CASE STUDY: CAPACITY AND CAPABILITY TO DELIVER DIPLOMA OF ENROLLED NURSING

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1 CASE STUDY: CAPACITY AND CAPABILITY TO DELIVER DIPLOMA OF ENROLLED NURSING History During the early 80s there were several attempts to start formal training for Enrolled Nurses in the Northern Territory. Despite resistance from some senior nurses, training began at the Alice Springs Hospital and ran for at least a decade. Darwin hospital did not participate. The training was exclusively on the job. The course attracted people who did not have the educational background to enrol in the Registered Nursing course, as well as some pre-registration students from Darwin hospital and the Darwin Institute of Technology (DIT), later to become the Northern Territory University (NTU) and then Charles Darwin University (CDU). There were approximately 20 students in each intake and there were two intakes each year. Eventually the numbers dwindled and the initiative struggled to survive. Between Northern Territory University began delivering a skills-based course to the staff of Council on the Ageing (COTA). This course was later extended to include the staff of the Juninga Aged Care facility. Following on from the success of this skills-based program, Frontier Services approached NTU to deliver training for their staff. Meanwhile Centralian College in Alice Springs started a range of Certificate III accredited courses suitable for people working in aged care. It also provided, intermittently, the Certificate IV in Enrolled Nursing. These were delivered with mixed success. Northern Territory University began delivering the Certificate III in Aged Care and in 1997 added the Certificate IV in Enrolled Nursing to its scope, adding a pharmacy unit to an existing accredited course from interstate. The courses were hugely popular with very successful outcomes, says Senior Lecturer Janie Mason who was one of the lecturers in the courses in the early days. At its height the Enrolled Nurse course attracted a strong non-english speaking background (NESB) cohort, some of them settled residents and others more recently arrived migrants, and there were always a couple of Indigenous students. Some of the students went on to further study in areas like social work, occupational therapy, psychology and Registered Nursing, but most just wanted to work as Enrolled Nurses some in the fields of aged care, others in acute care. Charles Darwin University continued to be the only Registered Training Organisation (RTO) delivering Enrolled Nurse training in the Northern Territory until Lecturer Beryl McEwan lectured in and coordinated the Certificate IV in Enrolled Nursing from mid 2006 until the end of 2007 and talks about her experiences in the following interview. Case Study: Capacity and Capability to Deliver Diploma of Enrolled Nursing Page 1 of 9

2 How was the course delivered in the Northern Territory? In 2007, there were approximately 170 students enrolled in the Certificate IV in Enrolled Nursing from all over Australia. The course was offered in internal and external modes. External students came to Darwin or Alice Springs to do the required clinical blocks before they could attend clinical placements. All travel and accommodation costs were the responsibility of the students. There were only a few Indigenous students and they were able to access some away from home funding. During the first block of the program, the Enrolled Nurse students did much of the course content with the Aged Care students because there was a lot of common content. There were some combined Enrolled Nurse and Registered Nurse lectures but this did not work well, mainly because of the difference in the students academic levels and expectations of the staff. Between 2006 and 2007, Enrolled Nurses completed the Northern Territory Certificate IV course. Some students completed the program in one year of full-time study, while others took two years or more to complete the course. How did you organise the work placements? Placements were centrally organised by Charles Darwin University. Students were placed near their location, where possible. At that time it wasn t hard to find placements. We usually started off with an aged care placement and by the end of the program all students had experience in acute care, paediatric and community settings such as community clinics, GP surgeries and Aboriginal health services. When the national (HLT07) health training package came online we had to replace the NT accredited course with the Certificate IV course from the new package. Some students were not able to complete their course in the teach out time we were given. We had expected to be able to give students some advance standing in the new HLT Certificate IV course, but unfortunately the old NT course did not map well to the new units of competency, so this was not possible. Why was the course so popular with external students? One of the reasons was cost. External students could access the course for the same fees as Northern Territory based students. External access was discontinued when the new course from the national health training package was introduced and the course delivery moved to the newly established VET structure. Another reason was that students liked studying from their home base, which allowed them to work at the same time. Most other Enrolled Nursing courses required regular on-campus attendance. What were some of the barriers? Case Study: Capacity and Capability to Deliver Diploma of Enrolled Nursing Page 2 of 9

3 Getting the students to stay engaged and finish the work was a struggle. Some of them had been doing the course for so long that it must have been hard for them to remain focussed. A significant number of students who had completed Another reason was that students liked the Certificate III in Aged Care had English as a studying from their home base, which second language. English language and literacy was allowed them to work at the same time. often a problem with this group of students. The gap Most other Enrolled Nursing courses between the Certificate III in Aged Care and a required regular on-campus attendance. Certificate IV in Enrolled Nursing is significant, rather like the gap between Enrolled Nurse and Registered Nurse. Many students struggled with the written work and with the change of role and responsibility in a regulated nursing role. Students who lacked English skills had communication difficulties with course work and during clinical placements. The lecturers did not have time to address the literacy gaps, or to give the students much extra time to help them develop the required level of skills. Students could access academic support offered by CDU but they had to contact the services themselves. I can t remember any of the students actually doing that. One of the other difficulties was operating the course from the same school as the Registered Nurse program. The VET course was less well resourced and always seemed to take second place. Lack of understanding and knowledge about VET processes sometimes caused problems and friction with administration and teaching staff. Nursing courses are resource intensive and the Enrolled Nurse course is no different. It s expensive to run, especially with the clinical placement component, and I don t think the VET funding received by CDU would have adequately resourced course delivery. What worked well and where did you get good outcomes? The external offering suited a lot of people. Some couldn t afford to be full-time students. Most mature age students were working, and the flexible nature of the program meant they could keep their jobs. If they didn t get through their assessments we just let them have another go at it when they were ready. We tended to be flexible with timeframes, partly because the program was so under resourced. There was little time to follow up students who had enrolled but were not actively engaged in the program. This meant that these students could take as long as they needed. This was partly because we had to focus on the ones who had a good chance of completing, so that CDU could access funding that was dependent on the number of successful completions. Case Study: Capacity and Capability to Deliver Diploma of Enrolled Nursing Page 3 of 9

4 Why did CDU not offer the Diploma course from the national health training package? At that time, in the Northern Territory, the requirement for registration to practice was Certificate IV and there was no advice from the Nursing and Midwifery Board that this was going to change in the immediate future. It would have been inappropriate only to offer the Diploma while the requirement for NT registration was at Certificate IV level. It was also agreed that CDU would start with the Certificate IV program and once it was running, we could then achieve accreditation for and deliver the Diploma course. Operating in a VET environment a new challenge After some deliberation the faculty decided to hand the enrolled nurse course over to the VET sector. In March 2008 CDU established a VET health team and the enrolled nurse course was placed with this team. The team had five academic staff and one administrative staff member. One of the academic staff members was based in Alice Springs. Campus Administrator Vicki Williams was the coordinator. In the following statements she reflects on the change from higher education to VET. How did you manage the transition from the faculty to your VET health team? The first challenge was to implement the new Certificate IV in Enrolled Nursing course from the national health training package. Our first task was to manage the teach out of the students who were still enrolled in the old qualification. We had until the end of 2008 to achieve this and finally 53 students completed and achieved the qualification. While this was going on we were developing the new program. Getting up and running included applying to the Department of Employment and Training (DET) for approval of the extension to scope for delivery of the course. This accreditation and approval process was not completed until August In October 2008 we took the first enrolments for the Certificate IV in Nursing (Enrolled/Division 2 Nursing) and delivery of the course started in that month. I believe one Aboriginal student applied but did not end up enrolling. How did you deliver the Certificate IV in Enrolled Nursing? The course was full-time and we only took internal students. The theory component of the units was delivered face-to-face at the CDU Casuarina campus. Additional to the lectures, tutorials were Case Study: Capacity and Capability to Deliver Diploma of Enrolled Nursing Page 4 of 9

5 offered every Monday, for this first term. There was limited uptake by the students. Some students sought individual assistance for particular needs throughout the course and this seemed to work well. The first cohort of students completed the course in September Eleven of the original 15 graduated. The VET health team became incorporated in to the VET community services team at the end of 2008 and I returned to my job with CDU in Katherine. What were the major hurdles during your time as team leader? The biggest hurdle to begin with and the one that had a major impact on getting good outcomes was the time it took to get our approval from DET for the extension to scope to deliver the course. For the students, juggling paid work and family commitments with full-time study was sometimes difficult. And there was extra pressure when they had to attend their clinical placements because these placements are unpaid and they were unable to work in their regular jobs during a placement. What were the major achievements in this period? We were only a small team, so getting the course up and running was a major achievement. We didn t have all the approvals until August 2008 yet we had people enrolled and beginning their study in October. And finally 11 of the original 15 students successfully complete the program. Would you like to add anything else? I still feel that requiring people to go straight in to the Diploma level course is not the best option for Northern Territory students. It is a huge leap from a Certificate III to Diploma level, and at this time there are no other pathways to help people develop their skills and knowledge to a Diploma level. In my opinion this limits access to nursing training for many people, not only in confidence to apply but also in workload and length of the course. Current state of play with CDU delivery of Enrolled Nursing courses Since the graduation of the first student cohort there has been no further delivery of the Certificate IV in Nursing (Enrolled/Division 2 Nursing) or any delivery of the Diploma of Nursing (Enrolled/Division2 Nursing). There has been some fractured activity in this area, including taking expressions of interest from prospective students, investigating a collaborative approach with Gold Coast TAFE and revisiting the course being delivered alongside Higher Education nursing courses within the Faculty of Engineering, Health, Science, and the Environment. None of this activity has translated into course delivery. Currently CDU is unable to say when and if it might consider delivery of the Diploma. Case Study: Capacity and Capability to Deliver Diploma of Enrolled Nursing Page 5 of 9

6 Henge Education a new player in the marketplace Henge Education opened its doors for business in Alice Springs in It is a locally owned, private Registered Training Organisation now operating from Darwin in the Northern Territory. Henge Education s core business is to deliver face-to-face training and education to nurses and health and community care workers from urban, regional and remote areas in the Northern Territory and Western Australia. Its scope of delivery includes Certificate III in Aged Care, Certificate III in Disability, Certificate III in Home and Community Care, Certificate III in Health Services Assistance, Certificate III in Pathology and the Diploma of Nursing (Enrolled/Division 2 Nursing). It also offers a range of accredited and non-accredited short courses. Henge began delivering the Diploma of Nursing (Enrolled/Division 2 Nursing) in July Funding to deliver the Diploma comes from a number of sources including 50% from the Productivity Places Program (PPP), 50% from private fees for services and a small amount from Commonwealth Government programs. Once the PPP funding finishes it will all have to come from fees for service. With CDU unable to determine when it might deliver this course again, Henge is the only Northern Territory based RTO delivering in this industry skills shortage area. The student cohort a picture of diversity The student cohort is drawn from the wider community. Seventy percent are mature age students who have always wanted to be nurses. They are usually juggling full-time jobs and family commitments, but are really determined to complete their studies. Within this group are students from an English as a Second Language (ESL) background, some of them refugees and some migrants. They make up 60-70% of all enrolments. 50% percent of students are doing the upgrade from the Certificate IV or other courses (such as a hospital certificate) to the Diploma. Currently there are no identified Indigenous students enrolled despite there being at least five from Alice Springs who expressed an interest. All five were interviewed and tested and subsequently accepted in to the course. They were sent information about and encouraged to apply for the Puggy Hunter scholarship, which would have covered most of their expenses. Establishing and maintaining a private Registered Training Organisation In the following interview, Jo Fox, the Director of Henge Education shares some of her experiences. Case Study: Capacity and Capability to Deliver Diploma of Enrolled Nursing Page 6 of 9

7 What were some of the challenges in starting Henge Education? Starting a Registered Training Organisation is a long and expensive process. You have to be passionate about it, or you would not be bothered with the frustration of getting it up and running. Maintaining it is also expensive. If you are delivering a nursing program there are the extra processes of meeting the requirements of the Australian Health Professionals Regulatory Agency (AHPRA) and the Australian Nursing and Midwifery Accreditation Council (ANMAC) which is the accreditation arm of AHPRA, both of them national agencies. It s more difficult now to deal with national entities, rather than a Northern Territory based agency. The response times are longer and there is a lack of understanding about local context and industry conditions. Costs associated with AHPRA processes went from no fee when it was Northern Territory based to $35,000 for accreditation. Charges associated with, for example, adding new delivery sites is an extra $10,000 for the application fee without the additional cost of site visits. When Henge applied for approval for face-to-face delivery of the Diploma in Katherine and Kununurra we were told that it would cost us approximately $20,000. This makes face-to-face delivery in regional and remote settings prohibitively expensive. However, if the mode of delivery was distance education, it would not cost us any extra, but that is not part of the Henge vision and ethos. We may be forced to reconsider this in the future if we want to expand our delivery sites. The only way we could continue to offer face-to-face in remote and regional sites is if we enter into partnerships with employers and other industry stakeholders who would be willing to support the additional costs. This would be preferable because distance education lacks the flexibility to accommodate and ensure students are consistently challenged with complex problem-solving scenarios and case studies, and have individual, face-to-face attention and tutoring. Costs associated with national registration and accreditation has skyrocketed. The Australian Skills Quality Authority (ASQA), which is responsible for registering and auditing RTOs, charges three times as much as it used to cost for a private RTO to start up. Thankfully we have just been notified that the Department of Education and Training (DET) has agreed to assist with a one-off subsidy to offset the costs of mandatory post registration audits. We have to employ RNs to deliver our training and assessment services, and Henge requires these RNs to be clinically current and competent. This is expensive because they command higher salaries, as they should. Currently we have one administrative staff member, one RN in Alice Springs and three in Darwin, including myself, all full-time. When we need them we bring in casual trainers with specific skills. Case Study: Capacity and Capability to Deliver Diploma of Enrolled Nursing Page 7 of 9

8 How does the new English skills standard affect Enrolled Nursing registration? The Nursing and Midwifery Board of Australia has introduced a new English language skills registration standard. This standard does not apply to students of nursing until they make an application for registration as a nurse or midwife. The expectation is that Enrolled Nurses will have to meet the same level of English proficiency as doctors, Registered Nurses and other health professionals who need to have a bachelor degree as a minimum requirement. To register to practice, Enrolled Nurses must provide evidence that they have completed five years of secondary education, or a combination of vocational and secondary, or vocational and tertiary or combined vocational, secondary and tertiary education, taught and assessed in an English-speaking country, for example Australia, Canada, New Zealand or Ireland. If an applicant cannot demonstrate this they will be required to demonstrate English language proficiency in accordance with Board approved English language tests. Currently this means sitting the International English language testing System (IELTS). To be successful the applicant has to achieve level 7 in all aspects of the test at the one sitting. Alternatively they can sit the Occupational English Language Testing (OET). The OET is problematic for Enrolled Nurses because the content covers occupational tasks that are outside the Enrolled Nurse scope of practice. What is it that keeps you operating in this challenging environment? All that we have discussed pales into insignificance when you The way we train, face-to-face, start doing what is important working with the students. The allows for the development of way we train, face-to-face, allows for the development of solid solid relationships and attention relationships and attention to detail. We are most concerned to detail. that the students get a solid grounding in the basics. We challenge them from the very beginning, pushing them to be curious and to ask lots of questions, which is fundamental if they are to be critical thinkers. We also allow time for reflection. And we never let them forget that the patient is their primary focus. We work with small groups so it is very hard for students to slip under the radar and we get good feedback from industry when they go for their clinical placements. I am particularly pleased that Royal Darwin Hospital (RDH) is once again employing trainee Enrolled Nurses and we have two enrolled with us. Our retention rate is pretty good. Our first intake from July 2010 is about to complete and we have only lost two from this group of 12. Case Study: Capacity and Capability to Deliver Diploma of Enrolled Nursing Page 8 of 9

9 Where the rubber hits the road a student perspective It is fitting that we give a student the final word. Sandar Tun is enrolled in the Diploma course with Henge and will complete her training program in March She is employed by RDH as a Patient Care Assistant (PCA). She intends to continue studies to become a Registered Nurse (RN). I have always been involved in caring for people so I have Everybody is supportive and really enjoyed this course. I also work as a volunteer in my patient and we are encouraged community, so my work supports my studies and my studies to ask questions at any time. support my work. One of the most enjoyable and interesting parts was the anatomy and physiology. Because of my work I am familiar with a lot of the aspects of patient care but I did not understand the things that make the body work. When we study here we learn the basics properly. Everybody is supportive and patient and we are encouraged to ask questions at any time. Because of the way we have been taught by the Henge staff I am now confident to try the RN course because I know I understand all the basics. Henge Education students 2012, Darwin, Northern Territory, Australia Front row L to R: Sherine Lauverjon, Gianna Douglas, Ajeesh Sundar, Sandar Tun. Back row L to R: Brylee McVicar, Sujeesh Sundar, Cherry Fermin, Gedeon Mabanza, Julieta Gabor. Case Study: Capacity and Capability to Deliver Diploma of Enrolled Nursing Page 9 of 9