The first degree education that nurses receive is in a university or polytechnic. Depending on the educational institution, nursing may be contained in a wider health sciences school, placed among social sciences, or operate in isolation. There is no common pattern in these arrangements. At the University of Auckland, the School of Nursing brings together medical, nursing and some other health professionals, while at the University of Otago, the health sciences school does not teach nursing at undergraduate level at all. Seventeen universities and polytechnics award an undergraduate degree in nursing through twenty different institutions and educational programmes in nursing, thirteen of which award post graduate degrees.
The engagement of universities and polytechnics with health services is usually with nearby DHBs. While no study has been carried out of these relationships, it is understood that they vary considerably. Even where they work at their best, the balancing of supply and demand for nurses is inevitably short term, and reflects the DHB capacity to employ nurses once graduated, and the university or polytechnic capacity to obtain applications at a sufficient level. This local balancing of supply and demand is independent of any organised study of national trends, potential shortfalls or surpluses elsewhere, or national targets. It can create great uncertainty as DHB budget balances fluctuate, and necessitates nurses being highly mobile if they are to be employed as nurses when they need to be.
The relationship between such an accumulation of independently managed local activities and a mix of national expectations may develop more effectively with both educators and practitioners contributing to their oversight. Without this, the more specific needs of the nurse workforce often get omitted, for example the needs of mental health, of Maori and Pacific Island communities. There is little capacity to balance long term benefits with current costs, as each institution in the system is accountable for the year on year viability of its finances, and few levers to make this happen at a national level.
Chart 6: Education provider student intake of Bachelor of Nursing first year students, 2008
Source: Ministry of Education
Note: this is a student headcount
The return an individual gets from obtaining nursing qualifications would be determined by their national and international employability. Given the high loss rate from nursing, it is possible that nurses perceive benefits from having the opportunity of other employment because of the value placed by other employers on the mix of aptitudes and skills that nurses typically bring.
The lower than usual return in the rewards from nursing from making an investment in nursing qualifications may also lead to a greater sensitivity to salary change of the number of former nurses available for re-engagement as nurses. Work on improving retention would need to evaluate how far the return on investment from nurse education is influenced by factors unique to nursing.
The Nurse Education system
Nurse education is initially aimed at achieving registration as a Nurse by the Nursing Council of New Zealand, with the national and international recognition of fitness to practice that this brings. Now, the usual path in New Zealand for this has been to graduate with a Bachelor of Nursing (or similarly named) degree at one of 17 accredited institutions in New Zealand. There are a large number of tertiary institutions delivering the same outcome – a degree and consequent accreditation after examination as a Registered Nurse. Many of the courses have few students. There are many advantages in having some diversity in the delivery of the educational programme, but we might wish to periodically assess:
Are the outcomes consistent amongst the 17 different tertiary institutions, and does any such variability influence the overall quality of education?
What is needed to increase collaboration in the form of programmes provided at each institution? Would one national programme provide consistent outcomes?
What could national leadership do to further the capacity and reach of successful innovative ways of educating and mentoring students that have improved outcomes for Maori and Pacific island students?
How far does the number trained in local tertiary institutions usually fit with local needs?
Along with the completion of a degree, and success in employment, one of the most critical stages in the development of the future nursing workforce is the willingness of people now to apply for acceptance into training. The last twenty years has seen a huge decline in the share of New Zealand women entering nurse training, although the effect of this on the nurse workforce has been offset by the increase over the past decade in the recruitment of overseas trained nurses. Overseas trained nurses are generally older than new trainees, and to this extent the reliance on overseas nurses will eventually exacerbate the long run fragility of the age composition of the nurse work force. In 2006, nursing was at a post war peak as a preferred occupation for women aged between 45 and 54 years, with just over four percent of the women born during the 1950s stating their occupation as nurse. In their twenties, this cohort had just over one in fourteen women enter nursing, although only half of these remained in nursing after ten years. This cohort had the highest rates of marriage and fertility seen in New Zealand, some 85 percent becoming mothers by the time they were aged 25. In starkest contradiction to this, we see now the lowest ever share of women 15-24 years working as nurses.
Chart 7: Ethnicity of Bachelor of Nursing first year entrants 2002 to 2008
Source: Ministry of Education
Note: excludes NZ European
Annually, applications to enter nursing education used to imply a long run average of four to five percent of all women born becoming nurses at some stage of their lives.
The selection criteria for acceptance into a nurse undergraduate degree course vary around New Zealand. In most courses there is little culling of applicants, and usually it is understood anecdotally that there may have been overall perhaps eleven or twelve applications per every ten entrants to BN training. The main exception to this is the BN course at Auckland University, which each year received some 700 applications across all health sciences that include nursing as a choice, in order to select 100 first year undergraduate positions. The independent management of information about applications by each institution, and their reluctance to share this makes it difficult to identify and distil trends, and share good practice. It reduces the capacity to effectively understand how much different generations seek careers in nursing.
Nationally, the average annual number of enrolments in undergraduate nurse programmes is over 1500, but the later completion of a degree and nurse registration is affected by high attrition rates. These vary across education centres and years. Some schools have 45 percent attrition, with a national attrition rate in the order of 20 to 25 percent. The attrition rates are higher for Maori and Pacific Island enrolments, as well as older students. Evaluation of attrition rates and what is associated with the high variation across institutes would identify good practice that could be shared, and supported nationally. It may also reflect differences across the country in the quality of the education nurse undergraduates have received at school.
One recent initiative of fundamental importance has been the Nurse Entry to Practice (NETP) Programme. This programme of structured clinical experience has been introduced in 2006 to provide nurses with a structured and managed introduction to working as a nurse. Entry into NETP follows immediately the completion of an undergraduate degree, and acceptance for registration as a nurse, In 2009, this course covered two thirds of all BN graduates of 2008. In Scotland, the NETP programme equivalent called “Flying Start” is a web based programme. DHBs are funded for the provision of clinical placements by the Clinical Training Agency, and the availability of the placements requires strong collaboration.
The entry into employment of nurses once registered has a high degree of variability. The generally poor monitoring of vacancies gives little understanding of pressures emerging on health employers, and the consequent volatility in employment is increasingly reflected in a shift in the balance between the recruitment of overseas nurses rather than longer term investment in the education of New Zealand nurses.