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
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
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
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
development for the discipline of critical care nursing via mechanisms which foster high
level leadership, political participation and collaboration between nursing practice and
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
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
• 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
• 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
exposed to the critical care environment, and consequently do not choose it as an area in
which to specialise.
Nurse education and training to meet future labour force needs
The ACCCN makes the following recommendations pertaining to the education of critical
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
• 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
• 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.
• 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.
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
• 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
• 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
• 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).
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;
2) measures to increase recruitment and retention of critical care nurses in the Australian
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
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
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,
4. Evaluate the implementation of recommendations from the report of the previous
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