Nursing and Midwifery in New South Wales by NSW Nurses and Midwives' Association

Nursing

and Midwifery

in New South Wales

New South Wales Nurses and Midwivesâ&#x20AC;&#x2122; Association

From left: NSWNMA Assistant General Secretary Judith Kiejda, NSWNMA General Secretary Brett Holmes, and NSWNMA President Coral Levett.

Nursing and Midwifery in New South Wales Nurses and midwives are regulated autonomous health professionals with a multitude of responsibilities as expressed in our codes of conduct and practice. We occupy a unique role within the system, both as planners and deliverers of patient-centred care. Our professional expertise is both a science and an art. Our commitment and tenacity is the â&#x20AC;&#x2DC;glueâ&#x20AC;&#x2122; that holds the system together. The health sector is continually evolving as demand grows, new technologies and ideas emerge and supply pressures drive a continuing debate about the values that underpin decisions about what is the best way to utilise resources. We believe that the system and the community are yet to realise the advances in quality and efficiency that could be achieved if the skills and expertise of nurses and midwives were fully embraced and implemented. Progress is being made and we are optimistic about the future.

This resource has been developed to provide you with important information about the NSWNMA, what we do and who we represent and the legal and professional context of nursing and midwifery practice in NSW and Australia. We welcome your feedback on this publication for future editions. NSWNMA also has a wealth of relevant information and resources available to our members through our library. We look forward to working with you to ensure that NSW nurses and midwives continue to deliver high quality professional care.

Brett Holmes NSWNMA General Secretary

Judith Kiejda NSWNMA Assistant General Secretary

Table of Contents Nursing and Midwifery in New South Wales �� 2 The New South Wales Nurses and Midwives’ Association (NSWNMA) �� 4 Nursing and Midwifery in Australia �� 5 The Nursing and Midwifery Care Team �� 8 Nursing Practice Continuum �� 10 Scope of Practice �� 12 Nurse Practitioners �� 15 Nursing and Midwifery Models of Care �� 18 Decision-Making in Nursing and Midwifery Practice �� 21 Transitional Year New Graduate Nursing and Midwifery Programs in NSW �� 24 Regulation of Nurses and Midwives �� 26 Regulation of Nursing and Midwifery Practice �� 28 Continuing Professional Development: Frequently Asked Questions �� 30 Legal Issues for Nurses and Midwives in NSW �� 34 The Challenges Facing the Nursing and Midwifery Workforce �� 37 The Figures �� 42 Reasonable Workloads �� 45 Work Health and Safety Legislation – the New Regime �� 48 Work Health and Safety – Violence and Aggression �� 53 Care of Older People in NSW �� 55 References �� 59

Nursing and Midwifery in NSW

The New South Wales Nurses and Midwives’ Association (NSWNMA) The New South Wales Nurses and Midwives’ Association (NSWNMA) is the registered union for all nurses and midwives in New South Wales. It represents the industrial interest of nurses and midwives employed under all awards and agreements registered in this State in both the public and private sectors. Its role is to protect the interests of nurses, midwives and the nursing and midwifery professions. As well, the Association represents and provides for the professional, educational and industrial welfare of nurses and midwives in government and non-government forums at state, national and international level. The NSWNMA has approximately 57,000 members and is affiliated to Unions NSW and the Australian Council of Trade Unions (ACTU). The NSWNMA signed a “harmonisation” Agreement in 1988 with the Australian Nursing Federation and eligible members of the NSWNMA are deemed to be members of the New South Wales Branch of the Australian Nursing Federation.

Nursing and Midwifery in NSW

The New South Wales Nurses and Midwives’ Association Vision Statement The NSWNMA will be a union that provides quality representation to a growing number of active members who see the NSWNMA as the vehicle for their own empowerment. We will work to be recognised by nurses, midwives and all others as a positive contributor to a fair and just society.

Nursing and Midwifery in Australia

In Australia, nurses are licensed professionals engaged in the practice of nursing, which is the application of specific knowledge and skills to promote, support and/or enhance the health of the community. Australia has adopted the International Council of Nurses definition of nursing (2001): Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.

Nursing practice includes: c providing direct care, which encompasses assessing, planning, implementing and evaluating care; c coordinating care and supervising others; c leading and managing; c teaching clients, promoting health and providing counselling; c educating other nurses and health workers; c undertaking research; and, c developing health and nursing policy and systems of health care management.

Nursing and Midwifery in NSW

In Australia, midwives are also licensed professionals who are engaged in the practice of midwifery.

The Health Care Team

Australia has adopted the International Confederation of Midwives (ICM) definition of midwifery (raised and adopted 15 June 2011):

Nurses and midwives frequently work within a heath care team which includes other licensed health professionals such as doctors and allied health professionals, and unlicensed health workers such as assistants in nursing or midwifery.

A midwife is a person who has successfully completed a midwifery education programme that is duly recognised in the country where it is located and that is based on the ICM Essential Compe tencies for Basic Midwifery Practice and the framework of the ICM Global Standards for Midwifery Education; who has acquired the requisite qualifications to be registered and/ or legally licensed to practice midwifery and use the title ‘midwife’; and who demonstrates competency in the practice of midwifery.

The health care team works collaboratively to meet the needs of the client who is central to the team’s activities. Clients are individuals, groups or communities who receive health care. They include patients and consumers, as well as their families or representatives. Value and respect for the contribution of each member of the team generates the most

Midwife practice includes: c working in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period; c conducting births on the midwife’s own responsibility; c providing care for the newborn and infant; c promoting normal birth, preventative measures, detecting complications in mother and child, accessing medical care or other appropriate assistance and carrying out emergency measures; c health counselling and education, not only for the woman, within the family and the community. This work involves antenatal education and preparation for parenthood, and may extend to women’s health, sexual or reproductive health and child care; and, c settings within the home, community, hospitals, clinics or health units.

Nurses and midwives in Australia work both independently and as members of a health care team providing professional and holistic care in a range of situations. They work in a wide variety of settings which include hospitals, rural and remote nursing posts, Indigenous communities, schools, prisons, aged care homes, the armed forces, universities, TAFE colleges, mental health facilities, detention centres, community health centres, statutory authorities, general practice offices, businesses, professional organisations, local communities and people’s homes.

Nursing and Midwifery in NSW

effective operation of the team and achieves the best outcomes for clients. The role of the nurse or midwife as clinician within this health care team incorporates the roles of manager, teacher, researcher, policy maker and consultant. As such, the nurse or midwife is integral to the effective delivery of health services. The complexity of the nurse or midwife’s role is influenced by the context within which the nurse or midwife practices.

Nursing and Midwifery in NSW

The Nursing and Midwifery Care Team Nursing care is provided by registered nurses (RNs) and enrolled nurses (ENs). Assistants in nursing (AiNs) assist in the provision of nursing care. Together, registered nurses, enrolled nurses and assistants in nursing comprise the nursing team. Nurse practitioners (NPs) are registered nurses, who are educated and endorsed to provide advanced nursing care. A registered nurse (RN) in NSW is a person with appropriate educational preparation, an approved three-year bachelor degree or equivalent, and competence for practice, who is registered and licensed under the Health Practitioner Regulation National Law (NSW) Act, 2009. An enrolled nurse (EN) in NSW is a person with appropriate educational preparation, an approved vocational education program of at least one yearâ&#x20AC;&#x2122;s duration, and competence for practice, who is enrolled and licensed under the Health Practitioner Regulation National Law (NSW) Act, 2009. The EN is an associate of the RN, practicing with the support and professional supervision of the RN. Under the National Law, registration as an enrolled nurse means that the EN is able to administer medications in accordance with the relevant state poisons legislation. An EN who is not qualified to undertake this practice, i.e. has not completed a Board approved qualification, has a notation on their registration stating that they are not qualified to undertake medication administration. An assistant in nursing (AiN) or nursing assistant is a nursing support worker. This role delivers aspects of nursing care

Nursing and Midwifery in NSW

and provides assistance to registered and enrolled nurses. AiNs are not regulated and do not yet have a consistent minimum standard of education for entry to practice. Nationally standardised qualifications to prepare AiNs for work in both the acute and aged care sectors are available but are not yet mandatory for entry to practice as an AiN (NSW Department of Health, Workforce Development and Innovation Branch, 2009). The Ministry of Health recommends that these national qualifications become mandated for entry to AiN practice as they provide an entry level towards a nursing career pathway. A nurse practitioner (NP) in NSW is a person with appropriate educational preparation, an approved masters degree or equivalent, and appropriate clinical experience, who is endorsed under the Health Practitioner Regulation National Law (NSW) Act, 2009.

Roles within the nursing team Registered nurses plan, implement and evaluate nursing care and are responsible for initial and ongoing assessment of nursing care needs and delegations of nursing activities to other members of the team as appropriate. RNs initiate health care and coordinate the care prescribed and/or provided by other health workers. Enrolled nurses contribute to planning and implementing nursing care and provide information to assist in clinical decision-making and the provision of nursing care. ENsâ&#x20AC;&#x2122; core

responsibilities include recognising normal and abnormal through assessment processes and carrying out delegated interventions. ENs monitor the impact of care by evaluating an individual’s health and functional status in collaboration with the RN. Assistants in nursing/nursing assistants assist in the provision of aspects of nursing care, working within a plan of care under the supervision and direction of the RN. AiNs’ role relationship with licensed nurses will vary according to the context. Registered nurses are responsible for the overall management of nursing care and for delegating appropriately to ENs and AiNs within the respective frameworks of those workers’ knowledge, skill, education and the practice context. At all times ENs and AiNs retain responsibility for their own actions and remain accountable to the RN for all delegated functions. Nurse practitioners function autonomously and collaboratively in an advanced and extended clinical role. The NP role includes

assessment and management of clients using nursing knowledge and skills and may include but is not limited to the direct referral of patients to other health care professionals, prescribing medications and ordering diagnostic investigations within their scope of practice.

The midwifery team A registered Midwife (RM) in NSW is a person with appropriate educational preparation, an approved three-year bachelor degree in midwifery or graduate diploma plus a nursing degree, and competence to practice, who is registered to practice under the Health Practitioner Regulation National Law (NSW) Act, 2009. Registered midwives work in partnership with women to give the necessary support, care and advice during pregnancy, labour and the post partum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.

Nursing and Midwifery in NSW

Nursing Practice Continuum Nursing practice occurs along a continuum from beginning to advanced practice, and across areas from generalist to specialist practice. All professional licensed nurses, regardless of their level of education, qualifications, experience and setting, and from entry to practice as a new graduate or at the peak of the clinical pathway as a nurse practitioner, are engaged in the practice of nursing.

Beginning practice Beginning practitioners are prepared for entry to practice as safe, competent and ethical practitioners on completion of their initial education programs, which must be approved by the Nursing and Midwifery Board of Australia (NMBA). These programs, which prepare individuals for registration as a nurse or endorsement as a nurse practitioner must ensure that graduates are able to demonstrate achievement of the national competency standards required for registration as a nurse or endorsement as a nurse practitioner. The national competency standards outline the knowledge, skills, judgement, values and attributes required by the RN, RM, EN or NP

to practice safely on entry to practice1. They are used to assess whether a nurseâ&#x20AC;&#x2122;s performance is sufficient to obtain, and retain, a licence to practice in Australia and form the basis for nurses and midwives to assess their own competence. As well as using the standards for annual renewal process, the NMBA accesses the competence and perfomance of nurses and midwives educated overseas as well as nurses returning to the workforce after a break in service. In NSW they are also used by the Nursing and Midwifery Council to assess nurses involved in professional conduct matters. The national core competency standards are the basis on which nurses and midwives build their practice and integrate their experience and knowledge to move along the continuum from novice as a beginning practitioner to expert as an advanced practitioner.

1 National Competency Standards for the Enrolled Nurse, available online at: www.nursingmidwiferyboard.gov.au/CodesGuidelines-Statements/Codes-Guidelines.aspx National Competency Standards for the Registered Nurse, available online at: www.nursingmidwiferyboard.gov.au/CodesGuidelines-Statements/Codes-Guidelines.aspx National Competency Standards for the Registered Midwife, available online at: www.nursingmidwiferyboard.gov.au/CodesGuidelines-Statements/Codes-Guidelines.aspx National Competency Standards for the Nurse Practitioner, available online at: www.nursingmidwiferyboard.gov.au/CodesGuidelines-Statements/Codes-Guidelines.aspx

Nursing and Midwifery in NSW

Beginning practitioners include all nurses on entry to practice; that is, both newly graduated nurses and more experienced nurses who are starting practice in a specialist or new field.

Advanced practice Advanced practice by registered nurses is characterised by greater and increasing complexity, where the nurse demonstrates more effective integration of theory, practice and experience accompanied by increasing degrees of autonomy in professional judgements and interventions. It is enabled by education, experience and competence development. Advanced enrolled nurse practice is also characterised by greater and increasing complexity within the framework of the enrolled nurseâ&#x20AC;&#x2122;s knowledge and skills. It is context specific and is enabled by experience, further education and delegation from a registered nurse and/or authorisation by the NMBA or employer.

Areas of practice Initial nursing education prepares registered and enrolled nurses for generalist practice, which encompasses a comprehensive spectrum of nursing activities. It is directed towards the diversity of the community and the varying health needs of individuals. It takes place in a wide range of health care settings and is reflective of a broad range of knowledge, experience and skills. Although generalist practice is the practice for which nurses are initially educated,

it may occur at any point on a continuum from beginning to expert practice. Specialist practice is a focus on one field of nursing practice or health care that encompasses a level of knowledge and skill in a particular aspect of nursing greater than that acquired during initial nursing education. It builds on the base of generalist preparation and is directed towards a defined population or defined area of activity. Specialist practice may also occur at any point on a continuum from beginning to expert practice. Many specialty nursing groups have developed competency standards to guide the practice of qualified practitioners in specialist areas. Unlike the national competency standards for RN, EN and NP, the status and authority of these guidelines and standards are uncertain. Prior to 1 July 2010, states and territories employed a range of legislative and regulatory approaches to specialist practice. This resulted in inconsistency in the nursing specialties that are regulated and in the mechanisms that were used to do this. The NMBA has determined that the national registration scheme will not include a specific provision for specialist areas of practice to be recognised in the national scheme.

Nursing and Midwifery in NSW

Scope of Practice In the simplest terms, scope of practice in the health care context means what health care workers actually do in the course of their employment. Nursing’s scope of practice therefore encompasses all of the nursing and health care activities undertaken by all nurses in the full range of environments in which nurses work. Elements of nursing’s practice are shared with other health professionals. This creates links which enhance mutual understanding of roles and facilitate the delivery of quality multidisciplinary health care. Nursing and nurses are responsible for articulating and disseminating clear definitions of nurses’ roles and the profession’s scope of practice to governments and other employers, and the community.

Nurses’ scope of practice The profession of nursing has a single scope of practice, which encompasses the full range of nursing activities. An individual nurse’s scope of practice refers to the activities which that nurse is educated and authorised to perform. The depth and breadth of an individual nurse’s engagement in the profession’s total scope of practice is dependent on their educational preparation, experience, role and the context of their practice. The national competency standards for registered nurses, enrolled nurses and nurse practitioners outline the knowledge, skills, judgement, values and attributes required by

Nursing and Midwifery in NSW

the RN, EN or NP on entry to practice1. These standards form the minimum core for nurses’ commencing scope of practice and are the basis on which nurses build their practice and expand their scope of practice. As licensed professionals, registered and enrolled nurses are expected to be able to assess and articulate their own competence and scope of practice.

Midwives’ scope of practice The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.

1 National Competency Standards for the Enrolled Nurse, available online at: www.nursingmidwiferyboard.gov.au/CodesGuidelines-Statements/Codes-Guidelines.aspx National Competency Standards for the Registered Nurse, available online at: www.nursingmidwiferyboard.gov.au/CodesGuidelines-Statements/Codes-Guidelines.aspx National Competency Standards for the Nurse Practitioner, available online at: www.nursingmidwiferyboard.gov.au/CodesGuidelines-Statements/Codes-Guidelines.aspx

The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to womenâ&#x20AC;&#x2122;s health, sexual or reproductive health and child care. A midwife may practice in any setting including the home, community, hospitals, clinics or health units.

Defining nurses and midwivesâ&#x20AC;&#x2122; scope of practice The role of the nurse and midwife is constantly changing and developing in response to the health needs of the population, advancements in nursing and midwifery knowledge and changes in the health care system. This means that nurses and midwives must continuously update their practice through the incorporation of new knowledge and skills for the benefit of clients. This also means that nursing and midwifery practice cannot be defined as a static list of tasks or procedures, which would be almost continuously out of date, but must be defined in such a way that allows for developments in practice. In recognition of this and reflecting an international trend, the professions have worked to develop a definition of scope of practice for nursing and midwifery that is broad and principle-based, so that nurses and midwives in any setting may reflect on and develop their own scope of practice as required. The nationally agreed and accepted definition of nurses and midwivesâ&#x20AC;&#x2122; scope of practice encompasses the scope of the profession and the individual.

Nursing and Midwifery in NSW

Scope of practice of a profession A profession’s scope of practice is the full spectrum of roles, functions, responsibilities, activities and decision-making capacity that individuals within that profession are educated, competent and authorised to perform. Some functions within the scope of practice of any profession may be shared with other professions or other individuals or groups. The scope of practice of all health professions is influenced by the wider environment, the specific setting, legislation, policy, education, standards and the health needs of the population.

Scope of practice of an individual The scope of practice of an individual is that which the individual is educated, authorised and competent to perform. The scope of practice of an individual nurse or midwife may be more specifically defined than the scope of practice of their profession. To practice within the full scope of practice of the profession may require individuals to update or increase their knowledge, skills or competence.

Decisions about both the individual’s and the profession’s practice can be guided by the use of decision-making tools. When making these decisions, nurses and midwives need to consider their individual and their respective profession’s scope of practice2. The actual scope of an individual nurse or midwife’s practice is influenced by the: c context in which they practice; c clients’ or women’s health needs; c level of competence, education and qualifications of the individual nurse or midwife; and, c service providers’ policies. As nurses and midwives develop expertise in their areas of practice, they must necessarily expand their scope of practice. National frameworks to support nurses and midwives to expand their scope of practice by incorporating new developments into their practice in a planned and structured way have been developed3.

2 ANMC, 2007, A national framework for the development of decision-making tools for nursing and midwifery practice, Available online at: www.nursingmidwiferyboard.gov.au/CodesGuidelines-Statements/Codes-Guidelines.aspx 3 Ibidem

Nursing and Midwifery in NSW

Nurse Practitioners

Nurse practitioners (NP) sit at the apex of the clinical nursing career path. They are registered nurses who have received the endorsement of the Nursing and Midwifery Board of Australia (the Board) to practice at an advanced level.

workforce has been disappointing; however the 2010 legislative breakthrough that enables eligible NPs and midwives to access Medicare and the Pharmaceutical Benefits Scheme represents the removal of a key structural barrier to wider implementation of the role.

The NP role has formally existed in the United States since the 1960s and there are now an estimated 135,000 NPs providing primary, acute and speciality health care in the US (Collins, 2010). The role has been slower to develop in Australia, largely due to powerful vested professional interests in the health sector.

Despite the rocky start, the NP role is continuing to develop in Australia. It has been promoted by the Productivity Commission and Health Workforce Australia as an important part of our response to rising health costs and demand for care (National Nursing & Nursing Education Taskforce, 2006). Crucially, the role is also being embraced by consumers.

The first Australian NPs were authorised in NSW in 2000 and there are now over 400 NPs practicing in a range of settings across Australia (The rise and rise of nurse practitioners, 2009; Report on the Evaluation of the Nurse Practitioner Role in NSW, 2009). The rate of growth for the NP

The safety and efficacy of the NP role has been widely researched and evaluated domestically and internationally. This growing body of knowledge demonstrates consistently that the NP role is safe, improves access and is cost-effective.

Nursing and Midwifery in NSW

Definition The Board has adopted the following definition: Nurse practitioner means a nurse whose registration has been endorsed by the Board as a nurse practitioner under section 95 of the National Law. A nurse practitioner is a registered nurse who is educated and endorsed to function autonomously and collaboratively in an advanced and extended clinical role. The nurse practitioner role includes assessment and management using nursing knowledge and skills. The role may include, but is not limited to, the direct referral of patients to other health care professionals, prescribing medications and ordering diagnostic investigations. The role is grounded in the nursing professionâ&#x20AC;&#x2122;s values, knowledge, theories and practice, and provides innovative and flexible health care delivery that complements other health care providers (National Competency Standards for the Nursing Practitioner, ANMC 2006, in Nursing and Midwifery Board of Australia. Endorsement as a nurse practitioner registration standard, 2011).

National Competency Standards The National competency standards for nurse practitioners have been constructed using the core competency standards for registered nurses and midwives as a basis. To this have been added advanced nursing practice competencies deemed appropriate by nurse practitioners in a variety of settings. These national competency nurse practitioner standards are used by the nurse practitioner to assess their own practice, to assess competence in the annual renewal license process, and to assess nurse practitioners educated overseas seeking to work in Australia. The Board has approved three national competency standards for NPs and these standards are underpinned by nine competencies.

Nursing and Midwifery in NSW

STANDARD 1 Dynamic practice that incorporates application of high level knowledge and skills in extended practice across stable, unpredictable and complex situations:

Competency 1.1

Conducts advanced, comprehensive and holistic health assessment relevant to a specialist field of nursing practice

Competency 1.2

Demonstrates a high level of confidence and clinical proficiency in carrying out a range of procedures, treatments and interventions that are evidence based and informed by specialist knowledge

Competency 1.3

Has the capacity to use the knowledge and skills of extended practice competencies in complex and unfamiliar environments

Competency 1.4

Demonstrates skills in accessing established and evolving knowledge in clinical and social sciences, and the application of this knowledge to patient care and the education of others

STANDARD 2 Professional efficacy whereby practice is structured in a nursing model and enhanced by autonomy and accountability:

Competency 2.1

Applies extended practice competencies within a nursing model of practice

Competency 2.2

Establishes therapeutic links with the patient/ client/community that recognise and respect cultural identity and lifestyle choices

Competency 2.3

Is proactive in conducting clinical service that is enhanced and extended by autonomous and accountable practice

STANDARD 3 Clinical leadership that influences and progresses clinical care, policy and collaboration through all levels of health service:

Competency 3.1

Engages in and leads clinical collaboration that optimise outcomes for patients/clients/ communities

Competency 3.2

Engages in and leads informed critique and influence at the systems level of health care

Endorsement To be eligible for endorsement as an NP, an RN must be able to demonstrate all of the following: 1. General registration as a nurse with no conditions on registration relating to unsatisfactory professional performance or unprofessional conduct. 2. The equivalent of three years’ full-time experience in an advanced practice role within the previous six years. Advanced practice defines a level of nursing practice that utilises extended and expanded skills, experience and knowledge in the assessment, planning, implementation, diagnosis and evaluation of care required. Nurses practicing at this level are educationally prepared at postgraduate level and may work in a specialist or generalist capacity. However, the basis of advanced practice is the high degree of knowledge, skill and experience applied in the nurse-patient/client relationship to achieve optimal outcomes through critical analysis, problem solving and accurate decision-making (Nursing and Midwifery Board of Australia. Endorsement as a nurse practitioner registration standard, 2011).

3. A Board-approved NP qualification at Masters level or education equivalence as determined by the Board. This education requirement can be met through two pathways. Pathway 1 is through successful completion of a Australian Nursing and Midwifery Accreditation Council (ANMAC) accredited and Board approved nurse practitioner program at Masters level. Pathway 2 involves successful completion of a Masters program in an area relevant to the applicant’s context of advanced practice and successful completion of supplementary education to meet the National Competency Standards for the Nurse Practitioner (ANMC, 2006; Nursing and Midwifery Board of Australia. Endorsement as a nurse practitioner registration standard, 2011; Nursing and Midwifery Board of Australia. Endorsement as a nurse practitioner – guidance for submitting portfolio (Pathway 1 & 2) (April 2012)). NPs must make an annual statutory declaration that they have met the Board’s requirements for ongoing registration and endorsement. A particular requirement for NPs over and above that required for general registration include an additional 10 hours of continuing professional development (CPD) on top of the 20 hours required for general registration. This CPD must be relevant to the NP’s context of practice and cover medicines prescribing and administration, diagnostic investigations, consultation and referral.

Nursing and Midwifery in NSW

Nursing and Midwifery Models of Care

Broadly speaking and for the purposes of this document, the term â&#x20AC;&#x2DC;model of careâ&#x20AC;&#x2122; is used to describe how care is organised and delivered. For the most part in NSW, care has been organised around an acute-care medical model. This has resulted in a system that is expensive, hospitalcentric and which fails to realise the efficiencies associated with a highly educated and effectively deployed nursing and midwifery workforce. There is no greater expression of the problems associated with excessive emphasis on medical models than the situation in maternity services.

Nursing and Midwifery in NSW

Midwives are experts in the provision of primary care during pregnancy and birthing and there is a robust body of evidence that demonstrates the health benefits of continuity of care by midwives (McLachlan et al., 2012). The medicalisation of the birth process is an obvious example of why models of care must be critically evaluated in terms of quality, safety and efficiency (Stigall, 2010). When we consider the potentially massive budget savings that would occur if the level of medical intrusion into Australian pregnancies and births was more appropriate, it is clear there is a very strong case for the implementation of midwifery models of care.

Similarly, the primary health care sector has been dominated by a medical model of care that situates the General Practitioner at the centre of care delivery, with a fee for service funding model. This approach has led to a range of inefficiencies, serious gaps in service provision and unacceptable inequity of access (Keleher, 2001). Nurses and midwives already work in a range of primary care settings but in recent years there has been growing recognition of the untapped potential of nursing and midwifery models of care in improving population health outcomes and access to primary health care (Keleher, 2001). Implementation of nursing and midwifery models of care has the potential to vastly improve quality, access and efficiency in the health sector: The needs of the person, rather than the needs of the professional, dictate what type of health care professional is required to lead the health care team and to coordinate overlapping aspects of care. Transdisciplinary care allows for appropriate use and focus of the expertise of a mix of health care professionals. Primary health care models of care go beyond multidisciplinary and interprofessional collaboration, allowing for greater efficiency of primary health care provision. Where interdisciplinary care involves only the collaboration of multiple disciplines in the assessment and treatment process, transdisciplinary care encompasses the flexibility of role extensions between health care team professionals through crossdisciplinary education. The transdisciplinary

approach helps to break down the barriers between professions (Primary Health Care in Australia: A nursing and midwifery consensus view (April 2009) on Australian Nursing Federation (ANF) www.anf.org.au). While the general medical practice model of care is and should remain a vital feature of the Australian primary health care sector, NSWNMA rejects the notion that GPs should act as the gatekeeper to the broader health system. Instead, we believe that the implementation of nursing and midwifery models of care will enable individuals and communities to have access to low cost, comprehensive primary health care by effectively deploying the skills, knowledge and experience of nurses and midwives.

... In recent years there has been growing recognition of the untapped potential of nursing and midwifery models of care in improving population health outcomes and access to primary health care. The shift from patient allocation to a team nursing model of care is a transition that many nurses and midwives in NSW in the acute care sector will become increasingly familiar with. This transition is undoubtedly being driven by cost considerations and changes in nursing skill mix, with the introduction of more AiN

Nursing and Midwifery in NSW

positions and a wider scope of practice for ENs (Chaboyer et al., 2008). When considering such shifts in models of care, safety and quality must remain our highest priority. Duffield, Roche, Blay & Stasa (2010) address ‘churn’ as being what happens to the workload when patients move from nursing wards. Moreover, Duffield states that when admissions from Emergency Departments (ED) occur, this increases patient movement to and from wards. Therefore as workloads intensify, patient activity increases, resulting in ‘churn’. Nurses and midwives must remain focused on delivering the essentials of care, including attending to hygiene, nutrition and skin integrity. If we fail in providing essential care, then we also risk surrendering these parts of our roles to new categories of workers, typically unlicensed carers such as care service employees and assistants in nursing.

Quality is the key factor that will determine how we are able to progress and evolve as professionals. We must not be afraid to acknowledge problems and we must be proactive in seeking solutions. We need to make an important decision – do we continue to maintain our role and control of these areas of care provision while at the same time developing the advanced, highly technical roles that are increasingly demanded by the system?

Nursing and Midwifery in NSW

The landmark study of nursing in NSW hospitals, Glueing it Together (Duffield, 2007, in Nursing and Midwifery Office, NSW Health), identifies that there is no one model of care and that nurses are adapting their approach in order to operate within resource limitations. In most circumstances the patient allocation primary nurse model is not consistent with the workplace reality. As health reform continues throughout Australia, the compelling reality is that patient allocation is no longer viable and the adoption of a team approach to the provision of care is required (Primary Health Care Reform in Australia, 2009). The challenge has become providing every beginning practitioner or student with the skills and capacity to provide holistic care. This transition demands that registered nurses and midwives accept and appreciate that inter and intra team communication, delegation, supervision, teaching and skill sharing are vital aspects of our roles. They are not, as some may believe, merely extra burdens. The Australian health sector has embarked on a major period of reform. Much work is ongoing to develop new and innovative models of care. NSW nurses and midwives have what it takes to not only confront these challenges, but also to flourish in new, expanded roles. This optimism is predicated on our belief in our capacity to provide high quality care. Quality is the key factor that will determine how we are able to progress and evolve as professionals. We must not be afraid to acknowledge problems and we must be proactive in seeking solutions.

Decision-Making in Nursing and Midwifery Practice Contemporary nursing and midwifery practice requires nurses and midwives to be involved in complex decision-making in a range of environments for a variety of purposes. The decisions that nurses and midwives make in their daily practice include those related to: clinical interventions and their effectiveness; unit/ facility policies and protocols; communication; role relationships among health personnel; delegation among nurses and midwives, and to other health care providers; expansions to scopes of practice; safe staffing levels; and, service organisation, delivery and management.

Clinical decision-making

The guiding principle for all decision-making in nursing and midwifery, irrespective of its nature and purpose, is to achieve the best health outcomes for patients, clients, the women and babies we care for.

Nurses and midwives make these decisions frequently each day while planning and delivering care by using the complex knowledge and skills they have gained through education and experience.

Decision-making models and frameworks

To maximise the effectiveness and appropriateness of clinical decisions which ensure the safety of all patients, clinical guidelines and toolkits, facility policies and protocols, best practice resources and other research evidence have been developed to support nurses and midwivesâ&#x20AC;&#x2122; clinical decisionmaking processes1.

As nursing and midwifery practice occurs in increasingly complex and diverse environments where nurses and midwives are accountable for their actions and the outcomes of the decisions that they make, models and frameworks which support nurses and midwives to make the most appropriate decisions in their practice have been developed. These range from accessible evidence databases to decision-making frameworks developed by regulatory authorities.

Clinical decisions made by nurses and midwives commonly relate to choosing and implementing nursing and midwifery interventions, evaluating their effectiveness and communication related to interventions to patients, families and colleagues. Effective clinical decisions which result in health care improvements for patients or women are the product of complex decision-making processes that take account of available evidence, the context of care and available resources, patient/ client preference and clinical expertise.

1 Clinical Excellence Commission, 2009, Resources, Tools and Toolkits, available online at: www.cec.health.nsw.gov.au/resources.html The Joanna Briggs Institute, 2009, Evidenced Based Nursing, available online at: www.joannabriggs.edu.au/about/eb_nursing.php

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Practice decision-making Current practice requires nurses and midwives to make decisions about delegation and advancement or expansion of scopes of practice in a context of increasing patient acuity and complexity of care needs, a growing volume of patients/clients/women with a diversity of casemix, and greater consumer expectations and demand for accountability. To assist nurses and midwives in making these decisions, national frameworks, have been developed to provide nurses and midwives with tools to guide their practice decisions so that quality and safety are maintained. The decisionmaking tools are principle based so they will be sustainable over time. The principles are intended to provide guidance for all nurses and midwives in professional decision-making while accommodating differences in the education and

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competence of the individual and the context in which they practice2. The frameworks and tools support nurses and midwives to incorporate new developments into their practice in a planned and structured way, taking account of the factors which influence nurses and midwivesâ&#x20AC;&#x2122; scope of practice. The frameworks also give nurses and midwives a mechanism that can be used to influence health workforce planning by providing a unified and coherent way to describe nursing and midwifery practice and dismantle the barriers to expanding scopes of practice. They 2 ANMC, 2007, A national framework for the development of decision-making tools for nursing and midwifery practice, Available online at: www.nursingmidwiferyboard.gov.au/CodesGuidelines-Statements/Codes-Guidelines.aspx

assist nurses and midwives to determine their own practice according to professionally agreed principles and escape unnecessary restrictions imposed by employers.

Staffing decision-making Contemporary nursing and midwifery practice takes place in an environment of increasing budgetary pressures which seek to ensure that care is delivered in the most cost-effective manner. Attempts to contain costs have resulted in reductions in the proportion of qualified nurses and midwives in the health system, which has the potential to compromise patient/client/women’s outcomes. To ensure patient/client/women’s safety and improve outcomes, adequate nurse and midwife staffing and appropriate skill mixes are required. Nurse and midwife staffing decisions based on evidence-informed principles, which ensure that the right number of appropriately qualified nurses and midwives is available to ensure safe and competent care, lead to the best outcomes for patients and clients. Evidence-informed principles for staffing decisions consider: c the health care needs of the patients/ clients/ women; c the acuity of the patients, the complexity of their specific health care needs and the predictability of the outcomes to the care provided; and, c the competence of the nurses and midwives which must take account of the individual nurse or midwife’s education, scope of practice (which is determined by education, experience, legislative and organisational factors) and familiarity with the setting.

Tools and classification systems which assist in measuring nursing and midwifery workload, patient acuity and patient/client/woman demand for nursing and midwifery care, provide nurses and midwives with empirical evidence to support nurse and midwife staffing decisions. However, these tools and systems are in various stages of development and are subject to managerial, political and budgetary influence. As such, they may result in inconsistent outcomes. Nurse-to-patient ratios or BirthRate Plus© provide a transparent mechanism which ensures minimum nurse or midwife numbers based on hospital classification, ward specialty and patient numbers. Nurse-to-patient ratios or BirthRate Plus© are strongly supported by nurses and midwives in all areas where they have been implemented.

All decisions made by nurses and midwives must be: c lawful; c appropriate for the context; c consistent with agreed professional nursing and midwifery standards; c consistent with the service provider’s policies; and, c intended to lead to better health out comes for patients/clients/women.

Other factors that are taken into consideration include: work intensity; physical layout of the unit; and, availability of adequate support staff.

Nursing and Midwifery in NSW

Transitional Year New Graduate Nursing and Midwifery Programs in NSW

Why are transitional year programs important? In 1984, the decision was made to transfer hospital-based training into the tertiary sector (Russell, 2005). Concerns were raised about graduates transitioning into clinical

Nursing and Midwifery in NSW

practice, hence the need for programs to bridge the theory-practice gap (Levett-Jones & Fitzgerald, 2006). Greenwood (2000, cited in Levett-Jones & Fitzgerald, 2006) believes the first three to six months is crucial in ensuring professional adjustment and for developing career commitment to the profession. Heath et al., (2002) reinforce that successful transition

programs encourage new nurses to stay in the workforce, as well as ensuring that the communityâ&#x20AC;&#x2122;s investment in the education and training of nurses is maximised. The general aim of the transitional year program is to provide a supported transition period of six to12 months. Graduates usually rotate through different specialities/wards to give them opportunities to implement their skills effectively and safely whilst gaining confidence as new practitioners in the clinical setting. The NSWNMA supports new graduate programs for its members. Programs such as these should aim to provide mentorship for the beginning practitioner in a supportive environment with the goal of developing and retaining a competent, skilled and safe clinician.

About transitional year programs in NSW Each year NSW Health employs the majority of graduating registered nurses/midwives through a statewide transitional year or new graduate program, available in metropolitan and rural Local Health Districts (LHDs). The program is also run in conjunction with some participating private hospitals and aged care providers. Every year, graduating nurses and midwives apply via a centralised, online application process. New graduate transitional year coordinators usually facilitate and oversee programs within LHDs. The Nursing and Midwifery Office (NaMO) provides some funding to hospitals and LHDs to conduct and run transitional programs. Gaining a place can be competitive and there is a possibility not all graduates who apply will gain employment into the program. Graduates are asked to nominate eight preferences, with their first preference forwarded to that hospital. The Hospital or LHD then contacts the applicant for an interview (Graduate Registered Nurse and Registered Midwife Transition Recruitment, 2013, in NSW Government of Health, Nursing and Midwivery Office).

Many graduates seek to apply for the NSW Health transitional year as they feel it provides for a more supported approach, enabling them to build confidence when beginning practice as a first year registered nurse or midwife. Beginning practitioners who do not secure a place in that program are left to seek employment as first year nurses in other areas, such as private hospitals, aged care and the disability sector. Once employed, it is no longer possible to gain access to graduate placement. Due to the NSWNMA successfully negotiating nurse to patient ratios in the public system (Ratios get a big tick, Nurse Uncut Australia, 2012), there was an increase in 2012 in the number of new graduates employed under the program in NSW.

Transitional year program placements There are a variety of programs on offer to graduates. These include placements in metropolitan, rural and remote areas as well as in paediatrics, Justice Health, community health and mental health, along with specific programs for midwifery graduates. Rural LHDs offer new graduates a chance to experience the country lifestyle whilst developing their skills. In addition to the transitional year program in the public system, some larger private hospitals and nursing homes have started conducting their own independent new graduate programs. Some examples are private hospitals from Healthscope, hospitals such as Prince of Wales Private Hospital in eastern Sydney, Newcastle Private Hospital and Nepean Private Hospital in western Sydney (Graduate-friendly hospitals. My Career, 2008). Examples of nursing homes are those run by Bupa, including Mosman, North Rocks and Waverley in the Sydney metropolitan area and in areas such as Armidale and Kempsey in rural NSW (Bupa. Our Care Homes, 2012).

Nursing and Midwifery in NSW

Regulation of Nurses and Midwives Nursing and midwifery in Australia is a regulated profession. By law, before nurses or midwives are able to practice, they must be registered or endorsed by the national regulatory authority, the Nursing and Midwifery Board of Australia. The mechanisms for this regulation are currently established by a national law and state and territory adopting legislation as tabled below: National

Health Practitioner Regulation (Adoption of a National Law) Act, 2009

ACT

Health Practitioner Regulation National Law (ACT) Act, 2010

NSW

Health Practitioner Regulation National Law (NSW) Act, 2009

Health Practitioner Regulation (National Uniform Legislation) Act, 2010

QLD

Health Practitioner Regulation National Law Act, 2009

Health Practitioner Regulation National Law (South Australia) Act, 2010

TAS

Health Practitioner Regulation National Law (Tasmania) Act, 2010

VIC

Health Practitioner National Law (Victoria) Act, 2009

Health Practitioner Regulation National Law (WA) Act, 2010

These laws, which commenced on 1 July 2010, form the legislative framework for the National Registration and Accreditation Scheme and outline the regulation of 14 health professions in Australia by nationally consistent legislation.

The purpose of the regulation of health professionals is to protect the safety of the public, which is entitled to receive quality care from legally qualified health professionals across the country. The public also has a right to know the position and qualifications and the standards of practice they can expect from those providing their care.

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Regulation of nurses achieves this by protection of the titles: c nurse; c registered nurse; c registered midwife; c enrolled nurse; and, c nurse practitioner.

This ensures that only those individuals who have undergone appropriate education and are able to demonstrate achievement of the national core competency standards of the particular role can be registered or enrolled as a nurse or midwife, or endorsed as a nurse practitioner.

Regulation of nurses and midwives in NSW The NSW Government has implemented a coregulatory model for the regulation of registered health professionals employed in NSW by adopting the parts of the National Law which deal with registration and accreditation and maintaining and revising NSW legislation for complaints handling. In the NSW law, the Health Practitioner Regulation National Law (NSW) Act, 2009 amends the National Law to provide for a Health Professional Councilâ&#x20AC;&#x2122;s Authority that includes individual Councils for each of the health professions in NSW. The Nursing and Midwifery Council is responsible for dealing with complaints about the conduct, professional performance and competence of any nurse or midwife employed in NSW. Other matters relating to a nurse and midwifeâ&#x20AC;&#x2122;s registration are dealt with by the Nursing and Midwifery Board of Australia (NMBA), the national regulatory authority for nurses.

Nursing and Midwifery in NSW

Regulation of Nursing and Midwifery Practice Regulation of the practice of nursing and midwifery in Australia is a shared responsibiÂlity. The national regulatory authority, the Nursing and Midwifery Board of Australia (NMBA), is accountable for public protection by ensuring that licensed nurses and midwives are safe, competent and ethical practitioners by determining standards for education and practice. Individual nurses and midwives are accountable for ensuring that they meet these standards and practice within the regulatory framework established by state, territory and federal legislation and other non-statutory mechanisms.

National Decision Making Framework for Nurses

Although legislation in Australia provides for the protection of nursing and midwifery titles, which include nurse, registered nurse, registered midwife, enrolled nurse and nurse practitioner, it does not specifically define or protect every aspect of the practice of nursing or midwifery.

Continuing Professional Development Registration Standard

Instead, a set of nationally agreed codes, standards, frameworks and guidelines provides the professional practice framework which governs the practice of nursing. The framework contains the following elements developed prior to 1 July 2010. For nurses: National Competency Standards for Registered Nurses, Enrolled Nurses and Nurse Practitioners Codes of Professional Conduct for Nurses in Australia Codes of Ethics for Nurses in Australia A Nurseâ&#x20AC;&#x2122;s Guide to Professional Boundaries

Nursing and Midwifery in NSW

National Framework for the Accreditation of Nursing and Midwivery Courses For midwives: National Competency Standards for the Midwife Code of Professional Conduct for Midwives Code of Ethics for Midwives And, with the commencement of national registration on 1 July 2010, many newly developed national standards and guidelines from the NMBA have been included for both nurses and midwives:

Standard on Recency of Practice Registration Standard Guidelines for Mandatory Notifications Guidelines for Advertising of Regulated Health Services Re-Entry to Practice Policy Guidelines for Professional Indemnity Insurance These codes, standards, frameworks and guidelines have been formally adopted by the NMBA (see references) to form the complete professional practice framework for nurses and midwives in Australia. The framework provides guidance to nurses and midwives in their practice and provides the public with information on the standards of practice that may be expected from licensed nurses and midwives in Australia. The NMBA expects nurses and midwives to conduct

themselves in accordance with the national professional practice framework and engage in a continuous process of self assessment against the standards included in the framework. In NSW, nurses and midwives are also expected to conduct themselves in accordance

with the state legislation for conduct, performance and health matters (go to Australian Health Practitioner Regulation Agency (AHPRA) website www.ahpra.nsw. gov.au and the Nursing and Midwifery Codes Guidelines and Statements).

Professional Practice Framework National Competency Standards for Registered Nurses, Enrolled Nurses and Nurse Practitioners c Sets foundations for entry to practice and continuing assessment of performance Codes of Ethics and Professional Conduct for Nurses and Midwives c Sets the minimum national standards of conduct and fundamental ethical standards for the nursing and midwifery profession Guidelines on Boundaries of Professional Practice c Provides guidance for nurses and midwives in maintaining professional relationships with clients National Framework for the Development of Decision Making Tools for Nursing and Midwifery Practice c Provides guidance for nurses and midwivesâ&#x20AC;&#x2122; practice decisions through the use of specific tools National Framework for the Accreditation of Nursing and Midwifery Courses c Sets standards for the development and accreditation of nursing and midwifery courses Continuing Professional Development Registration Standard c Sets out the annual requirements for nurses and midwivesâ&#x20AC;&#x2122; continuing professional development Recency of Practice Registration Standard c Sets out the requirements for nurses and midwives to demonstrate sufficient practice in their profession Guidelines for Mandatory Notifications c Provides guidance for nurses and midwives on requirements for mandatory notifications under the Health Practitioner Regulation National Law (NSW) Act, 2009. Guidelines for Advertising of Regulated Health Services c Provides guidance for nurses and midwives on requirements for advertising of regulated health services

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Continuing Professional Development Frequently Asked Questions What is Continuing Professional Development? Continuing Professional Development (CPD) is the purposeful maintenance and improvement of a professional’s knowledge and skills to remain competent in their chosen profession for the benefit of themselves, their patients or clients and the wider profession. CPD is recognised as a commitment to being professional, keeping up to date and continuously seeking to improve. CPD is intended to encourage the development of professionals so that they reflect on their practice and its quality, are able to adopt and assess new approaches to their practice and develop better ways of working as a result. CPD acknowledges varying learning styles among professionals and includes a wide range of formal and informal learning activities. The key principles behind CPD are that it: c is self-directed; c is based on learning needs identified by the individual; c builds on an individual’s existing knowledge and experience; c links an individual’s learning to their practice; and, c includes an evaluation of the individual’s development.

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Why is CPD necessary? CPD is a critical mechanism in ensuring that all members of the nursing and midwifery professions are able to deliver high quality nursing and midwifery care and services and keep pace with health care developments that affect their practice. The knowledge needed to function effectively as a professional nurse or midwife continues to expand and change while consumer demand and expectations continue to increase. Therefore, as registered health practitioners, nurses and midwives have a professional obligation to maintain their competence and to aim for continuous improvement in the standard of service they provide. Accordingly, nurses and midwives must complete CPD activities to meet the Nursing and Midwifery Board of Australia’s (NMBA’s) mandatory requirements for ongoing registration. (Full details can be accessed from the NMBA’s website: www.nursingmidwiferyboard.gov.au/)

Why didn’t the NSW Nurses and Midwives Board require nurses and midwives to complete CPD prior to July 2010? Unlike many other countries and some states and territories of Australia, nurses in New South Wales were not required to provide evidence of completion of CPD activities for renewal of registration prior to 1 July 2010. Instead, the Nurses and Midwives Board of NSW established the ANMC’s Code of Professional Conduct as setting out guidelines that should be observed by nurses in their professional practice. The Code required all nurses to maintain competence for current practice, including participation in ongoing professional development. The national registration scheme has now determined that requiring the completion of CPD for ongoing registration provides a more effective way of ensuring that all nurses and midwives maintain their competence for current practice.

Who is required to complete CPD? The NMBA requires all practicing registered and enrolled nurses, registered nurses endorsed as nurse practitioners, midwives and midwives endorsed as eligible midwives and midwife practitioners to complete CPD. ‘Practicing’ includes all clinical and non-clinical roles related to the delivery of nursing and midwifery services. ‘Non-clinical’ encompasses roles such as management, education, research, policy development, regulatory and industrial. Students or nurses or midwives who have non-practicing registration are not required to complete CPD.

What must nurses and midwives do to meet the NMBA’s annual CPD requirements? The NMBA requires all practicing registered and enrolled nurses and midwives to complete at least 20 hours of CPD per year. The CPD hours must be relevant to the individual nurse’s or midwife’s context of practice. If an individual is both a registered nurse and a midwife they must complete 20 hours of nursing CPD and 20 hours of midwifery CPD, unless the CPD activities are relevant to both professions, when they may be counted as evidence for both nursing and midwifery. Registered nurses who hold endorsements under the Health Practitioner Regulation National Law (NSW) Act, 2009 must complete at least a further 10 hours per year in CPD related to their endorsement. This is only for nurse practitioners. Midwives endorsed as ‘eligible midwives’ under the Act must complete a further 20 hours of CPD for their endorsement.

What is an hour of CPD? One hour of CPD equals one hour of active learning. It is the nurse’s or midwife’s responsibility to calculate how many hours of active learning have taken place.

Are CPD points required by the NMBA? No. CPD points are offered by several professional organisations and employers for their own professional development or continuing education programs. However, the use of CPD ‘points’ is not relevant to the NMBA’s requirements for CPD, i.e. the requirements for ongoing registration; only hours may be counted.

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Nurses and midwives may participate in formal CPD programs run by nursing or midwifery organisations but will need to calculate the number of hours the program represents for them to be recognised as CPD by the NMBA.

What activities can be included in CPD? There are no compulsory or prescribed activities for nursing and midwifery CPD. There are also no particular restrictions on the types or number of activities that may be included as nursing or midwifery CPD. The NMBA expects only that the CPD is relevant to the nurse’s or midwife’s context of practice and that the activities undertaken meet the individual learning needs of the nurse or midwife. Possible CPD activities may include, but are not limited to: c reflecting on feedback, keeping a practice journal; c acting as a preceptor/mentor/tutor; c participating on accreditation, audit or quality improvement committees; c undertaking supervised practice for skills development; c participating in clinical audits, critical incident monitoring, case reviews and clinical meetings; c participating in a professional reading and discussion group; c developing skills in IT, numeracy, communications, improving own performance, problem solving and working with others; c writing or reviewing educational materials, journal articles, books; c active membership of professional groups and committees; c reading professional journals or books; c writing for publication; c developing policy, protocols or guidelines; c working with a mentor to improve practice;

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c presenting at or attending workplace education, in-service sessions or skills workshops; c undertaking undergraduate or postgraduate studies which are of relevance to the context of practice; c presenting at or attending conferences, lectures, seminars or professional meetings; c conducting or contributing to research; c undertaking relevant online or distance education; and, c mandatory in-service education that is directly related to an individual’s context of practice.

Can mandatory in-service education be included in CPD? Yes, if it is directly relevant to a nurse’s or midwife’s context of practice and contributes to development of their practice, mandatory inservice education can be included in CPD.

Does CPD need to be provided by an accredited organisation? No. CPD activities may be undertaken in a range of ways including: self-directed, workplace based or through seminars, conferences or formal programs offered by professional organisations and education providers. The important point is that the activities are relevant to the individual nurse’s or midwife’s context of practice and are able to meet their learning needs.

Must nurses and midwives provide evidence of CPD to the NMBA every time they renew their registration?

What must nurses and midwives include in the documentation of their CPD evidence?

No. Nurses and midwives will only be required to make an annual statement when they renew their registration which includes a declaration that they have met the NMBA’s requirements for CPD.

Documentation of CPD evidence must include dates of the CPD activities, a brief description of the outcomes of the activities, and the number of hours spent in each activity. All evidence should be verified.

The NMBA will audit a small percentage of randomly selected nurses and midwives each year. If a nurse or midwife is selected for audit, they will then be required to provide evidence of their CPD to the NMBA. All registrants will be allowed a minimum of at least 12 months in the national scheme before being selected for audit.

Is there a prescribed way to record CPD evidence? No. Nurses and midwives must keep written documentation of their CPD that demonstrates completion of a minimum of 20 hours of CPD per year but there is no set format prescribed by the NMBA for demonstration of CPD evidence by nurses and midwives. Nurses and midwives may develop their own formats for documentation of their CPD evidence or may use formats or templates that have been developed by education providers, employers or professional associations. Some education providers, employers or professional associations advocate the use of ‘professional portfolios’. This is a sensible approach for nurses and midwives to organise the information which supports their professional practice, including evidence of CPD. Nurses and midwives may choose to keep a professional portfolio but this is not a requirement of the NMBA for CPD evidence.

The NMBA expects nurses and midwives to demonstrate that they have taken a planned approach to completion of their CPD for the year. This requires nurses and midwives to: c identify their learning needs based on an evaluation of their practice against recognised professional standards; c develop a brief learning plan based on the needs identified; c participate in CPD activities which meet these learning needs; and, c reflect on the value of these activities to their practice. This means that nurses and midwives need to keep evidence that explains why they chose the particular CPD activity and how it met their learning needs; how it was relevant to their context of practice; what they learnt from the activities and how it contributed to their practice.

How long should nurses and midwives keep evidence of their CPD? The NMBA currently recommends that nurses and midwives should keep their CPD evidence for a minimum of three years. However, this period may be extended to 5 years following finalisation and release of the NMBA’s audit policy.

Nursing and Midwifery in NSW

Legal Issues for Nurses and Midwives in NSW Due to the sensitive and emotional nature of health care, it is a reasonably expected hazard for nurses and midwives to become involved in a wide range of legal matters. This is because health practitioners and health care providers are often the subject of complaints and incidents which may lead to investigation by the police, the coroner or other statutory bodies.

As a result of this, there can be serious implications for a nurse or midwife with respect to their registration. For example, they may have conditions imposed on their registration, be the subject of disciplinary proceedings before a Professional Standards Committee (PSC) or Tribunal and potentially lose their registration as a nurse or midwife. Nurses and midwives should have legal representation in order to protect their interests if such matters arise. The NSWNMA provides legal representation to its members. If a nurse or a midwife is not a NSWNMA member then legal representation needs to be arranged privately at a cost to the nurse or midwife.

Nursing and Midwifery in NSW

Financial members of the NSWNMA are entitled to receive free legal advice, representation and support if they are involved in the above types of matters. For this reason it is important that nurses and midwives in New South Wales join the NSWNMA and ensure that they remain financial members whilst they are engaged in the practice of nursing or midwifery.

Complaints to the Health Care Complaints Commission Any person is entitled to make a complaint to the Health Care Complaints Commission (HCCC) about a health practitioner (registered or unregistered) or a health service provider. When a complaint is made, the HCCC is legislatively required to assess that complaint. Part of the assessment process involves writing to nurses and midwives and asking them to respond in writing to the complaint within a certain timeframe. If it is deemed that a complaint warrants investigation by the HCCC then the HCCC may request that the nurse or midwife provide them with further information either by another written response or interview. The HCCC has the power to compel a nurse or midwife to attend an interview as part of their investigation. Following an investigation, the HCCC may determine to prosecute a complaint against a nurse or midwife before a PSC or Tribunal. Notifications are made to the Nursing and Midwifery Board of Australia (NMBA) and/or the Nursing and Midwifery Council of NSW (NMC). Where there is concern about the conduct or health of a nurse or midwife, a person, health practitioner or health service provider can make a notification or complaint to AHPRA or the NMC. It is also open to a nurse or midwife to make a self-notification in relation to their conduct or health.

Regardless of who the notification is made to, the notification will be managed by the NMC. The NMC must consider whether in the circumstances there is a need to place conditions on the nurse or midwife’s registration in order to protect the public. The NMC will then consider whether the nurse or midwife needs to undergo a health or performance assessment or whether the complaint should be referred to the HCCC for investigation.

Mandatory Notifications Under the Health Practitioner Regulation National Law (NSW) Act, 2009, registered health practitioners have an obligation to make a notification to AHPRA if they form a reasonable belief that another registered health practitioner has engaged in “notifiable conduct”. Notifiable conduct is defined in the Act as where the registered health practitioner: “practiced the practitioner’s profession while intoxicated by alcohol or drugs; or engaged in sexual misconduct in connection with the practice of the practitioner’s profession; or placed the public at risk of substantial harm in the practitioner’s practice of the profession because the practitioner has an impairment; or placed the public at risk of harm because the practitioner has practiced the profession in a way that constitutes a significant departure from accepted professional standards.” Registered health practitioners may be concerned about the impact of making a notification and members can seek advice from NSWNMA about whether they are obliged to make a notification.

Coronial Inquests When a person dies and their death is considered to be a reportable death under the Coroners Act (NSW), 2009 the police will investigate that death on behalf of the Coroner.

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Part of the police investigation requires the police to obtain statements from witnesses and nurses and midwives who have often had contact with the deceased prior to their death. This means that the police who are seeking further assistance at coronial investigations can obtain this through statements provided by nurses and midwives.

The main purpose of coronial inquests is for the coroner to make findings in relation to the manner and cause of a personâ&#x20AC;&#x2122;s death and to make recommendations which attempt to prevent similar events in the future. When a coronial investigation proceeds to a coronial inquest, those nurses and midwives are usually then asked to give evidence in that inquest so as to assist police investigations. The main purpose of coronial inquests is for the coroner to make findings in relation to the manner and cause of a personâ&#x20AC;&#x2122;s death and to make recommendations which attempt to prevent similar events in the future. Those findings are often in relation to systemic issues and the recommendations that flow from that usually recommend changing or implementing policies. It is also open to the coroner to make a recommendation that the conduct of a nurse or midwife be referred to the Health Care Complaints Commission when they believe that further investigation into that conduct is warranted.

Nursing and Midwifery in NSW

Civil Claims In NSW, nurses and midwives who are employees are indemnified by their employers for torts (such as negligence) committed in the course of their employment provided that it was not serious, wilful misconduct. Despite this, nurses and midwives are frequently required to provide statements and appear in court as witnesses in civil claims by patients and their families.

Police Investigations Police often require nurses and midwives to provide statements and appear in court as witnesses for criminal matters. This is particularly common in circumstances where a nurse collects blood from a driver following a motor vehicle accident or where a patient who has been assaulted discloses information to the nurse that could assist the police with their investigation. This is also the case with assaults that occur in areas such as emergency departments and mental health units which may require nurses to provide statements to the police.

The Challenges Facing the Nursing and Midwifery Workforce

That Australia potentially faces a nursing and midwifery workforce crisis has been well documented. Over the last decade numerous authors have described a variety of challenges which are impacting globally and nationally on nurses and midwives. These include, but are not limited to, nursing shortages, shortened hospital length of stay (LOS), an ageing workforce, downsizing of health facilities, an increase in patient acuity and increased emphasis on cost effectiveness (Australiaâ&#x20AC;&#x2122;s Health Workforce, 2008; Duffield et al., 2010a; Mrayyan, 2004).

Unfortunately, the current political response focuses on issues of cost containment rather than addressing the issue of poor workforce planning and an increasingly challenging work environment. Insufficient staffing and inadequate skill mix are compromising nurses and midwivesâ&#x20AC;&#x2122; ability to maintain the safety of those in their care and to provide a level of health care that is satisfying for both those who deliver and those who receive it. The consequence is avoidable patient deaths and injury, and problems with workforce retention as nurses and midwives abandon their professions (Armstrong, 2009).

Nursing and Midwifery in NSW

Nursing and midwifery shortages

An increasing and ageing population

Health Workforce Australia (HWA) (2012) describes the current situation with respect to health workforce planning as “simply not tenable” (p. iii). Given current conditions and assuming a business as usual, ie. a do nothing scenario, HWA estimates that by 2016 there will be a nationwide shortfall of 13,162 registered nurses (RNs) and 6,918 enrolled nurses (ENs). By 2025 the shortfall in the RN and EN workforce will be 80,141 and 29,349 respectively.

The Australian Institute of Health and Welfare (2012a) reports that the number of nurses and midwives increased by 6.8% in the period 20072011; however, when compared to the population increase, the supply decreased by 1.3%.

With respect to the midwifery workforce, HWA (2012) reports that it is difficult to estimate the numbers of midwives needed in the future owing to data collection issues. However, they estimate that the midwifery workforce is most likely to be in balance in 2025. The NSW Nurses and Midwives’ Association (NSWNMA) Midwifery Reference Group (MRG) questions these assumptions and asserts that there are not enough midwives and argues that the problem is one of inadequate support structures to enable midwives to flow into the workforce (NSWNMA, Midwifery Reference Group, October 2012). This is not to imply, however, that there will be an equitable geographic distribution of midwives throughout NSW. It is likely that shortages of midwives in remote and rural NSW will be a continuing feature of the health care landscape. Notwithstanding the inception of BirthRate Plus©, there are shortages of midwives at a number of sites in NSW (NSWNMA, Midwifery Reference Group, October 2012). The safety of birthing mothers and newborns is being compromised by vacancies being covered by overtime and undertaken by RNs, ENs and Assistants in Midwifery (AiMs). The problem of access to appropriate midwifery care in rural NSW has been exacerbated by the closure of rural maternity units. Since 1995, approximately 130 rural maternity units have been closed across Australia, with 32 of these closures occurring in NSW (Dietsch et al., 2008). The interplay of a number of factors is conspiring to create the perfect storm with respect to the nursing and midwifery workforce.

Nursing and Midwifery in NSW

Between 2001-2031 the total population of NSW is projected to grow from 6.57 million to 8.26 million, an increase of 26%. The number of people aged 65 years and over will increase from 858,080 (13% of the total population) to 1,812,640 (22% of the total population) (NSW Government, Department of Planning, 2006). Consequently, there will be a smaller pool of people from which to draw the nursing and midwifery workforce. Correspondingly, there will be an increase in the number of older people requiring health care services, compounded by the changing burden of disease with increased prevalence of chronic conditions (HWA, 2012).

An ageing nursing and midwifery workforce Between 2007 and 2011, the average age of all employed nurses and midwives increased from 43.7 to 44.5 years and the proportion of employed nurses and midwives aged 50 years and over increased from 33.0% to 38.6%. The average age of rural nurses and midwives is slightly higher than the national average and in 2011 was 45.1, 43.9 and 44.1 years of age in outer regional, remote and very remote regions respectively (AIHW, 2012b). Australia has entered the ‘baby boomer’ generation retirement bulge as the 5.5 million people born between 1946-1964 begin to turn 65 (NSPAC, 2012). This retirement bulge, which began in 2008, will peak in 2025 and it can be expected that there will be a corresponding pattern for nurses and midwives, with an increased number reaching retirement age during this period.

Retention and recruitment issues It is well documented that the retention of nurses and midwives is a serious problem throughout the developed world. For example, the American Nurses Association reported in 2009 that only 80% of those licensed to practice as RNs were working in the profession; similarly, in Australia only 73% of qualified nurses were working in the profession in 2005 (Shacklock & Brunetto, 2012). Concern has been raised in Australia about the number of new graduates and younger nurses leaving or intending to leave the profession. It has been reported that 20% of graduates left the nursing profession within the first 12 months of employment (Armstrong, 2004) and it has been suggested that annual attrition rates are as high as 20% in NSW (Doiron & Jones, 2006). A number of factors have been identified in both national and international research as influencing intent to leave the profession. These include age, work environment, degree of practice autonomy, employment conditions, job satisfaction and safety (Eley, Eley, & RogersClark, 2010). The impact of these and other workplace challenges which nurses currently face place them at risk of stress and burnout and their loss to the profession as a consequence (Lee & Cummings, 2008). Four generations of nurses and midwives currently work in health care in Australia: Veterans (born 1925-1945); Baby Boomers (1946-1964); Generation X (1965-1979); and Generation Y (1980-2000) and they continue nursing for different reasons (Shacklock & Brunetto, 2012). Although the decision to leave the profession is probably determined by a number of factors, recent research suggests that devising solutions to nurse and midwife retention may well require a generational focus. It is suggested, for example, that Generation X individuals are motivated by lifestyle choices and are unlikely to continue to work in environments that have limited work flexibility or opportunity

Nursing and Midwifery in NSW

for career advancement (Francis & Mills, 2010). Generation Y also are motivated by work/life balance and flexibility; however, they also value the culture of the workplace and place high importance on being socially connected, with managers who communicate well and support them (Jamieson, 2009). The challenge for nursing and midwifery leadership is, therefore, to develop not only retention strategies that focus on improving the work climate for all generations of nurses and midwives but also generation-specific strategies. In particular, there is an imperative to develop strategies which target Generation Y nurses, as this is the cohort that is most likely to leave health care (Armstrong, 2004; Lavoie-Tremblay et al., 2010).

Lack of self-sufficiency in nursing and midwifery education Australia is not self-sustaining with respect to providing for the health needs of our community and is highly reliant on the recruitment of overseas-educated nurses to meet workforce requirements (HWA, 2012). One in six nurses working here is internationally trained and international recruitment provides a quick, flexible and relatively low-cost solution to workforce crises (Buchan, Naccarella & Brooks, 2011). The sustainability of such a strategy is questionable, given that a number of other countries are in the same situation and developing nations are building their own workforce capacity, resulting in increased competition for the health care workforce (HWA, 2012). In order for the nursing workforce to be in balance by 2025 through an increased number of nurses graduating there will need to be almost 11,000 additional nursing graduates per annum from 2016 onwards (HWA, 2012). Currently, the higher education sector is under strain with respect to attracting sufficient numbers of students with the required entry scores and the provision of adequate (and appropriate) clinical

Nursing and Midwifery in NSW

education. Additionally, it has been noted that there is an increasing age profile of students entering nursing (Duffield & O’Brien-Pallas, 2003) which will not ease the issue of an ageing nursing and midwifery workforce. With many qualified nurses and midwives not working in their professions, a strategy has been suggested to encourage their return. However, this is proving financially and logistically impossible for many (Chidlow, 2011). A re-entry program is required if a nurse has not practiced in the past five years and currently there is only one provider (in Sydney) approved to provide such a course. For many who live outside Sydney this is a powerful disincentive. Nurses can travel to an accredited course interstate and there are now two online courses that may be undertaken nationally. The situation for midwives is worse, with no approved program in NSW, requiring them to travel interstate to undertake a re-entry course. For nurses and midwives who have been out of the profession for 10 years or more, their only option is to undertake the entire preregistration undergraduate course of study.

Political Climate In September 2012, the NSW Government announced health service budget cuts of $3 billion over the next four years (Nicholls, 2012). The $3 billion is comprised of $775 million labour expense cap and $2.3 billion of efficiency savings (cutting “back office services to fund frontline). It has been stated by the Health Minister, Jillian Skinner, that nurses would be exempted. However, she did suggest that by cutting overtime and the use of agency nurses, savings could be found. The difficulty with this as a cost-cutting strategy is that there is an increased patient care burden on nurses and the potential for increased adverse patient outcomes. As pointed out by Dr. Andrew McDonald, the Shadow Minister for Health, “the only reason ... nurses are doing overtime in the first place is because they have to fill staff shortages” (AHHA, 2012).

Although the Health Minister has given assurances that “frontline nurses are quarantined from the labour expense cap”, there is concern about how “frontline nurses” is defined. It has been reported that nursing unit managers and clinical nurse educators could lose their jobs (Wachsmuth, 2012). These roles are frontline and essential to the quality of patient care. There is considerable evidence that first line nursing managers play a crucial role in creating a healthy work environment, which in turn impacts positively on nurse retention (for example: Duffield et al., 2010a; Lee & Cummings, 2008). Thus, the role is pivotal to stemming the number of nurses leaving the profession. New Zealand provides a concerning example of the impact of the loss of these essential nursing roles on health care. During the health care “re-engineering” in the 1990s (between 1993, the introduction of health care re-engineering, and 1996, the year the re-engineering policies were relaxed) there was the application of a philosophy of generic management, ie. the belief that a manager in one industry can effectively apply that experience to another industry (McCloskey & Diers, 2005). RN and EN FTEs decreased 36% and while average length of stay also decreased, there were statistically significant increases in the rates of central nervous system complications, decubitus ulcers, sepsis, urinary tract infections, physiological and metabolic derangement, pulmonary failure and wound infection (McCloskey & Diers, 2005). The significance of this study in the context of this discussion is that re-engineering also involved the dismantling of nursing leadership. In some instances, however, even nursing managers at the ward level were eliminated and nurses reported directly to generic managers from other industries. This resulted in a loss of senior nurses with essential experience and knowledge of the practice environment. The re-engineering of health care based on the ideology of managerialism in New Zealand not only negatively impacted on patient outcomes but also resulted in a pervasive legacy of distrust between nurses and government and, significantly, the loss of a generation of nursing

The current state government has removed the arbitration powers of the NSW Industrial Relations Commission in relation to pay and conditions outside the government regulated pay cap of 2.5% employee costs per annum.

leadership, the results of which are still felt today (Carryer, Diers, McCloskey & Wilson, 2010). A further challenge for nurses and midwives is that the current state government has removed the arbitration powers of the NSW Industrial Relations Commission in relation to pay and conditions outside the government regulated pay cap of 2.5% employee costs per annum. It has also legislated to deduct future compulsory superannuation increases from the 2.5% employee cost increases. The Government legislated wages policy also prevents all other legitimate claims such as improved shift for night shifts from proceeding unless paid for by the employees. Such attacks on nurses and midwives on top of the changes to the State Workers Compensation Scheme are counterproductive given the evidence of an impending nursing and midwifery shortage and the plethora of research findings which demonstrates that shiftwork has severely detrimental effects on health. There is now considerable evidence that nurses who undertake shiftwork (an inherent requirement of the role) are more at risk of disrupted circadian rhythms, which in turn have been linked to obesity, mental health issues, gastrointestinal disorders, reproductive problems and even more alarmingly increased risk for cardiovascular disorders, breast cancer and prostate cancer (Gordon & Marshall, 2012).

Nursing and Midwifery in NSW

The Figures National

Nurses

The Annual Report 2011-2012, page 149, for the Australian Health Practitioner Regulation Agency (AHPRA) shows that nursing and midwifery are the professions with the most practitioners, with 302,245 nurses and 39,271 midwives, totalling 341,516 registered nationally as nurses and midwives. This includes: Registered nurses (RN)

237,331

Enrolled nurses (EN)

60,967

RN and EN (dual registration)

3,974

Registered midwives

2,187

RM and RN (dual registration)

39,202

RM and EN (dual registration)

RM, RN and EN (triple registration)

268,410

(F)

33,487

(M)

348

(not stated)

Nurses and midwives 38,499

(F)

752

(M)

(not stated)

RN and EN (dual registration)

RM and RN (dual registration)

Enrolled nurses (EN)

Nursing and Midwifery in NSW

Registered nurses (RN)

M Nurses

not stated

Registered midwives

not stated

Females make up the largest proportion of the nursing labour force.

Nurses & midwives

The largest number of nurse registrants was aged 50-54 years (43,368), and for nurse and midwife dual registrants there were 8,465 persons between the ages of 55-59. For midwife-only registrants, the largest number was in the age bracket of 25-29 years (AHPRA Annual Report 2011-2012, p. 150).

Nurses and midwives worked on average 32.8 hours per week in 2011 (Nursing and Midwifery Workforce 2011 in AIHW, 2012, page 7). This is slightly down from 2007, when they worked on average 33.3 hours per week. However care should be taken with the interpretation of these results due to a low response rate in some areas like the Northern Territory (Nursing and Midwifery Workforce 2011 in AIHW, 2012, p. 42).

Clinical Nurse/Midwifery Specialist

New South Wales

Nursing/Midwifery Unit Manager

The total number of registered and enrolled nurses in NSW is the highest per state at 81,927, with Victoria close behind at 80,982. There were 15,108 registered enrolled nurses at this time (AHPRA Report 2011-2012, p. 152). These numbers do not include assistants in nursing or midwifery as this category of health worker is currently unregulated.

Clinical Nurse/Midwifery Consultant

The supply of both employed midwives and nurses decreased in New South Wales between 2007 and 2011, with 1,005.7 FTE (Full Time Equivalent) nurses per 100,000 population reduced to 971.8 FTE (Nursing and Midwifery Workforce 2011 in AIHW, 2012).

Nurse/Midwifery Practitioners

Assistant in Nursing /Midwifery 1,523

Enrolled Nurse without medication qualification 1-4 years and thereafter Special Grade

1,177 30

Enrolled Nurse 1-4 years and thereafter Special Grade

3,925 92

Registered Nurse/Midwife 1-8 years and thereafter

25,515

4,418

Clinical Nurse/Midwifery Educator Year 1 and 2

523

Nurse/Midwifery Educator Grde 1, years 1 & 2; Grde 2, Years 1 & 2; Grde 3, years 1 & 2 Level I, II, and III

The composition of the Full Time Equivalent nursing and midwifery workforce in NSW Health at June 2012 was determined through the Public Health System Nursesâ&#x20AC;&#x2122; and Midwivesâ&#x20AC;&#x2122; (State) Award 2011 and was:

1-3 years and thereafter

Grade 1, year1; Grade 2, Year 1 & Grade 2, year 2

Grade 1; Grade 2 & Grade 3 (All 1st & 2nd years)

212

1,728 1,617

Mothercraft Nurse 1-8 years and thereafter

Residential Care Nurse 1-4 years and thereafter

1-4 years

121

Nursing/Midwifery Managers Grades 1 through to 9 including 1st & 2nd years Total

1,292 39,372

In 2011 in NSW c the average length of service of the nursing and midwifery workforce was nine years; c the average age of the nursing and midwifery workforce was 44.25 years; and, c the average retirement age of the nursing and midwifery workforce was 62 years. The increase in population every year as well as challenges within the nursing and midwifery workforce have meant that nurses and midwives work within an environment of more complex patient care and reduced staffing, resulting in difficulty coping with increased workloads. However, with the 2011 introduction of the workplace management tool, Ratios, or Nursing Hours Per Patient Day (NHPPD), staffing levels were assessed and workloads could be managed appropriately.

Nursing and Midwifery in NSW

In 2010 NSWNMA ran a very successful campaign leading to the introduction of the ratios/nursing hours system for medical/ surgical, palliative care rehabilitation and acute mental health inpatient services in NSW. Sixty-seven percent of members believed ratios had a positive impact and enabled staff to deliver safer patient care (Ratios get a big tick. Nurse Uncut Australia, 2012). Geographical location is important to consider when discussing nursing/midwifery and patient care in NSW. The following table demonstrates just how much the ratio of nursing FTE to the population rises with the move towards the rural and remote areas of NSW. In 2007 and 2009 the numbers of nurses per population were higher in the rural and remote areas than in the city /metropolitan Local Health Districts (LHDs). Using the medical profession (doctors) as a comparison, rural and remote numbers suggest that there is a much greater role being undertaken by the nursing workforce in rural and remote areas

and that there may be changes in nursing skill mix. Remote registered nurses’ working hours are longer than those of nurses who work in major cities, with the greatest average hours being in very remote locations. In addition enrolled nurses, who tend to have similar working hour patterns to registered nurses, are markedly higher per 100,000 population in remote and very remote locations and their working hours are also longer on average than for enrolled nurses in city LHD locations (AIHW Medical Labour Source Surveys, 2005, 2007, 2009; Health Professionals Workforce Plan Taskforce, Technical Paper, 2011). Ratios have been a significant factor for nurses in New South Wales in assisting them to achieve a better workload outcome. This has had benefits for nurses themselves as well as improving patient care. The challenge now is to review and maintain ratios at their present level and to forge ahead to complete implementation across other nursing specialty areas in NSW.

Number of registered nurses and doctors in NSW per 100,000 population 900 800 700 600 500 400 300 200 100 0

NSW Nurses (FTE) – Major cities

NSW Medical practitioners (HC) – Major cities

2005

AIHW Medical Labour Source Surveys, 2005, 2007, 2009; Health Professionals Workforce Plan Taskforce, 2011. Interpretation of ‘doctor’ figures is based on the Head Count ratio to 100,000 of population of medical practitioners (doctors), including public, private and non-government organisations.

2007

2009

Nursing and Midwifery in NSW

NSW Nurses (FTE) – Remote/very remote

NSW Medical practitioners (HC) – Remote/very remote

Reasonable Workloads Reasonable workloads are essential for nurses, contributing to the provision of a sustainable health system for the people of NSW, one that not only meets present health needs but also plans for the health needs of the future. The employer has a responsibility to provide reasonable workloads for nurses. Clause 53(i) & (ii) of the Public Health System Nurses’ and Midwives’ (State) Award states: Unreasonable workloads compromise safe patient care and should be addressed. If a ward or unit meets one or more of the following checks on a regular basis, there maybe a reasonable workloads issue: c increased and consistent reliance on overtime (paid and/or unpaid) in order to staff the ward/ unit; c staff don’t finish their shift on time or don’t get tea breaks or meal breaks; c replacement nurses are not like for like (see Clause 53(iv) Section I Replacement of Absences); c there is an increased or high occurrence of sick leave; c high staff turnover; c nurses and midwives are being diverted away from direct patient care on a regular basis; c skill mix is too low for the ward / unit to meet safe patient care needs; c increased and sustained demand for beds and/or services; c increased acuity of patients or changes to the technology utilised to provide services; c an increase in adverse incidents or near misses involving patients and/or staff; and, c increased difficulty in meeting the requirements of relatives and visitors.

OR c if nurses and midwives believe that the work carried out on their ward or unit has increased significantly since the last staffing review, this could be compromising safe patient care and they may have a workloads issue. These issues are referred to in the Award Clause 53 Staffing Arrangements (iii) Principles.

How are minimum staffing arrangements established? A Reasonable Workload Committee (RWC) has the role of providing consultation, advice and recommendations to management. As well as discussing problem areas and possible changes, this Committee also looks at areas of the facility that have had success so that good ideas can spread to other parts of the facility (A Nurses’ & Midwives’ Guide to Reasonable Workloads Committees (nd.) NSW Nurses & Midwives Association.) The starting point for any conversation about workloads should be: What are the agreed staffing levels? There is a range of methods for establishing the appropriate minimum staffing arrangements, dependent on the type of service provided by the ward or unit. The following list provides an overview of some of these methods.

Nursing and Midwifery in NSW

Nursing Hours Per Patient Day (NHPPD) Ratios

Monitoring staffing arrangements

This method multiplies the average bed occupancy at midnight by the allocated NHPPD to give the total nursing hours to be provided for direct clinical care over a week (seven days). It applies to: c general inpatient wards in Peer Group A, B and C facilities;

Knowing the agreed staffing establishment and skill mix for wards or units is important. The N/MUM or Management can provide the Reasonable Workload Committee (RWC) with this information. Nurses and midwives on wards and units need to be aware of the levels as well, as they will be best placed to monitor changes. The best way to ensure the Award is enforced is to monitor and then act when workloads are excessive. The overriding responsibility of nurses and midwives is to always act in the interests of their patients or clients unless it puts the nurse or midwife at risk of injury. Nurses and midwives need to protect the safety of members of the community who are using health care services.

c dedicated palliative care wards/units; c dedicated wards; and, c inpatient adult acute mental health wards/units. The Award also ensures that staffing levels on nursing hours/ratio wards and units includes sufficient resources to allow for annual leave, sick leave, FACS leave and mandatory education.

ACORN 2008 The Australian College of Operating Room Nurses (ACORN) Standards 2008 are used to establish the minimum staffing arrangements for Operating Rooms, including that during each session the minimum staffing for each theatre will be as per Clause 53 Section IV(a).

Birthrate PlusÂŠ The NSWNMA and Ministry of Health have worked extensively to modify the Birthrate PlusÂŠ Calculation Tool to apply to the needs of women birthing within NSW. This tool allows an assessment of the minimum midwifery staffing levels needed for maternity services, including: c antenatal clinics;

Spot checks and the Nursing Hours per Patient Day / Ratio wards and units If a ward/unit is covered by the Nursing Hours/ Ratios provisions, nurses working on that ward / unit are able to ask their manager for a Spot Check. The Spot Check is used to see if the current staffing arrangements are being met and can assess if the average occupancy has increased, thereby requiring additional nurses. The Award states quite clearly that if at any time during the spot check or at its conclusion it is established that the provided NHPPD/Ratio falls short of the specified NHPPD/Ratio, then action must immediately commence to rectify the shortfall (see 53 Section II(s)(5)).

c antenatal and postnatal wards/units; c delivery and birthing suites; and, c domiciliary midwifery services.

Nursing and Midwifery in NSW

Work Health and Safety Legislation â&#x20AC;&#x201C; the New Regime Work Health and Safety legislation is highly relevant to nurses and midwives in their workplaces. As health workers, nurses and midwives need to understand work health and safety legislation as it covers the way health and safety risks can be reduced or minimised in the workplace. In New South Wales the current work health and safety legislation commenced on 1 January, 2012. While many aspects of the legislation are similar in principle and practice, there are also some significant changes, including new terminology. In NSW, the main aspects of the WHS regime consist of: c Work Health and Safety Act 2011; c Work Health and Safety Regulation 2011; c Codes of Practice; and, c Guidelines and other non-mandatory materials.

WHS Act 2011 The WHS Act provides a framework to protect the health, safety and welfare of all workers at work and other people who might be affected by the work. As described by Safe Work Australia, the WHS Act aims to: c protect the health and safety of workers and other people by eliminating or minimising risks arising from work or workplaces; c ensure fair and effective representation, consultation and cooperation to address and resolve health and safety issues in the workplace; c encourage unions and employer organisations to take a constructive role in improving work health and safety practices; c assist businesses and workers to achieve a healthier and safer working environment;

The WHS Act and Regulations contain in excess of 800 pages of requirements, including risk management, high risk work provisions, details of the powers and functions of the Regulator, fines, penalties and many more mandated provisions. The article below is only a small snapshot of some of these provisions. Information contained in this article has been largely sourced from the Safe Work Australia and WorkCover NSW websites. For more detailed information, including guidance material for workers, management and persons conducting a business or undertaking (PCBUs), please access the following websites: Safe Work Australia: www.safeworkaustralia.gov.au WorkCover NSW: www.workcover.nsw.gov.au

Nursing and Midwifery in NSW

c promote information, education and training on work health and safety; c provide effective compliance and enforcement measures; and, c deliver continuous improvement and progressively higher standards of work health and safety.

WHS Regulation 2011 The WHS Regulation specifies the way in which some duties under the WHS Act 2011 must be met, prescribes procedural requirements to support the Act and sets out specific requirements for the management of a number of hazards. Compliance with the WHS Regulation is mandatory.

Codes of Practice Codes of practice provide practical guidance on how to meet the standards set out in the WHS Act and WHS Regulation. Codes of practice are admissible in proceedings as evidence of whether or not a duty under the WHS laws has been met. Compliance with codes of practice is not mandatory as long as any other method used can provide an equivalent or higher standard than that laid down in the code.

Differences between the WHS legislation and the old OHS legislation Scope and wording There are some notable differences in the current WHS legislation in relation to its scope and wording. A ‘person conducting a business or undertaking’ (PCBU) is now used to describe any person or entity conducting a business or undertaking of any kind, alone or with others. The words ‘employer’ and ‘employee’ are no

longer used, as they depict only one type of employment relationship. A PCBU can be a sole trader, a partner, a company, unincorporated association or government department. A volunteer organisation or strata title body corporate that does not employ anyone is not a PCBU. This change now captures all forms of work, including new and complex working arrangements, and can include manufacturers, designers and suppliers of goods and services.

Reasonable practicability Duties placed on PCBUs under the WHS Act 2011 are qualified by the words ‘reasonably practicable’. As defined by Safe Work Australia, ‘reasonably practicable’ means what could reasonably be done at a particular time to ensure health and safety measures are in place. In determining what is reasonably practicable a number of issues must be considered, for example: c the likelihood of a hazard or risk occurring; c the degree of potential harm; c what the person concerned knows or ought reasonably to know about the hazard or risk and ways of eliminating or minimising it; c the availability of suitable ways to eliminate or minimise the risk; and, c the cost of eliminating the hazard or risk – whether it is disproportionate to the level of risk and potential harm.

Primary duties of PCBU Primary duties for PCBUs under the WHS Act 2011 are substantially the same as with the former legislation. The primary duty of care requires duty holders to ensure health and safety, as far as is reasonably practicable, by eliminating risks to health and safety or minimising them where elimination is not reasonably practicable. It is possible for more than one PCBU to have primary duties and these are owed to all workers and other people who may be at risk from work carried out by the business. Prosecution for failing in a duty of care carries substantial monetary and other penalties.

Nursing and Midwifery in NSW

Duties of Officers Officers have primary duties in relation to WHS. An ‘officer’ is defined according to Section 9 of the Corporations Act 2001 and Sections 247 and 252 of the WHS Act 2011. Other than a partner within a partnership, an officer is a person who makes or participates in making decisions that affect the whole, or a substantial part, of the organisation’s activities (other than municipal councillors or a minister of a state, territory or the Commonwealth). It is important to identify exactly who is and who is not an officer. For example, a manager or director of nursing, unless having the power to make decisions about the Local Health District as a whole or a substantial part of it, would be considered a ‘worker’ and would not assume the duties of an ‘officer’.

Duties of workers Under the WHS Act 2011, while at work workers must take reasonable care for their own health and safety and that of others who may be affected by their actions or omissions. Volunteers and contractors are considered ‘workers’ for the purposes of the Act and must act accordingly. The Act requires that they must: c comply, as far as they are reasonably able, with any reasonable instruction given by the PCBU to allow the PCBU to comply with WHS laws; and, c cooperate with any reasonable policy or procedure of the PCBU relating to health or safety at the workplace that has been notified to workers.

Consultation Effective consultation has been shown to contribute to work health and safety and has been prescribed as a general duty of care for the PCBU. Consultation provides an opportunity to share relevant information and participate in meaningful discussion on work health and safety matters. For example, it gives everyone the opportunity to:

Nursing and Midwifery in NSW

c discuss and share their health and safety concerns; c identify safety hazards and risks; c find and implement practical solutions; c contribute to the decision-making process; and, c communicate outcomes in a timely manner. The two main mechanisms to facilitate consultation in the workplace are:

Health and Safety Representatives (HSRs) HSRs can be elected to represent a work group and investigate health and safety issues. Deputy HSRs can also be elected to ensure that there is always a representative available to protect the interests of the work group, for example, there should be an HSR available on all shifts. The role of the HSR is broad ranging, including: c representing workers in their work group on WHS matters; c monitoring WHS measures implemented in the workplace; c investigating complaints; c inquiring into anything that appears to be a risk; c inspecting the workplace and accompanying an inspector when external investigations take place; and, c issuing notices to management and/or stopping work where an imminent risk to health and safety is identified. At least one HSR must be elected to represent each defined work group. Where one person in a workplace requests the election of an HSR, negotiations between staff and management must begin within 14 days. A union may participate in these negotiations if requested by a member. HSRs cannot be held personally liable when acting in good faith in the exercise of their powers. Training of HSRs is not mandatory unless requested by the HSR. Training by a provider approved by WorkCover NSW must occur within three months of the request. Without training, HSRs may not exercise their powers to issue

Nursing and Midwifery in NSW

notices to management about important WHS matters and stop work where there is an imminent risk to WHS. It is important the organisations have sound dispute resolution procedures to settle any disputes arising about WHS issues/notices. If unable to be resolved internally, a WorkCover NSW inspector may need to resolve the matter.

Health and Safety Committees (HSC) The main function of health and safety committees is to work collaboratively with the PCBU to develop policies and procedures to improve work health and safety outcomes. There is no requirement for members of a HSC to be trained; however, trained HSRs may participate to represent their workgroups in this forum and must be invited to join the HSC. Where disputes arise about setting up a HSC, any party may ask WorkCover NSW to decide the matter. A health and safety committee (HSC) can be established: c if requested by a HSR; or, c if requested by five or more workers; or, c on the initiative of the PCBU.

Union right of entry To exercise right of entry to a workplace for WHS purposes, a union official must be the holder of current right of entry permits at NSW and Commonwealth levels. Compulsory training is required and the holder must be a â&#x20AC;&#x2DC;fit and properâ&#x20AC;&#x2122; person to qualify for the permit. WHS entry permit holders may enter workplaces to: c inquire into a suspected contravention of the Act or Regulation which affects a member or worker eligible to be a member of that union; c inspect records or other documents relating to a suspected contravention; and, c consult or advise relevant workers on WHS matters.

Nursing and Midwifery in NSW

Prior notice to enter is not required if there are reasonable grounds to suspect a breach of legislation is occurring. However, notice must be given to the PCBU and person with management or control of the workplace as soon as reasonably practicable after entry. Where personnel records are requested, 24 hours notice must be provided to the PCBU. It is an offence for a PCBU to unreasonably prevent right of entry by the WHS entry permit holder or to withhold relevant documents. Any party to a dispute arising in relation to right of entry may request the assistance of a WorkCover NSW inspector to resolve the dispute. While at the workplace, the WHS entry permit holder may: c inspect any work system, plant, substance or structure relevant to the suspected contravention; c consult with the PCBU and relevant workers about the suspected contravention; and, c inspect and make copies of any document that is relevant, if the document is held at the workplace or is accessible from a computer at the workplace.

Work Health and Safety â&#x20AC;&#x201C; Violence and Aggression Violence and aggression have become a priority work health and safety concern for nurses and patients in health and residential care services in NSW. Yamini (March, 2012) suggests that approximately 30 percent of hospital workers - including paramedics, doctors and security officers - filed workers compensation claims associated with physical assaults in public hospitals over three years. The biggest rise in claims was by nurses, up 42 percent between 2008-09 and 2010-11. The impact for the nursing profession is difficult to determine, as many assaults and aggressive incidents go unreported. Only those resulting in workers compensation claims can be measured. Violence and aggression can come from many sources, including members of the public, patients, residents and hospital visitors. Behaviours can range from verbal abuse through to significant physical assault with sometimes fatal consequences. Public hospitals have a policy of zero tolerance, which is backed by many preventive strategies such as surveillance cameras, security support and building design that can protect staff. Most emergency department reception areas provide these supportive strategies to protect staff. Some of the identified predisposing factors related to incidents of violence and aggression are: c the design of facilities, particularly in residential care, can result in nurses becoming trapped, with no escape route or safe haven if being pursued by an assailant; c inadequate risk assessment and clinical treatment of patients and residents;

c people affected by drugs and / or alcohol; c nurses working alone and in isolation; c inadequate or absent duress equipment; c lack of staffing to effectively respond to incidents should they occur; c the location of facilities, particularly in country areas, in relation to timely support from police. For example, some country police stations close at night and help may be many kilometres away; and, c lack of training in causes de-escalation and duress response.

Nursing and Midwifery in NSW

Risk management is mandated in the Work Health and Safety (WHS) Act and WHS Regulation 2011. Managing risks is the responsibility of persons conducting a business and should be undertaken in consultation with staff. The new regulatory regime in NSW makes provision for health and safety representatives (HSRs) to be elected and/or health and safety committees (HSCs) to be set up. HSRs act on behalf of the work group to which they are elected and can participate in consultation about risk management, which is an important function to eliminate and control risks at source.

Approximately 30 percent of hospital workers â&#x20AC;&#x201C; including paramedics, doctors and security officers â&#x20AC;&#x201C; filed workers compensation claims associated with physical assaults in public hospitals over three years. Some elements of a risk management framework include: c identifying sources of risk, including contributing factors; c developing risk control strategies, including: 2 risk assessment of clients, premises, systems, equipment and training; 2 clinical procedures that enable early identification and treatment of medical and psychiatric conditions that can cause violent behaviours;

Nursing and Midwifery in NSW

2 methods of communicating the risks to staff and others who need to know (eg. visiting clinicians); 2 design of premises to reduce risks, for example, the provision of secure perimeters, the separation of staff and patient areas, as well as lighting; 2 installation of equipment to alert staff of incidents, for example, installation of duress alarms, patient alarms and door alarms; 2 safe systems of work, including staffing and skill mix; 2 education of managers and staff; and, 2 emergency response procedures, including duress response teams. c consulting with staff, clients and their representatives on risks and how to manage them; and, c reporting and the review of systems and incidents. Systematic and escalating incidents of violence and aggression against nurses in our health system can lead to death, serious and permanent injuries, including damage to psychological health, and attrition in an already depleted nursing workforce. Assessment of risk and continuous improvement in preventive action supports the concept of zero tolerance and must become a priority for all health care establishments if violence and aggression is to be controlled.

Care of Older People in NSW Overview of Ageing and Aged Care in NSW The health and wellbeing of older people in our community connects with many public sector services in NSW, as well as services in the non-government and private sectors. Most people in NSW will continue to age in their own homes with the support of family and friends, and will need access to a range of primary care and community services. A smaller proportion will access Commonwealth funded in-home packages or residential aged care.

There are over one million people aged 65 years and over in NSW, comprising 13.8% of the Stateâ&#x20AC;&#x2122;s population, slightly higher than the national average. Life expectancy has increased, and birth rates have declined and these factors change the age profile of our communities. It is predicted that by 2020, residents aged 65 years and over will make up nearly 20% of the stateâ&#x20AC;&#x2122;s population (Long-Term Fiscal Pressures Report in NSW Government (Treasury) Budget Paper 6, 2011-12 NSW). Overall, older people in NSW have a high standard of health and good access to health care services (People: Population Atlas of NSW, 2012).

Nursing and Midwifery in NSW

However, as the proportion of older people increases, so will the incidence of age-related health consequences, including acute and chronic illness, frailty and disability. Most significant are dementia, cardiovascular illness, some disabilities and some cancers. Other factors that are not specifically age related but impact on health and wellness during ageing include insecure housing or homelessness, lack of transport, social isolation, poverty, mental illness, violence and exploitation, and effects of drug and alcohol use.

It is predicted that by 2020, residents aged 65 years and over will make up nearly 20% of the stateâ&#x20AC;&#x2122;s population ... As the proportion of older people increases, so will the incidence of age-related health consequences, including acute and chronic illness, frailty and disability. The majority of older people receiving some sort of care receive this from informal carers such as spouses, family members, neighbours and friends. Based on national figures, 80% of the personal and household care provided to people in their own homes comes from informal carers (Caring for Older Australians, Report in Australian Government Productivity Commission, 2011). Health and community support services in local communities need to be readily accessible to older people and their carers, to support their health and wellbeing and respond to illness and other needs as people age. There are 885 residential aged care homes in NSW operated by federally funded providers

(Aged Care Standards & Accreditation Agency Ltd, June 2011). About three quarters are run by non-government organisations (NGOs) such as church, and charitable providers, with some run by community organisations and local government. Approximately a quarter of residential aged care homes are run by private companies. There are also a small number of nursing homes managed by the NSW Government, although the government is in the process of transferring its state-run homes to the non-government sector, and has only ten remaining residential aged care homes (State Nursing Home Transfer Project, 2011, in NSW Government of Health). Aged care beds are also operated by the NSW government in Multi Purpose Services. These are attached to public hospitals in rural and remote areas, and include a mix of beds for short term and long term stay. Overall, NSW Health has 1714 high care, low care and transitional aged care beds, across 56 services.

Aged care nursing and care workforce The aged care workforce would need to quadruple by 2050 to meet the care needs of our ageing population (Caring for Older Australians, Report in Australian Government Productivity Commission, 2011). While this is based on national figures, the impact for NSW is clear. The demand on aged care and health services will increase as the proportion of older people grows, while the pool of nurses and care staff, and informal carers, may also decrease due to overall population ageing. Nursing care in aged care is provided by registered and enrolled nurses, and assistants in nursing (however titled). Nurses and AiNs working in federally funded aged care facilities and services come under the federal award and enterprise bargaining system. While progress is being made via enterprise bargaining, there is still a significant gap between the wages of nurses working in

Nursing and Midwifery in NSW

this system and their counterparts working in the public system. This wage gap is a major contributor to staffing pressures in aged care.

Older people, hospitals and community support Older people, especially those who are very old, frail or living with illness, dementia or disability, will need hospital nursing care to attend to medical emergencies, traumatic injuries or infections. However alternative strategies should be in place to attend to their general care needs so that hospital admissions are minimised.

There must be commitment to reduce reliance upon hospitals and emergency departments as the main response for older people, through better alternatives that support quality of life and care at home. The length of hospital stay for older people tends to be longer, as there is an increased risk of deterioration and post-discharge recuperation is slower. Despite knowing that older people fare better outside of hospital, people aged 75 years and over are occupying 29% of acute bed days and with an average annual growth of almost 1% since 1997 (NSW Health, Access Issues at NSW Public Hospitals: Key Strategies, 2003). In recent years, there has been an 8% annual increase in attendances by people aged 80+ years in emergency

Nursing and Midwifery in NSW

departments, and this is the entry point for 90% of older people who are admitted to hospital. Emergency departments create added burden on older people, particularly those with complex health problems, dementia or other cognitive diseases. These environments have high stimulus, are unfamiliar, bring contact with multiple new people and systems, long wait times, and can increase anxiety, confusion and immobility, even in a relatively short period of time. There must be commitment to reduce reliance upon hospitals and emergency departments as the main response for older people, through better alternatives that support quality of life and care at home. These include ensuring support services, early intervention and health promotion and prevention services are prioritised. For example, c allocating extra funding to the Dementia Services Framework 2010-15 which is largely allocated within existing resources (NSW Health Dementia Services Framework 2010-15, 2011); c ensuring specialist services that support older people at home and in their community such as palliative care services and advanced care planning services are granted secure funding so that peopleâ&#x20AC;&#x2122;s end of life choices are clear and enacted; c support of informal carers, who are the main support for older people in the community; c extending the Hospital in the Home program; and, c increasing the number of nurse practitioners in Local Health Districts (LHDs) who can provide quick response to older people in their own homes or within residential aged care homes to intervene before escalation of health problems and prevent unnecessary hospital admissions.

References Aged Care Standards and Accreditation Agency Ltd. June, 2011.Downloaded 19/11/12 from www.accreditation.org.au/about-us/the-standard AIHW Medical Labour Force Surveys, 2005, 2007, 2009, unpublished ABS estimated resident population data. Armstrong, F. (2009). Ensuring quality, safety and positive patient outcomes: Why investing in nursing makes $ense. Melbourne: Australian Nursing Federation. Downloaded 09/11/12 from http://anf.org.au/documents/reports/Issues_ Ensuring_quality.pdf Armstrong, F. (2004). Can you hear us? There’s a nursing shortage. Australian Nursing Journal, 12, 21-24. Australian College of Operating Room Nurses Incorporated (ACORN) 2007. Downloaded 14/06/13 from www.acorn.org.au/about-us.html Australian Government Productivity Commission (2011). Caring for Older Australians, Report, No. 53. Final Inquiry Report, Canberra Australian Healthcare & Hospitals Association (24 September, 2012). Health budgets will leave NSW hospitals dangerously short staffed. Downloaded 19/11/12 from http://ahha.asn. au/news/health-budget-cuts-will-leave-nswhospitals-dangerously-shortstaffed Australian Health Practitioner Regulation Agency (AHPRA). Website Downloaded 03/01/13 from www.ahpra.gov.au/AboutAHPRA/Contact-Us/Make-an-Enquiry.aspx Australian Health Practitioner Regulation Agency (AHPRA). The Annual Report for 20112012. ACT, Canberra. ISBN: 1858-5060. Australia’s Health Workforce Online (2008). Mental Health Workforce: Supply of mental health nurses. Downloaded 19/12/12 from www.ahwo.gov.au

Australian Institute of Health and Welfare (AIHW) (2012). Nursing and midwifery workforce 2011. National health workforce series no. 2 Cat. No. HWL 48. Canberra:AIHW. Australian Institute of Health and Welfare (AIHW) (2012a). Numbers of nurses and midwives increasing – but not keeping up with population growth. Media Release 28 June. Downloaded 16/11/12 from www.aihw.gov.au/ media-release-detail/?id=10737422242 Australian Institute of Health and Welfare (AIHW) (2012b). Nursing and midwifery workforce 2011. National health workforce series no. 2. Cat. no. HWL 48. Canberra: AIHW. Downloaded 09/11/12 from www.aihw.gov.au/ publication-detail/?id=10737422167 Australian Nursing Federation(ANF) (April 2009). Primary Health Care in Australia: A nursing and midwifery consensus view. Downloaded 19/12/12 from http://anf.org.au/ documents/reports/PHC_Australia.pdf . Australian Nursing and Midwifery Council (ANMC) (August, 2008). Code of Professional Conduct for Midwives. Downloaded 14/06/13 from http://nursesstaging.elcom.com.au/Codeof-Professional-Conduct/default.aspx Australian Nursing and Midwifery Council (ANMC) (January 2003). Code of Professional Conduct for Nurses in Australia. Downloaded 14/06/13 from www.google.com.au/url?sa=t&rct= j&q=&esrc=s&frm=1&source=web&cd=4&sqi=2 &ved=0CDwQFjAD&url=http%3A%2F%2Fwww. nmb.nsw.gov.au%2FArticleDocuments%2F97%2F ANMC_Professional_Conduct.pdf.aspx&ei=P3q6 UavQA87ukgW3m4CQBQ&usg=AFQjCNGApH PE-ooi6zcmaby_tREEeD5hcw&sig2=a1ViH73plSF vrViYezIXyw

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Australian Nursing and Midwifery Council (ANMC) (2006). National Competency Standards for the Nurse Practitioner. Downloaded 03/01/13 from www.nursingmidwiferyboard.gov.au/en/ Codes-and-Guidelines.aspx Australian Nursing and Midwifery Council (ANMC) (May, 2013). National Guidelines for the Accreditation of Nursing and Midwifery Program Leading to Registration and Endorsement in Australia. Downloaded from www.anmac.org.au

Dietsch, E., Davies, C., Shackleton, P., Alston, M., & McLeod, M. (2008). ‘Luckily we had a torch’: Contemporary birthing experiences of women living in rural and remote NSW. Faculty of Science, School of Nursing and Midwifery, Charles Sturt University. Downloaded 13/11/12 from http://bahsl.com.au/ old/pdf/birthing-in-rural-remote-NSW.pdf Doiron, D., & Jones, G. (2006). Nurses’ retention and hospital characteristics in New South Wales. The Economic Record, 82(256), 11-29.

Buchan, J.M., Naccarella, L. & Brooks, P.M. (2011). Is health workforce sustainability in Australia and New Zealand a realistic policy goal? Australian Health Review, 35, 152-155.

Duffield, C., Roche, M. A., Blay, N., & Stasa, H. (2010). Nursing unit managers, staff retention and the work environment. Journal of Clinical Nursing, 20, 23-33.

Bupa. Our Care Homes. Downloaded 19/12/12 from www.bupaagedcare.com.au/choosing-ahome/Our-care-homes

Duffield, C., Roche, M., O’Brien-Pallas, L., Diers, D., Aisbett,C., Aisbett, K.,& Homer, C. (2010a). Nursing Workload and Staffing: Impact on Patients and Staff. Centre for Health Services Management. UTS, Broadway, NSW.

Carryer, J. B., Diers, D., McCloskey, B., & Wilson, D. (2010). Effects of health policy reforms on nursing resources and patient outcomes in New Zealand. Policy, Politics and Nursing Practice, 11(4), 275-285. Chaboyer, W., Wallis, M., Duffield, C., Courtney, M.D., Seaton, P., Holzhauser, K., Schluter, J., & Bost, N. (2008). A comparison of activities undertaken by enrolled and registered nurses on medical wards in Australia: an observational study. International Journal of Nursing Studies, 45(9), pp. 1274-1284. Chidlow, L. (2011). Want to get back into nursing? Well, good luck! Downloaded 19/11/12 from www.abc.net.au/local/ stories/2011/11/30/3379896.htm Collins, C. (2010). American Academy of Nurse Practitioners Celebrating 25 Years as the Voice of the Nurse Practitioner. Seabury & Smith Inc. Downloaded 02/01/13 from http://issuu.com/ faircountmedia/docs/aanp25?mode=window&p ageNumber=4 Commonwealth Corporations Act. Section 9. 2001. Coroners Act (NSW) 2009.

Nursing and Midwifery in NSW

Duffield, C., & L. O’Brien-Pallas, L. (2003). The causes and consequences of nursing shortages: a helicopter view of the research. Australian Health Review, 26(1): 192-199. Eley, R., Eley, D., & Rogers-Clark, C. (2010). Reasons for entering and leaving nursing: an Australian regional study. Australian Journal of Advanced Nursing, 28(1):1 -13. Francis, K.L.,& Mills,J.E. (2010). Sustaining and growing the rural nursing and midwifery workforce: Understanding the issues and isolating directions for the future. Collegian,18(2),55-60. Downloaded19/11/12 from www.collegianjournal. com/article/S1322-7696(10)00075-2/fulltext Gordon, C. & Marshall, N. (2012). Is shiftwork a health hazard? Why nurses are at risk. Presented at the Sydney Nursing School, University of Sydney Research Seminar, November 8th, 2012. Graduate-friendly hospitals. My Career. (1 March, 2008). Downloaded 19/12/12 from http://content.mycareer.com.au/advice-research/ graduate/guide/healtth/healthdc Health Professionals Workforce Plan Taskforce. Technical Paper. (October, 2011). NSW Ministry of Health, North Sydney.

Health Workforce Australia (HWA).(2012). Health Workforce 2025 – Doctors, Nurses and Midwives (Vol.1). Adelaide, SA: HWA.

Mrayyan, M. T. (2004). Nurses’ autonomy: influence of nurse managers’ actions. Journal of Advanced Nursing, 45(3), 326-336.

Heath, P., Duncan, P., Lowe, E., Macri, S., & Ramsay, J. (2002). Australian Department of Education, Science and Training. National Review of Nursing Education 2002: Our Duty of Care. www.dest.gov. au/highered/nursing/pubs/duty_of_care/html

National Nursing & Nursing Education Taskforce (2006.) Towards Consistent Regulation of Nursing and Midwifery Practice in Australia: A select analysis of the legislation and professional regulation of nursing and midwifery in Australia. A report prepared by Amanda Adrian and Associates for the National Nursing and Nursing Education Taskforce.

International Confederation of Midwives (2011). Downloaded 04/03/13 from website www.internationalmidwives.org International Council of Nurses (2001). Defining Nursing. ICNP Review process: How to participate. Geneva: ICN. Jamieson, I. (2009). Generation Y – why nursing must retain this workforce. Kai Tiaki Nursing New Zealand, 15(7), 18-20. Keleher, H. (2001). Why primary health care offers a more comprehensive approach for tackling health inequities than primary care. Australian Journal of Primary Health, 7(2), 57-61. Lavoie-Tremblay, M., Paquet, M., Duchesne, M-A., Santo, A., Gavranic, A., Courcy, F., & Gagnon, S. (2010). Retaining nurses and other hospital workers: An intergenerational perspective of the work climate. Journal of Nursing Scholarship, 42(4), 414-422.

National Seniors Productive Ageing Centre (NSPAC) (2012). Ageing Baby Boomers in Australia: Understanding the effects of the global financial crisis. Canberra: NSPAC. Downloaded 19/11/12 from www.productiveageing.com.au/userfiles/file/PAC_ BabyBoomersReport%20-%20low%20res(1).pdf New South Wales Government, Department of Planning (2006). New South Wales Statistical Local Area Population Projections 2001-2031. Redfern, NSW: New South Wales Government. Downloaded 16/11/12 from www.planning.nsw. gov.au/LinkClick.aspx?fileticket=0pSSHdnFAc0 %3D&tabid=124&language=en-AU New South Wales Nurses and Midwives’ Association (October, 2012). Midwifery Reference Group: Feedback on professional, education and workforce matters. Waterloo, NSW: NSWNMA.

Lee, H., & Cummings, G. G. (2008). Factors influencing job satisfaction of first line nurse managers: a systematic review. Journal of Nursing Management, 16, 768-783.

New South Wales Nurses and Midwives’ Association. The Public Health System Nurses’ and Midwives’ (State) Award 2011. Waterloo, NSW: NSWNMA.

Levett-Jones, T., & FitzGerald, M. (2006). A review of graduate nurse transition programs in Australia. Australian Journal of Advanced Nursing, 23(2), 40-46.

Nicholls, S. (14 Sept, 2012). Health budget slashed by $3 billion. Sydney Morning Herald. Downloaded 19/11/12 from www.smh.com.au.nsw/healthbudget-slashed-by-3-billion-20120914-25vzg.html

McCloskey, B. A., & D. K. Diers (2005). Effects of New Zealand’s health re-engineering on nursing and patient outcomes. Medical Care, 43(11), 1140-6. McLachlan, H.L., Foster, D.A., Davey, M.A., Farrell, T., Gold, L., Biro, M.A., Albers, L., Flood, M., Oats, J. & Waldenstrom, U. (Nov, 2012). Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomized controlled trial. An International Journal of Obstetrics and Gynaecology, 119(12): 1483-1492.

NSW Department of Health (2003). Access Issues at NSW Public Hospitals: Key Strategies. NSW Department of Health (2009). Workforce Development & Innovation Branch. Health System Support Division. Assistants in Nursing Working in the Acute Care Environment Health Service Implementation Package.

Nursing and Midwifery in NSW

NSW Government (The Treasury) Budget Paper 6. 2011-12 NSW: Long-Term Fiscal Pressures Report, Appendix D:2006-07 Long Term Fiscal Pressures Report: Projections Summary, p. D-1. NSW Government, Health. Nursing and Midwifery Office. Graduate Registered Nurse and Registered Midwife Transition Recruitment 2013. Downloaded 17/12/12 from www0.health.nsw.gov.au/nursing/recruit.html NSW Government, Health. State Nursing Home Transfer Project (29.4.11). Downloaded 30/11/12 from www0.health.nsw.gov.au/Initiatives/ nursinghomes/about.asp NSW Health. Dementia Services Framework 2010-2015 (10/03/2011). Downloaded 30/11/12 from www0.health.nsw.gov.au/policies/gl/2011/ pdf/GL2011_004.pdf NSW Nurses & Midwives’ Association. A Nurses’ & Midwives’ Guide to Reasonable Workloads Committees (nd). Downloaded 14/06/13 from www.nswnurses.asn.au/multiattachments/35130/ DocumentName/A%20nurses%20and%20 midwives%20guide%20to%20reasonable%20 workloads%202011%20Version.pdf NSW Nurses and Midwives’ Association website. Downloaded 20/11/12 from www.nswnma.asn.au Nursing and Midwifery Board of Australia (NMBA) (February, 2010). A nurse’s guide to professional boundaries. Downloaded 14/06/13 from www.nursingmidwiferyboard.gov.au/ Codes-Guidelines-Statements/Codes-Guidelines. aspx#professionalboundaries Nursing and Midwifery Board of Australia (NMBA). Australian College of Midwives. Australian Nursing Federation (August, 2008). Code of ethics for midwives in Australia. Downloaded 14/06/13 from www.bing.com/searc h?q=code+of+ethics+for+midwives.+australian+ nursing+%26+midwifery+council.+australian+co llege+of+midwives.+australian+nursing+federatio n&qs=n&form=QBRE&pq=code+of+ethics+for+ midwives.+australian+nursing+%26+midwifery+ council.+australian+college+of+midwives.+austra lian+nursing+federation&sc=0-0&sp=-1&sk=

Nursing and Midwifery in NSW

Nursing and Midwifery Board of Australia (NMBA). Australian College of Nursing. Australian Nursing Federation (August, 2008). Code of Ethics for Nurses in Australia. Downloaded 14/06/13 from www.google.com. au/url?sa=t&rct=j&q=&esrc=s&frm=1&sourc e=web&cd=1&ved=0CCwQFjAA&url=http% 3A%2F%2Fwww.nursingmidwiferyboard.gov. au%2Fdocuments%2Fdefault.aspx%3Frecord%3 DWD10%252F1352%26dbid%3DAP%26chksu m%3DGTNolhwLC8InBn7hiEFeag%253D%253 D&ei=Q1K6UdzaN4XNkgXbloDwBg&usg=AF QjCNGoKmCj7fYBIvSVAp742-CL3oguwQ&sig 2=OVmYD24h7WpxCBk25hPGxg&bvm=bv.47 883778,d.dGI Nursing and Midwifery Board of Australia (NMBA). Continuing Professional Development Registration Standard. Downloaded 04/03/13 from www.nursingmidwiferyboard.gov.au/ Codes-Guidelines-Statements.aspx Nursing and Midwifery Board of Australia (NMBA). Endorsement as a nurse practitioner registration standard (2011). Nursing and Midwifery Board of Australia (NMBA). Endorsement as a nurse practitioner guidance for submitting portfolio (Pathway 1 & 2) (April 2012). Nursing and Midwifery Board of Australia (NMBA). Guidelines for Advertising of Regulated Health Services. Downloaded 04/03/13 from www.nursingmidwiferyboard.gov.au/Search. aspx?q=guidelines%20for%20Advertising%20 of%20Regulated%20Health%20Services Nursing and Midwifery Board of Australia (NMBA). Guidelines for Mandatory Notification. Downloaded 04/03/13 from www.nursingmidwiferyboard.gov.au/Search. aspx?q=guidelines%20for%20Advertising%20 of%20Regulated%20Health%20Services Nursing and Midwifery Board of Australia (NMBA). Guidelines for Professional Indemnity Arrangements for Midwives. Downloaded 04/03/13 from www.nursingmidwiferyboard.gov.au/Search. aspx?q=guidelines%20for%20Advertising%20 of%20Regulated%20Health%20Services

Nursing and Midwifery Board of Australia (NMBA). Guidelines for Professional Indemnity Insurance Arrangements for Nurses and Nurse Practitioners. Downloaded www.nursingmidwiferyboard.gov.au/Search. aspx?q=guidelines%20for%20Advertising%20 of%20Regulated%20Health%20Services Nursing and Midwifery Board of Australia (NMBA). Recency of practice registration standard. Downloaded 14/06/13 from www.shiregps.org.au/documents/Practice%20 Nurse%202010/Recency%20of%20practice.pdf Nursing and Midwifery Board of Australia (NMBA). Re-Entry to Practice Policy 2011– Consultation Draft. Downloaded 04/03/13 from www.nursingmidwiferyboard.gov.au/documents/ default.aspx?record=WD... Nursing Review (13 November, 2012). NSW Government targets pay and conditions. Downloaded 20/11/12 from www.nursingreview.com.au/pages/ section/article.php?s+News&idArticle=24734 NSW Work Health & Safety Act 2011. NSW Work Health & Safety Regulation 2011. Nursing and Midwifery Board of Australia (NMBA) website. Downloaded 03/01/13 from www.nursingmidwiferyboard.gov.au Nursing and Midwifery Office, NSW Health. Duffield, C. (2007) Glueing it Together: Nurses, Their Work Environment and Patient Safety, Downloaded 28/11/12th from www.health.nsw. gov.au/pubs/2007/pdf/nwr_report.pdf Nurses and Midwives Board New South Wales website. Downloaded 03/01/13 from www.nmb. nsw.gov.au Primary Health Care Reform in Australia (2009). Report to Support Australia’s First National Primary Health Care Strategy. ISBN: 1-74186936-6. Online ISBN: 1-74186-937-4. Publications Number: P3 -5480.

Ratios get a big tick. Nurse Uncut Australia. NSW Nurses & Midwives’ Association. Downloaded 16/11/12 from www.nurseuncut.com.au/ratiosget-a-big-tick Report on the Evaluation of the Nurse Practitioner Role in NSW. (July, 2009). School of Nursing & Midwifery. Curtin University of Technology. Russell, R.L.(Feb, 2005). From hospital to university – the transfer of nurse education. Nursing History Research Unit. Faculty of Nursing, University of Sydney. Downloaded 16/12/12 from www.cdnm. edu.au/wp-content/uploads/2011/09/His Shacklock, K., & Brunetto, Y. (2012). The intention to continue nursing: work variables affecting three nurse generations in Australia. Journal of Advanced Nursing, 68(1): 34-46. doi: 10.1111/j.1365-2648.2011.05709.x. Stigall, R. (March 31, 2010). The “Medicalization” of the Birthing Process. EzineArticles.com. Downloaded 02/01/13 from http://ezinearticles. com/?The-Medicalization-of-the-BirthingProcess&id=4033461 The rise and rise of nurse practitioners. (7 August, 2009). Medical Observer. Parliamentary Library Western Australia. Downloaded 02/01/13 from www.parliament.wa.gov.au/intranet/libpages.nsf/ WebFiles/ITS+-+nurses+article+Mansberg+2009/ $FILE/nurses+article+Mansberg.pdf Wachsmuth, L. (10 October, 2012). Threat of nursing job cuts: opposition. Illawarra Mercury. Downloaded 20/11/12 from www.illawarramercury.com.au/ story/387023/threat-of-nursing-jobs-cuts-opposition Yamini, E. (March 21, 2012). Violent hospital attacks increase, especially on nurses. The Daily Telegraph. Downloaded 10/12/12 from www.dailytelegraph.com.au/newssydney-news/v/ iolent-hospital-attacks-increase-especially-onnurses/story-e6freuzi-1226305689405

People: Population, Atlas of NSW. Downloaded 30/11/11 from http://atlas.nsw.gov.au/public/ nsw/home/index-2.html

Nursing and Midwifery in NSW

Nursing

and Midwifery

in New South Wales ISBN: 978-1-921326-10-3

NSW Nurses and Midwives’ Association 50 O’Dea Avenue, Waterloo NSW 2017 T 8595 1234 (metro) 1300 367 962 (non-metro) W www.nswnma.asn.au

Authorised by B.Holmes, General Secretary, NSW Nurses and Midwives’ Association | August 2013