     It is essential for the future of nursing that the clinical component of nursing is
     linked with education and research. These components need to be valued and
     recognised through both time commitments from the highest level, and



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     support/funding for research endeavours that maintain the professional
     standards and practice of nursing.

     Strategies

     • Nursing Research needs to be adequately funded to develop mentorship and
       infrastructure to support emerging nurse researchers. This will ensure the
       development of a baseline of nursing standards founded in best practice
       which are developed within the context of our health sector.
     • Credentialling of nursing requires exploration and support to ensure that
       appropriate and relevant tools of measurement are developed. These should
       aim to support nursing standards rather than create additional bureaucracy
       and regulation.
     • The concept of a portfolio for nurses is supported in order to demonstrate
       currency and relevance of professional practice.

Strategies to retain nurses in the workforce and to attract nurses back into the
profession including the aged care sector and regional areas.

     It is essential for the future of nursing that we have industry ready graduates who
     have alternative career paths and flexibility to provide them with opportunities to
     have some transition within the discipline throughout their career.

     Strategies

     • It is essential that we have a mechanism to review workloads across the
        industry so that issues of management imperative versus professional
        standards of practice can be agreed and explored. Underpinning this
        process needs to be both consistency across the nursing industry and local
        flexibility in the agreement on workload issues. This needs to be clearly
        simple and clear for implementation at a clinical level and defendable at the
        senior levels of nursing so that progress of workload issues can occur.
     • Targets for appropriate levels of staffing should be established at an industry
        level irrespective of nursing shortages and difficulties in funding appropriate
        levels.
     • Retention of nurses in the workforce can be enhanced through the provision
        of ongoing education in the workplace. Clinically relevant, vocationally
        oriented continuing education will assist nurses to ride the continual wave of
        change in health care and thereby help to retain them in the health system.
     • In addition one of the most significant factors in influencing nurses to remain
        within the nursing profession is the ability to recognise a potential career
        path. There are currently limited opportunities within the clinical, research or
        education arenas at middle to senor levels of nursing and as a result nurses
        choose either to remain at the clinical level or leave the profession to seek
        satisfaction in other areas.
     • A broadening of access to senior roles will create opportunities for greater
        diversity and strength of leaders who wish to remain in their areas of
        expertise.
     • It is essential that issues such as the differential for level 2 to 3 nurses is
        addressed if we are to ensure a meaningful career path for nurses. In
        conjunction broad banding of roles based on levels of responsibility and
        accountability are required to give flexibility to meet future as well as existing
        patient needs.



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     • An option worth considering is the establishment of bonuses for staff who are
       retained for defined periods of times within the Health sector and / or
       organisations.
     • Recognition of the diversity within institutions should be reflected in board
       representation at organisation and regional level.
     • Retention of experienced nurses can be enhanced by development of
       packages for postgraduate study that create opportunity and diversity as
       careers within the Health Sector.
     • There may be benefit in exploring the principle of repayment and waiving of
       educational loans that are linked to periods of time served within an
       organisation.
     • Reduction in HEC’s levy for both undergraduate and postgraduate
       components is suggested.
     • An association between institution and clinical schools requires exploration.
     • The development of multidisciplinary, integrated, clinical learning centres to
       provide clinically relevant, vocationally based, continuing education will assist
       in the retention of nurses in the health system.


     Other Significant Considerations;

     It is pivotal to the future of Nursing that nurses are adequately represented
     across the Health Sector. Issues should be addressed that will ensure a positive
     future for nursing and require consideration at several levels. The most
     significant impact on professional practice for nursing will be based on continual
     development of strong leadership roles within all areas of nursing. A consistent
     level of leadership needs to be demonstrated across nursing and is essential to
     provide a politically astute united profession. The future of nursing should include
     the establishment of a significant power base so that nursing has a voice in
     decisions that are made about the care they are delivering, whether this is at a
     local level such as a ward or across the health sector.
     Strong, visionary leadership today should endeavour to create an attractive
     career path in the future.

    Strategies

     • It is essential that there is executive level leadership demonstrated across
        nursing in Australia. This is required at a State and Commonwealth level
        through initiatives such as the inclusion of the Principal Nursing Adviser
        within the Executive of these senior structures .
     • A framework for developing potential leaders and engaging them in the
        development of leadership skills is essential. Encouragement of participation
        at state and national level forums as part of key professional development
        programs for identified nursing leaders may be one process that can be
        instituted to assist in this.
     • Increasing nurse’s control over their practice environment by decentralised
        decision making. There is potential to assist nurses in developing autonomy
        in their clinical decision making within their area of practice and competence.
        This is reflected in the Nurses Board of WA initiative, which creates a flexible
        approach to expanding the role of Nursing within the range of professional
        expertise through the “Scope of Nursing Practice – A Decision-Making
        Framework”. Support of innovation such as this is essential for the
        development of nursing.



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     • It is essential that boards of governance recognise the diversity and the
        impact of nursing as a professional group. Nursing significantly affects
        patient’s outcomes and as such should be included as ex officio members of
        the governing boards.

     ! CONCLUSION

     The recommendations for future initiatives in nursing have been broad in nature
     The Nursing Services Committee has explored specific strategies and some of
     these issues require refinement, which has not been included in our submission.
     Should it be feasible for a member of the nursing executive to address the
     Committee and/or provide additional information to further explore some of these
     ideas the Nursing Services Committee at Sir Charles Gairdner would be keen to
     participate.


     Contact

     Catherine Stoddart

     Nursing Co Director
     Heart and Lung Clinical Service Unit
     SCGH
     Phone 089 346 1828
     Fax 089 346 1829
     Email catherine.stoddart@health.wa.gov.au



     On Behalf of the
     Nursing Executive
     Sir Charles Gairdner Hospital


     Date of Submission
     27 June 2001




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