Eight into one: national registration y 2010: it has been a long-fought battle by peak nursing bodies and there has been strong opposition from doctors but a national registration and accreditation system for health professionals is about to become a reality. Cate Carrigan investigates what will it mean for nurses across Australia.
In March this year the Council of Australian Governments (COAG) signed off on a scheme viewed by nursing bodies and leading health reformers as a way to deliver increased flexibility and portability to the health care sector, while guaranteeing quality and uniform standards across the country.
The National Accreditation and Registration system, to be in place by July 2010, will abolish state and territory registration boards and establish a national agency to oversee the registration and accreditation of nine professional health groups: medicine; nursing and midwifery; physiotherapy; dentistry; pharmacy; chiropractic; psychology; optometry; and osteopathy.
Under the system, the national body will decide on an overall policy but nine profession-based boards will carry out functions on its behalf, including dealing with disciplinary matters of registrants.
National accreditation bodies such as the Australian Nursing and Midwifery Council (ANMC) and the Australian Medical Council will continue their work for a time before being reconstituted under a national body with committees and offices at the state and territory level.
In announcing the move to a national system, the state, territory and federal health ministers said the aim was to improve patient protection by ensuring only suitably trained and competent practitioners were registered; to cut red tape and allow for a more mobile workforce; to ensure high quality education and training; and for a more responsive and sustainable Australian health workforce.
COAG's decision followed a 2006 Productivity Commission report into Australia's health workforce that highlighted a major shortage of health professionals, particularly in outer metropolitan, rural and remote communities. The Productivity Commission called for a national integrated registration and accreditation system, arguing the efficiency and effectiveness of the health workforce was inextricably linked to Australia's education and training regime.
It found that while there had been growth on workforce numbers (the 2006 figures showed 450,000 health professionals in Australia, of whom over half were nurses), there were still shortages, particularly in general practice, mental health, aged care, disability services, various medical specialty areas, nursing and dentistry.
The report also found a growing reliance on foreign trained doctors (25% of the workforce), and systematic problems in having competencies fully developed, assessed and recognised meant the skills of many health workers were not being used to furl advantage.
But COAG's decision to implement a national system was not welcomed by all health professionals with the Australian Medical Association (AMA) arguing it would strip medical colleges of their control in setting educational and training standards for doctors, and put it in the hands of politicians and people without expertise.
The AMA also claimed bringing the nine health professional bodies together under one agency could undermine quality by creating a system where other health workers were seen as interchangeable with doctors.
However peak nursing bodies see the objections as more about self-interest than patient care and health quality, with the Australian Nursing Federation's national professional officer Julianne Bryce arguing a national framework "can only stand to benefit both doctors and the community."
Another who's critical of the AMA is the chair of the Centre for Policy Development in Sydney, John Menadue, who told a March health summit that nurses must take on "the nonsense" of doctors who argued health workforce reform would imperil the quality of service to their patients.
Mr Menadue said that resistance by doctors had held back the deployment of nurse practitioners (NPs) across Australia, saying there should be thousands rather than the current 300 and that in many areas they can substitute for general practitioners.
Workforce flexibility was one of the main objectives outlined by the ministers in signing the intergovernmental agreement (IGA) but the main aim remains increased public safety and patient care.
Health Minister Nicola Roxon has hailed the new system as a way of preventing rogue doctors from being able to practice when deregistered.
Chief executive officer of the Australian Nursing and Midwifery Council (ANME), Karen Cook, agrees that protecting the public and making sure every person caring for a member of the community is a safe and competent practitioner is the main aim of the system.
The ANMC, which has been working towards a national system since it was established in 1992, sees national accreditation and consistency in education and training standards as paramount to this objective.
The present system, with eight different ways of doing things across the states and territories, is "letting the community down", says Ms Cook. "Now we'll be able to ensure that health care consumers know that the nurse looking after them, wherever they have been educated, meets the same standards of professional practice."
While Ms Cook believes there are currently good systems in place to ensure information is shared if a nurse has been deregistered or if there's a disciplinary matter, she argues these systems are not perfect and need to be consistent across the country.
The ANMC would also support the inclusion of mandatory reporting, which is now in place in states such as New South Wales, into the national laws in a bid to encourage people to speak up if they have concerns about colleagues' competence.
"Whistleblowers are often treated very badly and this makes people reluctant to come forward. We need to create a culture of safety where it's OK to raise concerns about colleagues," Ms Cook says.
The ANF's Julianne Bryce agrees that raising complaints is an onerous issue.
"The main benefit (of the national register) is that it will be more difficult to slip under the radar and go from state to state or territory if you have issues," she says.
A national system is also being hailed as a major breakthrough for career portability and flexibility. Pointing to the bureaucratic hurdles of the current system, the ANMC's Karen Cook says nurses and midwives wanting to go to another state to assist in a natural disaster such as a cyclone can't just "pack her bags and go" but requires registration in that state.
Ms Bryce says the problem is confronted by nurses living in border towns every day. "In towns like Albury-Wodonga (on the New South Wales/Victoria border) and Tweed Heads (Queensland/New South Wales) you have to be registered in both states and, in some instances, have had different scopes of practice in the two states."
There are also the career portability barriers and Ms Bryce says that until recently, Victoria required maternal and child nurses to be midwives, something not needed in other states.
The president of the Australian Nurse Practitioners Association, Andrew Cashin, is looking forward to a set of consistent rules for nurse practitioners (NPs) across the country. As part of the new system, Mr Cashin wants the abolition of practice guidelines that require the approval of individual formularies (the range of medicines the NP can prescribe). "It should be a national classification system where a nurse practitioner is recognised as having the expertise to access a formulary that is in line with their specialty area, so for example a mental health nurse could have access to medicines used in psychiatry."
Mr Cashin is hopeful national registration and accreditation will go hand-in-hand with a rethink on access to MBS and PBS funding for NPs to enable their patients to access subsidised medicines.
Such reforms would enable NPs to fully meet their potential both within the hospital setting and within the community. "If this happened, I'd imagine we'd be seeing a lot more (NPs) in hospitals, at large general practices and in their own practices."
The chair of the Council of Deans of Nursing and Midwifery (CDNM), professor John Daly is also confident about such changes. "There was recognition at the recent 2020 Summit that we need to move away from a physician-centric acute care system to one that is more patient centred and has much stronger primary health care.
"I think there will be diversification and we will see others with prescribing rights and access to MBS benefits for the services they provide. I think this will include nurses and midwives but also others, such as pharmacists."
Professor Daly acknowledges there will be opposition. "Of course the conservative arm of the medical profession will rail against all of this but there's no way with the workforce issues confronting us, that medicine will be able to service all of the rural and remote areas so that we have equitable access to quality health care services."
Standardising benchmarks and requirements for nurses and midwives across the country is a major part of the new system and is being conducted through the national accreditation process overseen by the ANMC.
The ANMC's Karen Cook says while the work toward national consistency in education and ongoing training has come a long way, it has been held back by the eight different pieces of state and territory legislation.
The ANF's Julianne Bryce says the work going on with the National Accreditation Standards development will examine appropriate levels of qualification and curriculum expectations. "We do have quite a bit of consensus about the Bachelor of Nursing and Bachelor of Midwifery degrees and a lot of work is being done to ensure graduates have consistent levels of skill," she says.
Elizabeth Foley, the policy director with the Royal College of Nursing Australia argues the national accreditation standards aren't about trying to stifle the creativity of universities, but ensuring certain core areas such as Indigenous health are covered. "Other units can be offered as add-ons but we need to know certain key units are taught."
The CDNM's John Daly says there are currently differences in standards across the states and territories. "This is an opportunity to take a really good look across the landscape and create a level playing field of quality and accreditation processes."
Professor Daly cites variation in clinical education hours as one area that needs addressing. "The requirement range is from 400-1800 hours across the country; that's just not sensible. There has got to be some consideration of what are the essential elements in the curriculum in order for us to best prepare a clinician for work now and into the future."
However, there are some elements of the current system he wants retained, such as the link between regulation and accreditation. "In NSW, the Nurses and Midwives Board is responsible for regulating and implementing the Nurses and Midwives Act, while also reviewing and accrediting courses for enrolled and registered nurses and midwives, we want that sort of link maintained.
"It's also important that there is ongoing consultation with professional bodies. We will be looking very carefully at how they will do this and we would expect to be consulted and listened to. We don't want to end up with flaws in the mechanisms and policies that will cause problems further down the track," says professor Daly.
Whether or not the new system can break down barriers between the health professions remains to be seen, but the ANMC's Karen Cook believes if it does, it will be a plus. "I think we have some amazing multidisciplinary teams in health services around the country and we've got good models on interprofessional learning with a lot of universities. But if it helps to enhance those relationships, it's got to be better for the consumer."
Ms Cook agrees there is still a long way to go in sorting through the details of the new system, such as ensuring registration fees for nurses and midwives are not used to cross-subsidise other professional groups.
There is also still a question mark about the relationship between the state and territory committees and existing disciplinary bodies such as the health commissions and how they will interact in dealing with cases against health professionals. But she is confident these issues can all be worked through and the system will be up and running by July 2010.
NATIONAL REGISTRATION AND ACCREDITATION THE BASICS
The National Registration and Accreditation Scheme is scheduled to be in place by July 2010.
The scheme will initially cover nine health professional groups: physiotherapy; optometry; nursing and midwifery; chiropractic care; pharmacy; dental care; medicine; psychology; and osteopathy, and allow for one registration and accreditation system across the country.
The scheme will consist of a Ministerial Council (federal, state and territory health ministers); an independent Australian Health Workforce Advisory Council; a national, agency with an agency management committee; national profession-specific boards; committees of the boards; a national office to support the operations of the scheme; and at least one local presence in each state and territory.
The nine profession-based boards will be responsible for both registration and accreditation functions.
The boards will establish state and territory committees to carry out functions on their behalf, including dealing with disciplinary matters related to registrants.
Existing state and territory based health registration boards will be abolished to make way for the new national system.
Funding for the scheme will be drawn from registration and accreditation fees and current government funding.
There will be a single national set of fees for each profession, agreed between the boards and the national agency.
The scheme will be reviewed after three years.
Canberra-based Elissa O'Keefe, who is the only specialist sexual health nurse practitioner currently working in Australia, is enthusiastic about the new national system and the opportunities it will offer to nurse practitioners.
Elissa, who works from the Canberra Sexual Health Centre at Canberra Hospital with predominantly at-risk young people, has been a nurse practitioner (NP) for four years. She wants more recognition and use of the skills of those in her profession.
"What's wonderful about the proposed system is that it will give us national benchmarks and consistency in training and education, so that across the country everyone will know exactly what a nurse practitioner is and what they do."
Elissa argues NPs are in big demand and potentially an important part of the solution to the over-stretched health system but the current system doesn't make use of their skills as it should. At present, formularies (the medicines they are authorised to use) are signed off by a local multidisciplinary team, but a national system could see NPs of the one specialty recognised under a unified scope of practice and with access to the same formulary. National recognition and benchmarking add weight to the argument for NPs to get access to the MBS and PBS systems, Elissa says.
"At the moment nurse practitioners are governed by local and state requirements which can be complex and can be reliant on an individual to 'champion' the implementation of the nurse practitioner role.
A more national approach could streamline education, registration, employment and clinical practice and enable nurse practitioners to work to their full potential to fill gaps in service delivery."
The standardisation of educational requirements is another welcome move.
"At the moment, some states require a Masters of Nursing for nurse practitioners and others don't. We really need consistency across the states and territories."
While Elissa sees that there's still a long way to go in making the new system a reality, she's confident it's going to happen and is happy with the "tremendous support" of the peak nursing bodies.
FLYING HIGH NO PLACE FOR STATE BORDERS
For nurses flying across borders to retrieve patients and take them to the best treatment centre, the multiple registration systems in Australia just does not make sense.
That's the view of the president of Flight Nurses Australia, Judy Whitehead, who sees the current system as expensive, bureaucratic and out of step with a very mobile job.
Ms Whitehead, who has worked for The Royal Flying Doctor Service in Broken Hill for 16 years, says it's an ever-changing workload. In May, she had to fly to Moomba oil and gas field in South Australia to pick up an injured worker, take him to Adelaide and then return to Broken Hill, finally getting home at 7pm.
"Borders don't mean terribly much to air ambulance organisations because we can be sent anywhere in Australia."
Ms Whitehead says while there is a system of mutual recognition of flight nurses skills across the various jurisdictions; the registration requirements are an unnecessary and time-consuming problem.
"The present system hinders us because of the bureaucratic requirements of being registered across state borders. We recently had a nurse who had to go on an outback car trek to Queensland and although she was only there for six days, we had to pay $140 to get her registered in Queensland."
The new system will make it much easier tot nurses moving between states and organisations as the one registration will cover all jurisdictions, Ms Whitehead says.
"At the moment, you may hold several registrations all at once. I hold three but if I moved to Western Australia, that's another one I would have to get."
Another welcome change in the new system will be the national accreditation of education and training. Ms Whitehead says organisations can ask for different requirements from flight nurses and this can discourage nurses even if they have the skills necessary for the job. "The whole move to a national system is a major step forward for us. Having the same set of skills accredited in the same way will be the best thing out and I can't imagine why it isn't in place already."
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|Publication:||Australian Nursing Journal|
|Article Type:||Cover story|
|Date:||Jun 1, 2008|
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