Introduction

Australia is an island continent in the Southern Hemisphere that is not quite as large as the continental United States. It has a population of approximately 18 million people who live primarily along the eastern seaboard in several large metropolitan regions. It is a Western developed country that was established as such by British settlers in the late 1700's and early 1800's. However, the indigenous peoples of the land who have dwelled on the continent for at least 40,00 years were displaced by this "settlement" and at times they refer to the advent of the British as an invasion onto their land.

The style of government is a democracy based on the British Westminster system. There are many layers of government, the Commonwealth (federal), State and Territory (seven states and two territories) and local agencies.

Conceptualisation of Nursing in Australia

Any attempt to be specific and certain as to a singular conceptualisation would be fraught with problems; however, nursing in Australia has been influenced strongly by the British nursing tradition. The apprenticeship style of nurse education, based largely on the British systems, has been replaced by education in the higher education sector for registered nurses. This significant break with the past, in which nurses were often seen as handmaidens of doctors or dutiful employees of an institution, heralded an opportunity for Australian nurses to develop the discipline of nursing in an academic environment. Educationally qualified nurses now play a role in the academic life of universities in Australia, and therefore have seized the opportunity to advance their discipline through scholarly endeavours.

Conceptualisation of nursing in Australia has been influenced not only by British traditions, but also by developments in the North America. For example, Virginia Henderson's definition of nursing is often used to introduce beginning students to nursing (White & Chiarella, 2000). Definitions of nursing based on the International Council for Nursing are also used in Australia. Nationally, definitions of a beginning nurse are found in the competency statements of the Australian Nursing Council Inc. (1998). The concept that nurses are concerned with human responses to health and illness are prevalent throughout the country. The extent to which Australian nurses have embraced research into the experience of illness (e.g., Madjar & Walton, 1999) serves as testament to the commitment of the Australian nursing profession to understanding the "human response" aspects of health and health care delivery.

Australian Health Care System

The health care system in Australia is based on the principle of universal access to health care. Through a levy on wages the Commonwealth government collects funds for a universal benefits scheme, called Medicare.

The Medicare levy provides funds for reimbursement of private medical services such as general medical practitioners (who play a major role of first line health care) and specialist medical practitioners. Although these practitioners establish their own fees there is a set amount for reimbursement through the Medicare scheme. The Medicare levy also provides subsidies for specifically listed (and commonly used) medications through the Pharmaceutical Benefits Scheme. In addition, the levy helps to fund the public hospital system, which provides the bulk of acute health care that is available to all Australian citizens and permanent residents.

The state and territory governments operate the public hospital systems. As such, the health care system in Australia is largely government-run, with the Commonwealth government assuming a broad leadership and financing role and the state and territory governments playing a planning and delivery role of public sector health services. Local governments focus on community based and home care services, as well as environmental health issues.

National spending in health care is 8-9% of the gross domestic product, with public funding accounting for 67% and private sources for 33% (Podger & Hagan, 1999). Increasingly, the private sector is playing a role in the delivery of health care in Australia through a system of private hospitals. Privitisation of health care is an issue that is discussed and debated by members of the society as private care offers choice of doctors, yet poses threats to equity and access in the delivery of health care.

Nursing Work Force in Australia

In Australia there are two levels of nurses who are qualified to practise, registered nurses (RNs) and enrolled (ENs). Registered nurses complete a three-year university bachelor degree to qualify and enrolled nurses complete a one-year vocational educational program to qualify. As a rule, enrolled nurses work under the direction and professional guidance of registered nurses.

In 1998 there were 264,819 nurses registered and enrolled nurses in Australia, a 21.4% decline in ENs and a 0.9% decline in RNs from 1993 (Australian Institute of Health and Welfare [AIHW], 1998). This figure represents 1,064 full time equivalent nurses per 100,000 population in the nation. Of the nurses who are registered or enrolled there are 197,700 employed, a reduction of 1.6% over the last decade (AIHW, 1998). The reduction percentage figure is adjusted to account for the increasing number of nurses working part-time.

The average age of nurses is Australia is 40.1 years of age for RNs and 38.7 for ENs. Typically nurses are female, with 7.8% males in 1996, and work in acute care public hospitals in metropolitan regions of the nation (AIHW, 1998). The geographic distribution of nurses mirrors the overall Australian population with 63.2% in capital cities, 6.8% in other metropolitan areas, 27.0% in rural areas and 1.3% in remote (outback) areas of the country.

Educational Programs for Nurses in Australia

During the mid 1970s to the early 1990s all educational programs that prepared registered nurses for entry into practice were transferred from the health care sector to the higher education sector (i.e., post secondary schooling). The previous programs that were delivered in the health care sector were apprenticeship style courses of study, during which student nurses were paid employees of health care institutions. In the current system, students of nursing still enter the clinical environment, but now do so in service to their education rather than in service to an employer.

The transfer of basic nursing programs to the higher education sector was heralded as an opportunity to enhance the professional status of nurses in Australia. Earning an educational award from an institution of higher education, rather than a hospital, carried with it the potential to place nurses on a par with other professionals in the health care arena. However, until 1991 Australian nurses were being conferred diplomas and had not yet achieved the educational level of a bachelor degree for entry into practice. This was to happen as a result of a change to the structure of the Australian higher education sector.

At the time of the transfer of nursing education from hospital-based programs the Australian higher education sector had three tiers: technical and vocational educational institutions comprised one of the tiers, while traditional universities comprised another. In between these tiers sat a third one, represented by former teachers' colleges and institutes of technology. Institutions in the middle tier were referred to as colleges of advanced education, and at the time of the transfer did not offer educational awards at the level of bachelor degree and beyond. Nursing programs were placed in this middle tier at the time of the transfer from hospital-based training.

Subsequent to the transfer of nursing education the federal government collapsed the three tiers of higher education into two by amalgamating the colleges of advanced education into the university sector, thus forming two tiers, universities and vocational educational institutions. As a result nursing educational programs for RNs were placed into the university sector and educational programs for ENs remained in the vocational sector. Shortly after the formation of a two-tiered higher education system the federal government agreed to fund basic nursing education for RNs at the level of a bachelor degree.

Determining the difference between preparation at a three-year diploma level through a college of advanced education and a three-year degree level through a university posed challenges for nursing educators. Both levels of educational award took the same length of time to complete, three years. Nevertheless, the nursing profession celebrated the accomplishment of an entire work force of registered nurses entering practice with a university degree as an important milestone in Australian nursing.

Postgraduate programs for nurses proliferated as a direct result of the transfer of professional nursing education into the higher education sector in Australia. At present, registered nurses can study at university level from a Bachelor of Nursing to a PhD award. In between are numerous other educational awards. Graduate certificates and graduate diploma, 6 months and one year full time study respectively, offer education preparation for specialty clinical practice. Such preparation is necessary because the basic qualification for entry into practice, a bachelor degree, is generic in nature. Master's programs in nursing can be either course work based, that is, students undertake a series of subjects and complete set requirements for each subject, or they can be research-based. The latter, a research training degree, involves the completion of an independent piece of research that makes an original contribution to the knowledge of the discipline. The former, a course work degree, requires completion of classroom learning and set assignments for evaluation of educational achievement.

In disciplines other than nursing the traditional route into the research training degree is through an honours program, which is a one year "add on" to a bachelor program. In the honours program students undertake a supervised research project. A high level of grade for the honours year project enables graduates to enter PhD study directly. However, nursing graduates aspiring to doctoral study often enter through a master's program, either course work or research based.

A recent development in Australia is the introduction of professional doctorates, including a Doctor of Nursing and a Doctor of Midwifery. They were introduced to complement, rather than replace, existing doctoral study leading to a PhD. PhD study in Australia is considered to be a research training degree, involving the design and implementation of an original piece of research; there is no classroom work or set assignments. Although at the same level of scholarship and rigour, the professional doctorate is different from the PhD in three ways. First, the professional doctorate involves some course work, that is classroom learning and set assignments. Second, the requirement for original research in a professional doctorate may involve a series of projects linked together through a dissertation. Third, the scholarly endeavour for a professional doctorate is designed to influence directly the practice of nursing. As such, the professional doctorate is both a research training degree and a vehicle for professional activism.

The recent history of education for Australian registered nurses (RNs) is different than that of another level of practice for nurses in Australia, the enrolled nurses (ENs). The EN system of basic education was not altered as dramatically as that for the preparation of RNs. The Enrolled Nurses undertake educational programs of study in the vocational higher education sector, generally a one year full time course of study. The course includes a split between practical training, during which students are paid employees of hospitals and health care agencies, and theoretical training in the classroom and nursing laboratory. This structure serves to develop a perception that ENs are more practically oriented while RNs are theoretically oriented. While understandable, this only serves to perpetuate the theory - practice gap so widely discussed in the nursing literature.

ENs usually work under the direction of a registered nurse; however this varies from region to region, with rural and remote health care services presenting a different picture than metropolitan regions of the country. At present there is variability across the nation in relation to the role and function of ENs and this has sparked a push for the development of national consistency in the education, role and responsibilities of Enrolled Nurses.

Registration of Nurses in Australia

As indicated above there are two levels of registration for nurses in Australian, Registered Nursing and Enrolled Nursing. Nurses do not carry a licence per se, but are registered or enrolled to practise in a state or territory. Regulation of the registration of nurses is controlled through individual statutory authorities, nurses registration boards, that are under the auspices of state and territory governments. The nurses' registration boards of each state and territory function independently though state legislation. However the boards have agreed on national competencies to enter RN and EN practice, thus enabling mutual recognition from state to state.

The national competencies were developed in the early 1990's and currently are maintained and updated by the Australian Nursing Council, Inc (ANCI). Referred to as the ANCI competencies they are used by each state and territory board to determine if education programs meet competency standards. Individual nurses are not assessed or examined, but rather the competencies are applied by the registration boards when accrediting programs. Additionally, the competencies are used to assess qualification of nurses migrating from overseas.

Renewal of registration requires evidence of competence for continuing practice in all states and territories of Australia except New South Wales, the most populated state. Currency of practice or completion of a refresher course demonstrates evidence of competence if a nurse has not practised within 5 years. However, the issue of continuing competence currently is being investigated and deliberated on the national scene.

Issues about advanced and specialty practice credentialling and accreditation are accelerating the deliberation, and issues of professional responsibility to maintain competence are burgeoning on the national level. National nursing organisations representing specialty practice areas are developing systems of accreditation of educational programs and credentialling of individual nurses. Educational programs preparing nurses for registration and enrollment must be accredited by registering authorities. Universities are maintaining the position that their internal accreditation processes for professional courses are sufficient for programs beyond the qualifying level. This is one of the professional issues facing Australian nurses at present.

Nursing Organisations in Australia

A major national nursing organisation is the Australian Nursing Federation (ANF), whose major role is the industrial welfare of nurses. State nurses' associations also play a major role in workplace relations and industrial issues through bargaining on behalf of nurses. In addition there is a Royal College of Nursing Australia (RCNA) whose major aim is professional enhancement of nursing practice through policy influence and educational endeavours. Both the ANF and RCNA keep their members informed of issues that are of national interest to nurses.

In addition there are a number of national nursing organisations (NNOs) that represent the interests of specialists' nurses. As noted previously, the NNOs currently are involved in the movement to establish competencies for specialist practice and criteria for the accreditation of education programs to prepare specialist nurses.

Nursing Research in Australia

As would be expected, the transfer of nursing education into the higher education sector has enabled nurses in Australia to assume legitimate places in an academic environment, where advancement of disciplines through research is expected and supported. The same cannot be said for practicing nurses in clinical environments. At present there is insufficient infrastructure to support clinical nurses in undertaking research in the practice setting. Nurses in clinical setting who want to undertake research often do so as part of an educational endeavour that is completed "on their own time". Even when not part of their educational preparation, nurses wanting to do research find it difficult to acquire the necessary resources to do so. This is another of the professional issues currently challenging Australian nurses.

Additionally, many practising nurses cannot appreciate the research efforts of nursing academics, at times believing research is not addressing real issues in nursing practice. This, coupled with a perception that universities do not adequately prepare beginning practitioners to fulfil an RN role, leads to a widened practice-theory gap. At present there is much effort in Australia aimed at addressing the "gap issue".

Nevertheless, nursing research in Australia has grown by leaps and bounds in the past decade. Nurses working toward research degrees have conducted much of the research. Another factor that is contributing to the proliferation of nursing research in Australia is the creation of clinical professor positions. Clinical professors hold positions in the academy but are placed in clinical settings and funded by government area health services or through private endowments. These innovative roles have enabled suitably qualified academic nurses to work closely with nurses in clinical settings in research endeavours, thus serving to bridge the infamous theory-practice gap.

Clinical professors, who are financially sponsored by endowments or government health services, conduct research that is directly relevant to practicing nurses. Recent examples of such research include exploring the experience of patients who have been in Intensive Care Units, and understanding the experience of first time fathers. Studies such as these are assisting in the conceptualisation of nursing in Australia and are part of the development of disciplinary knowledge.

Current Issues in Nursing in Australia

Currently the nursing profession in Australia is faced with numerous challenges not simply related to its identity and definitions; its long-term viability is threatened as critical nursing shortages are predicted. How can the health care delivery survive without them? The answer to this question is complex and unclear, although one thing is known. Health care is an intrinsic aspect in the lives of people and in any social system; and something akin to nursing as it is currently constructed will be part of the future of Australia.

There are anticipated shortages of nurses in the national work force, especially for rural and remote areas. Adequate and appropriate provision of health care in these areas is of national concern. While the nursing work force in rural and remote areas mirrors national demographics, the percentage of other health care professionals working in these areas does not. Interestingly, the largest percentages of nurses working in rural and remote regions are enrolled nurses, not registered nurses.

National shortages are also projected in some specialty clinical areas, including, critical care, mental health, aged care, perioperative care, cardiothoracic care and midwifery. In general, projected shortages are fuelled by decreasing enrollments in basic nursing education programs with a 15.9% decline from 1991 to 1998; an ageing work force coupled with an increasing age of those entering nursing (24.5 years old in 1998); and, retention problems as nurses leave health care settings because of family commitments and not feeling valued at work (AIHW, 1998).

There is movement across the country to introduce another level of nurse as a nurse practitioner, who will function more independently than other RNs. This movement is, in part, a response to the need for better health care in remote and rural areas; although RN nurses working in these areas have been able to gain prescribing rights for some pharmaceuticals. In 1999 legislation passed through the State government of New South Wales that enables the registration of Nurse Practitioners who will have specified prescribing rights and extended roles, including such activities as ordering diagnostic tests. Other states and territories in Australia are currently investigating introduction of Nurse Practitioners in their local areas of jurisdiction.

Due to anticipated nurse shortages there are current drives to introduce generic health workers and to substitute nurses with unskilled labour. At present there is a level of health care provider referred to as personal care assistants (PCAs) who work in aged care facilities. Of concern to the nursing profession is the need to clarify the role and function of PCAs, along with the development of consistency of standards applied to their work.

Current Issues in Health Care in Australia

Like other nations in the Western world the Australian population is ageing and this, plus the growth of technology will put increasing fiscal demands on the health care system. The money available for health care is finite and public hospitals have been experiencing and will continue to experience government budget cuts. This will force decisions about priorities in care. Like other western English-speaking countries there is a disproportionate amount of the health care dollar expended on acute care rather than preventative services. Expenditure on cure rather than preventive services contributes to the growth of private health care industry as more money is earned directly on the former.

The growth of the private health care industry serves to exacerbate two current issues in health care in Australia. One of these is the relatively poor health care provided to rural and remote areas of the country. The Australian population is predominantly located in metropolitan, coastal regions of the country and expenditures of health care funds reflect this demographic reality. Increasingly, rural and remote Australians feel disenfranchised and health care delivery is but one issue, albeit central to a good quality of life.

However, it is the second issue that is one of, if not the most, pressing issue facing the Australian health care system, namely, the poor health of the indigenous peoples of Australia, the Aboriginal and Torres Strait Islander people. For example, the projected life span of indigenous Australians is nearly twenty years less than white Australians; between the ages of 24 to 44 they are five times as likely to die as non-indigenous people; and their maternal mortality rate is ten times that of non-indigenous mothers (AIHW, 1996). These health care concerns reflect a major issue facing the entire nation, that of reconciliation between indigenous Australians and the white settlers of the continent.

Summary

Nursing in Australia is exciting because of the numerous opportunities offered by the complete transfer of all registered nursing education into the higher education sector. Nursing research and the development of the discipline have blossomed in an environment not constrained by rigid traditions. The concept of "an emerging discipline" offers numerous opportunities for expansion and growth. However, a major challenge facing Australian nursing relates to recruitment and retention of a qualified nursing work force. Without nurses to take up the challenge, it is unlikely that the present opportunities will be seized to the fullest.

Author

Jane Stein-Parbury, PhD, RN, FRCNA
E-mail: jane.stein-parbury@uts.edu.au

Jane Stein-Parbury has extensive experience in nursing education. Originally from the USA, she has resided in Australia since 1984. She has been a member of the academic staff at the University of Technology, Sydney since 1986. Currently Jane is an Associate Professor in the Faculty of Nursing, Midwifery and Health. Her current position is Director of Research in the Faculty. She is best known in Australia for her textbook entitled Patient and Person: Developing Interpersonal skills in Nursing, originally published in 1993 with a new edition due in 2001. She teaches in the area of interpersonal aspects of nursing care and researches in the area of psychosocial aspects of illness and recovery