Australian College of Critical Care Nurses Ltd (ACCCN)
ACN 088 184 383
National Review of Nursing Education
Submission p...
demand places significant workload pressure on those who remain. This in turn affects
wastage rates, recruitment, retent...
development for the discipline of critical care nursing via mechanisms which foster high
level leadership, political par...
• The increasing casualisation of the workforce, and greater use of agency nurses and
inexperienced nurses to staff crit...
exposed to the critical care environment, and consequently do not choose it as an area in
which to specialise.
• Increase incorporation of expert practising clinicians to teach in undergraduate and
postgraduate programs with approp...
2) measures to increase recruitment and retention of critical care nurses in the Australian
health system;
3) support th...
Anderson &, Hart G. 2000. ANZICS Intensive Care Survey 1998: an overview of Australian
and New Zealand critic...
of 8

National Review of Nursing Education

Published on: Mar 3, 2016
Published in: Health & Medicine      
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Transcripts - National Review of Nursing Education

  • 1. 1 Australian College of Critical Care Nurses Ltd (ACCCN) ACN 088 184 383 National Review of Nursing Education Submission prepared by Patricia Johnson on behalf of ACCCN ________________________________________________________________________ Preamble The following submission addresses some of the issues highlighted in the DETYA National Review of Nursing Education terms of reference. Specifically, this submission addresses issues pertinent to the speciality of critical care nursing, although many of the issues highlighted in this paper are relevant to nursing as a whole. This submission was developed after consultation with the members of The Australian College of Critical Care Nurses (ACCCN) National Education Advisory Panel, and the wider critical care nursing community. ACCCN is the peak national professional body representing critical care nurses at the local, state, national and international level. ACCCN sets professional practice standards for critical care nurses and provides professional leadership through education, research and policy development and industrial advice. Currently there are over 2500 registered nurse members of ACCCN primarily employed in critical care settings in metropolitan, rural and remote areas across Australia. The ACCCN believes that the community should receive high quality health care. Nurses at all levels should be prepared to the highest possible standard to ensure practice is underpinned by knowledge that supports clinical decision making in an increasing complex health care environment. Critical care nursing is a specialty area of nursing that requires a level of skill and knowledge that is beyond the scope of undergraduate nursing programs. In order to provide optimal nursing care in the area of critical care, nurses must have access to educational programs that reflect the established standards of the speciality. However, there have been major changes in health care over the past twenty years that impact on nursing services and nurses. The very nature of hospitalisation has changed as reflected in the higher acuity of in-patients, the widespread provision of high level care, and shorter lengths of stay (Beckman et al., 1998). This situation has increased demand for all nurses, including qualified critical care nurses. However, recent studies indicate that the number of qualified critical care nurses is decreasing (Ferrari, 1997; Beckman et al., 1998). As a consequence, the workplace is becoming an increasingly stressful place in which to work, as the dwindling numbers of critical care nurses with specialist qualifications relative to
  • 2. 2 demand places significant workload pressure on those who remain. This in turn affects wastage rates, recruitment, retention, the reputation of education and training providers, the reputation of employers and the public image of nursing and ultimately the quality of care that can be delivered. This crisis is also reflected internationally (Clarke et al., 1999). ACCCN has published a position statement on speciality critical care nursing education (Underwood et al., 1999), which considered and supported some recommendations from a previous DETYA report on the same issue (Russell et al., 1997). Our response highlights our major concern with the current nursing workforce crisis, specifically the shortage of critical care nurses and the impact this shortage has on the provision of quality health care, retention of nurses in the workforce, professional development and nursing education. Our view of the most important issues for critical care nursing follows. The Issues 1. The Profession • Nurses constitute the largest number of health-care professionals and provide the human face of quality care to the general public. The Morgan Image of Professions Poll (2000) reported the nursing profession has been ranked for the seventh consecutive year as the most highly regarded by the community in terms of honesty and ethical practice. • The current need to recruit and retain critical care nurses is of prime concern to the public as well as the profession, yet there is little understanding by the general population outside of nursing of the realities of nursing practice or of nursing’s unique knowledge and educational base. • National nursing competency standards developed in the early 1990’s have created benchmarks for good and best practice (ANCI, 2000). These standards guide all undergraduate educational programs for nurses. ACCCN (CACCN, 1996) has developed specialist competencies for critical care nurses that are used to: inform and guide practice, inform postgraduate curriculum development, assess clinical practice in many critical care postgraduate programs, as well as forming a part of performance management reviews in maintaining specialist standards in practice areas. These Competency Standards (CACCN, 1996) also form the basis of Credentialling specialist practice in critical care nursing. • Historically, members of the nursing profession have little input into health policy, despite being the most numerically dominant group implementing health initiatives. • A number of peak nursing bodies exist, with ACCCN being the professional body for critical care nurses in Australia. ACCCN is attempting to address issues of strategic
  • 3. 3 development for the discipline of critical care nursing via mechanisms which foster high level leadership, political participation and collaboration between nursing practice and educational organizations. 2. The Workplace • There is commonly a lack of incentive or financial support to undertake specialist or postgraduate study. Those who do attempt to mix work and study have few workplace supports, given the gradual phasing out of hospital continuing education departments and unit based support resources in the form of clinical educators. However, there has been some development of strategic partnerships between the health care and tertiary education sectors (Elliott, 1998) although much more is possible with an appropriate national strategic direction (Russell et al, 1997). In particular, the lack of funded study leave for nurses to undertake postgraduate courses requires urgent attention. • While there are appropriate professional demands for nurses to maintain expertise, there is little support in the form of paid leave or fee subsidy provided by employers and health departments for nurses to access those activities. For example, support for conference attendance and continuing education would contribute to the maintenance of expertise and the continual development of the workforce. • Despite the efforts of employers there are few truly family-friendly workplaces. Many nurses have financial obligations as the major income earner and find difficulties in meeting the requirements of work, study and family responsibilities. • Nurses interact daily with an increasingly informed, demanding and at times aggressive public. 3. The Workforce • Although it is widely known that there are problems of wastage and workforce shortages, there are no accurate, ongoing, national workforce data that can be used as a basis for planning. The Australian Institute of Health and Welfare has attempted to quantify the national nursing workforce data broadly (ACHS, 1997; FICANZCA 1997; AMWAC, 1999). However, due to the wide differences in state based data collection processes, comprehensive information at a national level is often dated when published and very broad, thus lacking the detail necessary to assist policy makers. • There are a decreasing number of nurses with critical care qualifications due to a lack of a clinical career structure that acts to retain senior nurses within the clinical environment, inadequate financial remuneration and recognition, and workplace stresses. This situation can only worsen in the future if urgent measures are not taken to address these issues.
  • 4. 4 • The increasing casualisation of the workforce, and greater use of agency nurses and inexperienced nurses to staff critical care units, further increases the demands put on critical care nurses. This also leads to wide variations in skill mix and work practices, and can potentially compromise patient care. • Minimum ratios for qualified specialist critical care nurses in intensive care units are stated (ACCCN, 2000), but are rarely adhered to because of the staffing crisis, and thus affect the quality of patient care 1. Nursing Education • A wide range of postgraduate critical care nursing programs are available in the tertiary sector at the graduate certificate, graduate diploma and Masters level, with varying levels of theoretical and clinical content (Russell et al., 1997; Elliott, 1998). Furthermore, there are no agreed national guidelines on the expected outcomes for graduates of postgraduate critical care courses (Underwood et al., 1999), a situation that has the potential to create differing standards and lead to employer confusion. • The most recent information indicates that the majority of postgraduate critical care courses are conducted on campus in metropolitan universities (Russell et al., 1997; Dunn et al., 1998), hence there is a lack of access to postgraduate programs for nurses located in non-metropolitan areas. In addition, appropriate clinical experience obtained in conjunction with postgraduate education is sometimes more difficult to obtain outside of the metropolitan areas. • There are significant costs associated with undertaking postgraduate courses. Many are not HECS allocated and are only offered on a full fee paying basis. • The lack of HECS exempt places for nurses indicates a lack of response to the need for specialised preparation. • Due to difficulties securing clinical placement opportunities for undergraduate nursing students, many nurses are not exposed to the critical care environment, and consequently do not choose it as an area in which to specialise later in their careers. • Undergraduate Nursing programs are disproportionately costly, primarily because of the need for clinical practice placements. As health agencies downsize, bed numbers reduce and length of stay shortens, it is becoming increasingly difficult for Universities to place students in clinical agencies and for students to receive an appropriate range of clinical practice experiences. As clinical staff become burdened with the workplace stress, they are less likely to welcome students to areas not resourced with clinical educators. Due to the additional workload they represent in these under-resourced areas, the students can be perceived as a burden and this in turn severely limits the practices students can undertake with acutely ill patients. As a consequence, many student nurses are not
  • 5. 5 exposed to the critical care environment, and consequently do not choose it as an area in which to specialise. Recommendations Nurse education and training to meet future labour force needs The ACCCN makes the following recommendations pertaining to the education of critical care nurses Postgraduate, specifically critical care • Critical care courses should be at postgraduate level. Consideration should be given to establish alternative entry pathways, where appropriate, for nurses who have completed hospital based introductory courses of sufficient academic rigor to allow this to occur. • Increase the number of supported postgraduate positions available in critical care courses to meet anticipated future demands. • Postgraduate scholarships including paid study leave to undertake critical care nursing courses be made available. • HECS liable postgraduate courses restored, with HECS exempt scholarships for nurses enrolled in postgraduate critical care courses. • Increase the number of nurse educator positions in critical care areas to support new staff and ongoing education programs in the workplace. These positions should be appropriately compensated. • Greater alignment of University Faculties of Nursing with clinical agencies. Increased number of Clinical Chairs in Critical Care, joint appointments in education and research, and establishment of Clinical Schools within health care agencies (Russell et al., 1997; Dunn et al., 1998; Elliott, 1998). • Inclusion of appropriately qualified and clinically based representatives on University advisory committees, when planning and/or evaluating critical care courses. • On-going funding to ensure that a sufficient number of postgraduate places for nurses wishing to specialise in critical care available are made available each year so that a consistent supply of critical care nurses is available to meet demand (Williams and Clarke, 2001). • Clinicians should be given scope and resources to explore and formalise advanced practice that is recognised professionally and industrially. Advanced practice should be the goal for all qualified critical care nurses with a clinical career structure that recognises expertise and encourages retention of experienced critical care nurses in the clinical setting. Credentialling (Kendrick et al, 2000), provides a process to identify and recognise excellence in practice. The nurse practitioner role in critical care should be further investigated for opportunities to enhance health care delivery.
  • 6. 6 • Increase incorporation of expert practising clinicians to teach in undergraduate and postgraduate programs with appropriate remuneration and professional recognition for the individual and the participating health institution. • Greater recognition of the role of critical care nurses in health care and future planning (Williams and Clarke, 2001). Appropriately qualified critical care nurses should be involved at all levels of policy and decision-making. Workplace Recommendations The ACCCN also makes the following recommendations pertaining to the workplace. • Provide funding for research studies that systematically examine the characteristics of workplace environments that would address recruitment and retention strategies. • Establish mechanisms for implementing a real career path with appropriate remuneration and incentives for enhancement of nursing care and retention of experience and expertise in the clinical area, such as appropriate remuneration and recognition for Credentialled Nurses. • Support research activities that influence critical care nursing knowledge and practices. • Provide incentives for critical care innovation and best practice in developing education and industry links that draw upon the strengths of both sectors. • Mandate staffing levels that enable nurses to provide high quality care through federal legislation. • Ensure appropriate support structures and ancillary staffing so nurses are able to provide high quality, safe nursing care and concentrate on nursing. • Provide adequate study and conference leave. • Increase opportunities for professional development. • Increase opportunities for promotion. • Improve wages and conditions that appropriately reflect the level of skill and qualifications of nurses. • Ensure a safe and secure workplace • Provide funding that recognises nursing as a 24-hour service that requires 24-hour support in education, clinical practice and management. • All Intensive Care Units should be funded to provide a staffing level as per the ACCCN Interim Position Statement on Intensive Care Nurse Staffing (ACCCN, 2000). Conclusion The ACCCN believes that a number of urgent initiatives are necessary to ensure that the community receives appropriate and high quality nursing care. These changes include: 1) increased Government and public awareness of the contribution that nursing is making in Australian health care;
  • 7. 7 2) measures to increase recruitment and retention of critical care nurses in the Australian health system; 3) support the development of agreed outcomes for critical care courses 4) facilitate opportunities for undergraduate placements in critical care areas 5) support for workplace based clinical learning and continuing professional development for nurses; 6) improvements to occupational health and safety practices; and 7) substantial and ongoing funding provided for the education and development of what is a valuable yet under-utilized resource for the health and wellbeing of the Australian public. ACCCN recommends that the funding formula proposed (Williams and Clarke, 2001) should be evaluated with appropriate support from DETYA. The ACCCN acknowledges that many of the recommendations will require substantial resources and a significant financial commitment. However, if these recommendations are not implemented the shortfall in the critical care nursing workforce will continue. Critical care bed availability and effective critical care nursing is central to efficient health care delivery and optimal patient outcomes. To achieve these goals a strategic pro-active plan is needed to revive and sustain the critical care nursing workforce of Australia. ACCCN would welcome funding from DETYA for a project that will: 1. Investigate current aims, processes and outcomes of Australian critical care nursing courses 2. Specifically evaluate current clinical competency assessments implemented by various education providers, and compare against the National competency standards developed by ACCCN (CACCN, 1996) 3. Test the ACCESS model for staffing resources in intensive care (Williams and Clarke, 2001) 4. Evaluate the implementation of recommendations from the report of the previous DETYA national review of specialist nurse education (Russell et al., 1997).
  • 8. 8 References Anderson &, Hart G. 2000. ANZICS Intensive Care Survey 1998: an overview of Australian and New Zealand critical care resources. ANZICS. Australian College of Critical Care Nurses 2000 Interim Position Statement on Intensive Care Nurse Staffing Australian Council on Healthcare Standards. 1997. Guidelines for intensive care units. Sydney, ACHS. Australian Medical Workforce Advisory Committee 1999. The Intensive Care Workforce in Australia, AMWAC Report 1999. 1, Sydney. Australian Nursing Council Inc. 2000. National Competency Standards for the Registered Nurse.(3rd ed.) ANCI: Dickson. Beckman U, Baldwin I, Durie M, Morrison A & Shaw L. 1998. Problems associated with nursing staff shortage: an analysis of the first 3600 incident reports submitted to the Australian Incident Monitoring Study (AIMS-ICU). Anaesth. Intensive Care, 26 (4): 396-400. Clarke T, MacKinnon E, England K, Burr G, Fowler S, Fairservice L. 1999. Intensive care nurse staffing practices in the US: what lessons for Australia? Australian Critical Care 12 (3):109-18. Confederation of Australian Critical Care Nurses. 1996. Competency Standards for Specialist Critical Care Nurses. Inkpress: Subiaco. Dunn S, Aitken L, Chaboyer W, McCullough S, Perrott J, Theobold K. 1998. Critical care nursing Australian tertiary postgraduate courses information guide. Kelvin Grove: Queensland University of Technology. Elliott D. 1998. Current issues influencing Australian critical care education. Critical Times, 1(2): 2-3. Faculty of Intensive Care, Australian and New Zealand College of Anaesthetists. 1997. Minimum Standards for Intensive Care Units. IC-1. Melbourne. Ferrari J. 1997,Vulnerable patients suffer nurses, bed shortages. The Australian Jan 7:4. Kendrick, T., Greenwood, M., Grech, C., Gill, F., Birkett, K. & Porter, J. 2000. Credentialling Australian critical care nurses: the pilot study. Australian Critical Care, 13, (3): 113-116. Roy Morgan Research Centre 2000. Image of professions poll. The Bulletin, Nov. 9. Russell RL, Gething L, Convery P. 1997. National review of specialist nurse education. Canberra: Evaluations and Investigations Program, Department of Employment, Education, Training and Youth Affairs. Underwood, M., Elliott, D., Aitken, L., Austen, D., Currey, J., Field, T., Grech, C., Kiegaldie, D., Pittard, M. & Worral-Carter, L. 1999. Australian College of Critical Care Nurses Ltd.: Position statement on postgraduate critical care nursing education Australian Critical Care, 12 (4): 160-164. Williams, G. & Clarke, T. 2001. A Consensus Driven Method to Measure the Required Number of Intensive Care Nurses in Australia. Australian Critical Care, 14 (3): 106-115.

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