Meeting the challenges of recruitment and retention of Indigenous people into nursing: outcomes of the Indigenous Nurse Education Working Group

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1 Meeting the challenges of recruitment and retention of Indigenous people into nursing: outcomes of the Indigenous Nurse Education Working Group Kim Usher, James Cook University, Maria Miller, Australian Catholic University Sue Turale, La Trobe University, Sally Goold, CATSIN It has been recognised internationally that increasing the number of Indigenous people working as health professionals is linked to the improved health status of Indigenous people. When comparing Australian Indigenous and non-indigenous populations, Indigenous people continue to have poorer health standards and are much less likely to be involved in employment in health professions than other Australians. In 2000, the Indigenous Nurse Education Working Group (INEWG) was formed by government with the mandate to work collaboratively with universities and important professional nursing bodies across the nation in an attempt to increase the number of Indigenous registered nurses and to prepare nursing graduates with better understanding of, and skills to assist with, Indigenous health issues. This paper describes the work of the INEWG from 2000 to mid-2003; firstly in developing and implementing strategies aimed at increasing the recruitment and retention of Indigenous people into undergraduate nursing programs; and secondly by helping university schools of nursing increase faculty and student understanding of Indigenous culture, history and health issues through educational processes. Lastly, it summarises the INEWG s 2002 recommendations to achieve a higher rate of Indigenous participation in nursing. The results of research into the success of these recommendations will be the subject of a later paper. Keywords: Indigenous nurses, nursing recruitment, nursing retention, Indigenous health Kim Usher RN RPN DipNEd DHSc BA MNSt PhD, Head and Associate Professor, School of Nursing Sciences, James Cook University kim.usher@jcu.edu.au Maria Miller RN RM BAppSc DipAppSc(Community Health) MEd, Head of School of Nursing, Australian Catholic University Sue Turale RN RPN RM DAppSc(AdvPsychNurs) BAppSc(Adv Nurs) MNSt DEd, Adjunct Associate Professor, La Trobe University Sally Goold OAM RN RM DipNEd BAppSc (Nurs) MNSt DNurs(HC), Chairperson CATSIN Acknowledgement: The INEWG would like to thank OATSIH for their support for this project, and Liz Spring, the INEWG project officer who assisted with the conduct of the surveys. Associate Professor Dawn Francis also provided assistance with this manuscript and her help is recognised. Introduction On a wide range of indicators, the health and wellbeing of Indigenous Australians is documented as being significantly lower than that of non-indigenous Australians (National Aboriginal Health Strategy [NAHS] 1989, Australian Bureau of Statistics [ABS] 2001, Australian Institute of Health and Welfare [AIHW] 1999). This situation is significantly worse in rural and remote areas (NAHS 1989). Further, the health and wellbeing of Australian Indigenous people is poorer than that of Indigenous populations in other countries on a number of indicators (AIHW 1999). The participation rate of Indigenous people in higher education health courses is unsatisfactory. When compared to all Australian students completing health education courses in 1998, Indigenous students were 30 times more likely to complete lower level (prebachelor) courses of study (Schwab & Anderson 1999, p10). Participation in nursing courses is lower for Indigenous Australians, being only 0.5% compared with 2.3% of the non-indigenous workforce (ABS 1996) and this is recognised as a possible contributor to the poor health outcomes of Indigenous Australians. Further, there is a reported shortage of adequately prepared health professionals, both Indigenous and non-indigenous, for Indigenous health service provision, and this is occurring at a time when there is a shortage of nurses both in Australia and internationally. This includes a serious shortage of registered nurses adequately prepared and available to work within rural and remote communities, Indigenous or otherwise. In 2000, in a concerted effort to increase the recruitment and retention of Indigenous Australians in nursing, the Commonwealth Office of Aboriginal and Torres Strait Islander Health (OATSIH) liaised with the Congress of Aboriginal and Torres Strait Islander Nurses (CATSIN) and the Australian Council of Deans of Nursing (ACDON) (now the Council of Deans of Nursing and Midwifery, Australia and New Zealand [CDNM]) to establish the Indigenous Nurse Education Working Group (INEWG). This group consisted of four leaders in nursing education representing CATSIN and ACDON, supported by officers from OATSIH. INEWG s mandate was two-fold: firstly, to develop and implement strategies to increase the number of Indigenous people in the nursing workforce; Collegian Vol 12 No

2 and secondly, to encourage university schools of nursing to promote faculty and student understanding of Indigenous culture, history and health issues through educational processes. Around the same time, another group was established by OATSIH to try to increase the numbers of Indigenous people in medicine and to make medical curricula more inclusive of Indigenous health issues. These are two of a number of initiatives supported by the Commonwealth to reduce the poor health status of Indigenous people and increase their participation in health care delivery. This paper discusses reasons for the low participation of Indigenous people in nursing programs and describes the work of the INEWG until mid Its main purpose is to try to ensure that a broad range of nurses are able to understand, and help to support, strategies for increasing the numbers of Indigenous nurses working in this country. Further, better understanding of the issues surrounding low Indigenous participation in health care professions and the poor health of Australian Indigenous peoples may better prepare the Australian nursing workforce to work with Australian Indigenous people to improve their health. Background Evidence from other countries with a significant Indigenous population indicates that improvements in health are linked to greater participation by Indigenous people in health service delivery (Womack 1997). However, a key difference between Australia, North America and New Zealand is the relative failure to reduce the gap in Indigenous peoples life expectancy in Australia, which is still 18 to 19 years less than the non-indigenous population (ABS 2001 p39). Increased participation by Indigenous Australians in health care has been acknowledged as one way of improving the health of our Indigenous people (Goold 1995) and a strategy of government has been to achieve sustained growth in this regard. Another reason for increasing Indigenous people in nursing is to help create a more equitable society where all Australians can enjoy a productive working life and better health standards. The National Review of Nursing Education in Australia (1994) emphasised a need for nurses and nurse educators to become better attuned to cultural diversity, to increase the numbers of Indigenous nurses, and provide more training programs for people in rural and remote areas. This message was once again echoed in the report of the recent national review of nurse education (Heath 2002). CATSIN (1998) identified areas where it could most appropriately contribute to increasing the numbers of Indigenous nurses, for example by helping to create a critical mass of Indigenous nurses who can act as visible role models for Indigenous community members. CATSIN also highlighted areas where higher education could contribute, particularly in developing some affirmative policies aimed at attracting and retaining Indigenous students, and recognising and removing institutional barriers to success. Additionally, at an Aboriginal Health Worker Conference in 1998, the Australian Nursing Federation (ANF) issued a statement supporting an increase in the uptake of Indigenous people into nursing. This statement voiced the ANF s intention to work with CATSIN on initiatives to achieve greater articulation between courses for Aboriginal Health Workers and courses for nurses as a means of promoting increased participation and career pathways for Indigenous people in nursing. Small numbers of registered Indigenous nurses have been prepared in hospital-based and tertiary programs for many years. However, in the past, accurate data on actual numbers has been scant and the reasons for this are multi-dimensional. One reason is that Indigenous Australians have often been reluctant to identify their cultural background because of perceived racism or alienation in health and education sectors. Another is that when data was sought from nurses by state and territory nurse registering authorities they often did not request information related to cultural background. Thirdly, data arising from Australian Health and Welfare surveys collected from nurses at the time of their reregistration was often many years out of date and thus rendered meaningless. However, what is known is that at the 2001 census there were only 912 registered Indigenous nurses in Australia (ABS & AIHW 2003 p64). Issues affecting recruitment and retention of Indigenous nursing students A number of factors continue to inhibit the achievement of a larger Indigenous registered nursing workforce. Indigenous people continue to have low success rates in secondary school education. For example, in 1998 the retention rate for Indigenous students in year 12 was 32.1% compared to the non-indigenous student rate of 72.7%. This has resulted in limited participation of Indigenous people in tertiary level courses. Research has indicated that a number of factors are involved in Indigenous students educational outcomes. These include remoteness and rurality, local social environments, poor health, social alienation, parents occupation and education, poor quality and crowded housing, household members who have been arrested, and English language proficiency (Hunter & Schwab 1998, Schwab & Anderson 1999). When Indigenous students do enter the tertiary sector, they are more likely than non-indigenous students to undertake lower level health related courses such as pre-bachelor courses and diplomas (Schwab & Anderson 1999), and more likely to be enrolled in remedial programs of study (Maslen 1999). Compounding this is the fact that there is a problematic and continuing high dropout rate of Indigenous students and thus Indigenous Australians remain significantly under-represented in nearly all health professions in this country (ABS 1996). In addition, cultural factors have been proposed as a determinant of poor retention of Indigenous students if they do enroll in university programs of study. For many Indigenous students, university life is totally different to any other previous educational experience. Schwab (1996) claimed that Indigenous students find universities to be unfamiliar, foreign, and or hostile to their presence, and this has been supported in a recent study on Indigenous students of nursing (Usher et al 2003). A study by Weaver (2001) reported that Indigenous students struggled with issues such as culture 28 Collegian Vol 12 No

3 shock, racist attitudes, stereotyping and isolation from others of a similar culture; concerns also described by students interviewed in the Usher et al (2003) study. Another factor that has been identified as contributing to the low levels of enrolment and success of Indigenous students in health programs is related to curricula that are not sufficiently culturally sensitive or inclusive of Indigenous peoples health and other related issues (ABS 2001, Usher et al 2003). It has been argued for some time now that improvement in health outcomes for Indigenous people is dependent upon educational programs designed to improve understanding between Aboriginal and non-aboriginal people (Matthews 1997, CATSIN 1998). However, despite the importance of these factors in deterring students from entering or remaining in nursing courses, financial hardship appears to be the single most important factor that determines the success or failure of Indigenous students of nursing (ABS 2001, Usher et al 2003). While many non-indigenous students might also experience financial hardship, it appears that the financial concerns for Indigenous students are different, more complex and of greater significance. For example, students interviewed in the Usher et al (2003) study described instances where they were expected to share what money they did receive with extended family members and as a result, often went without themselves. Scholarships and schemes In recent years, both commonwealth and state governments have recognised the growing crises within the nursing workforce, focusing particularly on the fundamental issues of recruitment and retention. A primary focus of this attention has been upon nurses in rural and remote areas, who because of the context and the scope of their practice, experience unique professional and workforce challenges compared with their urban colleagues. These include isolation, lack of professional support, and professional burn-out (Bushy 2002, Hanna 2001). Moreover, there are multi-faceted issues surrounding the recruitment and support of rural and remote students of nursing, Indigenous or otherwise, including the distance and isolation of study, a lack of appropriate mentorship and financial hardship (Courtney et al 2002, Neill & Taylor 2002). One response by governments has been the establishment of various scholarship schemes to financially support undergraduate and postgraduate nurses within rural and remote areas. These include two Puggy Hunter Memorial Scholarships for Indigenous students; the previous Commonwealth Undergraduate Rural and Remote Nursing Scholarships (CURRNS) scheme; and the current 110 scholarships for rural and remote students offered by the Commonwealth Department of Health and Ageing and administered through the Royal College of Nursing, Australia. Ten of these latter scholarships are currently designated for Indigenous students and a strong mentorship scheme has been established for all of these scholarships to enable students to be better supported through their studies. Queensland Health also offer annual scholarships to nursing students and have a number set aside specifically for Indigenous nursing students. Another response by government, aimed at increasing the number of Indigenous students enrolled in nursing courses, has been the specific funding by OATSIH, Department of Education, Science and Training (DEST) and Queensland Health, of some purposely designed university nursing programs. These include the Deakin University s undergraduate program in Mount Isa ( /8) and more latterly in Victoria (since 2002); and James Cook University programs in Mount Isa (since 1998) and Thursday Island (since 2003), to name two. Flinders University and the University of South Australia have also conducted programs aimed specifically at increasing the number of Indigenous students enrolled in nursing courses. However, there have been some tensions regarding whether such programs delivered for Indigenous groups in isolated regions may discourage their wider participation in university on-campus activities and fail to equip them for involvement in nursing in a variety of settings ( getting em n keeping em Report 2002). To date, programs have had varying success rates (definite figures are not available) in producing Indigenous nurse graduates, and have operated in different ways: for example, nursing courses have been run specifically for Indigenous groups in various remote locations; bridging programs have been designed to enable Indigenous people to enter mainstream programs; programs have been conducted to support Indigenous people during studies in mainstream programs; and there has been a combination of all these. Unfortunately, there have been no serious attempts to benchmark factors that lead to success for Indigenous students across university programs nor have there been clear guidelines regarding funding of such programs. Currently, OATSIH is developing criteria for the funding of future programs proposed specifically for Indigenous nursing students and this is clearly needed to ensure that Indigenous people have access to the best quality and most appropriate programs possible. The Indigenous Nurse Education Working Group (INEWG) A further initiative, funded by the Commonwealth Department of Health and Ageing, was the establishment in 2000 of the INEWG. The purpose of this group (membership identified earlier) was to make recommendations to government pertaining to the recruitment and retention of Indigenous Australians into nursing and to develop strategies to improve the competency of the Australian nursing workforce to deliver appropriate and culturally sensitive care to the Indigenous population through the development of culturally sensitive and inclusive nursing curricula. In consultation with a wide range of stakeholders, this group set out to achieve three objectives of recruitment, retention and curriculum review. An extensive international literature review was conducted, and this informed an initial survey sent in 2000 to all deans/heads of 30 Australian university schools of nursing that offered bachelor of nursing courses. This survey was supported by the Australian Council of Deans of Nursing. The survey sought to identify any recruitment and support strategies, and articulation pathways for undergraduate and postgraduate Indigenous students in nursing as well as pertinent curricula content and delivery. Specifically, it sought clarity regarding the content taught in undergraduate and postgraduate nursing courses about Indigenous culture, health and history. Collegian Vol 12 No

4 The state of play in 2000: results of an initial survey 22 out of a possible 33 schools of nursing in Australia responded to an open-ended survey conducted by the INEWG. Results revealed that there was a wide range of initiatives instigated to recruit and retain Indigenous students. Some schools worked with their university s Indigenous support unit and/or local Indigenous community to recruit and support students though literacy courses, mentoring, school visitation, or teaching within nursing programs. One school was planning to conduct a specific degree designed to encourage Indigenous students into nursing. No school mentioned assistance for students to complete application procedures, or how they identified Indigenous students who applied. It is to be noted that university application procedures are often daunting and complex, and often off-putting for mature students who have come from disadvantaged Indigenous backgrounds. Alarmingly, very few schools of nursing in 2000 offered cultural awareness training programs for their faculty. The INEWG was disappointed to find that curricula outlines provided by universities as part of the survey did not give a good indication of the extent to which Indigenous history, identity, culture and health were taught in undergraduate programs. Often content was subsumed in cross-cultural content, and only three schools offered discrete subjects in Indigenous health. The picture in post graduate courses was not very different: 50% of courses did not include mandatory or elective content on Indigenous history, health or culture, and the remainder had content that was strongly cross-cultural or socio-cultural in nature. However, approximately 66% of schools explained that they utilised Indigenous teaching staff for such units, even though the content was not transparent. Moreover, 66% of schools indicated that they offered elective clinical placements in Aboriginal communities, but it was clear that many students did not undertake these because of distance, financial problems or lack of suitable accommodation. The results of the survey formed the basis for a discussion document outlining draft recommendations for action. The INEWG circulated this widely and consulted with a wide range of interested parties nationwide, including Indigenous groups, government and non-government bodies, professional nursing organisations, unions and universities. Following modification, the recommendations were published in the gettin em n keepin em Report (ABS 2001) and launched by Helen Evans, First Assistant Secretary of OATSIH, at the 2002 CATSIN conference. This document outlined a strategic framework as a way to increase the number of Indigenous people in nursing and made 32 recommendations for action. These recommendations are summarised here, and the importance of collaboration across the health sector, higher education, Indigenous bodies and government, in order to achieve success in producing more Indigenous graduates of nursing programs, is recognised. Recommendations for recruitment and retention of Indigenous students into university nursing courses The INEWG recommended that all universities set aside specific places and streamline the application and enrolment procedures for Indigenous students. Schools of nursing were encouraged to employ where possible Indigenous liaison nurses to communicate with potential students about nursing and to further liaise with and utilise the services of university Indigenous centres and local Indigenous community members for support and mentorship of students and staff where appropriate. Also, it was recommended that each university implement appropriate strategies to recruit Indigenous students, based on local need and resources, and to facilitate Aboriginal Health Workers and Indigenous enrolled nurses to undertake further studies to become registered nurses. The INEWG also called on governments to increase the number of non-bonded scholarships for Indigenous students of nursing three-fold from those already available in 2003 and to consider providing Higher Education Contribution Scheme scholarships where students were not receiving any other support. Other recommendations that focused on retention included re-introducing travel allowances for clinical placements for Indigenous students not receiving ABSTUDY; providing Indigenous students with culturally appropriate and safe counseling and referral services; collaborating with appropriate bodies to facilitate appropriate clinical mentors (for example, through CATSIN); and conducting exit interviews and exploring personal accounts of Indigenous students experiences in their nursing studies to ascertain better ways of supporting them. In terms of the production of more accurate and timely data gathering about the numbers of Indigenous students entering nursing, there were two major recommendations. The INEWG called for more encouragement of Indigenous students to declare their Indigenous status, recognising that this is often difficult given historical factors and continued racism that discourages such identification. Further, as mentioned previously, it is difficult to obtain accurate data on Indigenous student participation in undergraduate nursing programs and the number of enrolled and registered nurses in Australia. As a result, a recommendation was made to streamline mechanisms at state and commonwealth levels to facilitate the collection of more accurate data on the numbers of Indigenous registered nurses, students of nursing and nursing graduates. Recommendations for curriculum development and implementation The first major recommendation was for schools of nursing to establish compulsory subjects/units/modules on Indigenous culture, health and history in all nursing curricula. One important strategy to ensure this recommendation was adopted was for the INEWG to request the Australian Council of Deans of Nursing to adopt this recommendation and promote the inclusion of content specifically related to Indigenous history, cultural and health in all undergraduate nursing curricula. Australian nurse registering bodies were also asked to take this into account when re-accrediting undergraduate nursing curricula in the future. The INEWG considered it essential to disseminate to schools of nursing examples of Indigenous content to be adopted for local conditions and 30 Collegian Vol 12 No

5 this information was included in the getting em n keeping em Report (2002). It was also recommended that schools of nursing involve Indigenous people in the development and teaching of that content in both undergraduate and postgraduate programs. Moreover, schools were encouraged to provide support to Indigenous people to allow their greater participation in nursing academia. The INEWG considered it crucial that all academic staff teaching in nursing courses received appropriate training about Indigenous history, health and culture since data indicated that this was not occurring across the university sector. In addition, schools of nursing were asked to make available clinical experiences in Indigenous communities where relevant and appropriate and also encouraged the building of more and stronger partnerships between local Indigenous communities and schools of nursing. Conclusion Clearly the Australian Government, key nursing organisations and universities have begun to recognise the link between an adequately prepared Indigenous nursing workforce and the potential for improvement in the health of Australian Indigenous people. This paper has provided an overview of the steps being undertaken by the INEWG to encourage the participation of more Indigenous people in nursing and to support their progress through nursing courses once enrolled. Members of the INEWG believe it is now the responsibility of key stakeholders to implement the recommendations of the getting em n keeping em Report (2002), and in so doing, ensure progress towards the achievement of a larger Indigenous nursing workforce and nursing graduates with better understanding of the health issues facing Australia s Indigenous people. Progress towards the achievement of these recommendations will be the subject of a further paper in the near future. References Australian Bureau of Statistics (ABS) 2001 Commonwealth of Australia,AGPS, Canberra Australian Bureau of Statistics (ABS) and Australian Institute of Health and Welfare (AIHW) The health and welfare of Australia s Aboriginal and Torres Strait Islander peoples Australian Institute of Health and Welfare 1999 Nursing labour force 1998,AGPS, Canberra Bushy A 2002 International perspectives on rural nursing: Australia, Canada, USA. Australian Journal of Rural Health 10: Commonwealth Department of Health and Ageing, Office for Aboriginal and Torres Strait Islander Health. Gettin em n keepin em Report of the Indigenous Nursing Education Working Group. Canberra, September 2002 Congress of Aboriginal and Torres Strait Islander Nurses (CATSIN) 1998 Recommendations to develop strategies for the recruitment and retention of Indigenous peoples in nursing. CATSIN, Brisbane Courtney M, Edwards H, Smith S, Finlayson K 2002 The impact of rural clinical placement on student nurses employment intentions. Collegian 9:12-18 Goold S 1995 Why are there so few Aboriginal registered nurses? In: Gray G & Pratt R (eds) Issues in Australian Nursing 4. Churchill Livingstone, Melbourne, pp Hanna L 2001 Continued neglect of rural and remote nursing in Australia: the link with poor health outcomes. Australian Journal of Advanced Nursing 19(1):36-45 Heath P 2002 The National Review into Nursing Education Our duty to care, Government Printer, Canberra Hunter B, Schwab R 1998 The determinants of Indigenous educational outcomes. Discussion paper no 160/1998. Australian National University, Canberra Indigenous Nurse Education Working Group 2002 Gettin em n keeping em Report, Commonwealth Government Printer, Canberra Maslen G 1999 Aborigine enrolment increases in Australia. The Chronicle of Higher Education May 7:pA55 Matthews J 1997 Historical, social and biological understanding is needed to improve Aboriginal health. Recent Advances in Microbiology 5: National Aboriginal Health Strategy Working Party 1989 A National Aboriginal Health Strategy, AGPS, Canberra Neill J & Taylor K 2002 Undergraduate nursing students clinical experiences in rural and remote areas: recruitment implications. Australian Journal of Rural Health 10: Schwab R 1996 Indigenous participation in higher education: culture, choice and human capital theory. Centre for Aboriginal Economic Policy Research, Australian National University, Canberra Schwab R, Anderson I 1999 Trends in Indigenous participation in health sciences education: the vocational education and training sector, , discussion paper No 179/1999. Australian National University, Canberra Usher K, O Connor T, Miller M, Turale S, Lindsay D, Miller A 2003 Successful strategies for the retention of Indigenous students in nursing courses. Report to the Queensland Nursing Council Research Committee. School of Nursing Sciences, James Cook University, Townsville Weaver H N 2001 Indigenous nurses and professional education: friends or foes? Journal of Nursing Education 40(6): Womack R 1997 Enhancing the success of native American nursing students. Nurse Educator 22(4):22-36 Collegian Vol 12 No