MRCNA. Dr Alison Hutton RN, BN, MN, PhD, Dip App Sci (Nursing), Paed Cert. MRCNA. .... imposed by student registration, including the implications of signing the Board's .... This study is important because the findings inform and document:.
The School of Nursing & Midwifery
Exploring nursing students’ understanding of being regulated Report June 2011
Authors Arbon P, Cusack L, Hutton A, Starr L, Verdonk N. This research was funded by the Nurses Memorial Foundation of South Australia Inc.
ACKNOWLEDGEMENTS This research was made possible through generous funding by the Nurses Memorial Foundation of South Australia Inc. We thank them for their support. We also want to thank the undergraduate nursing students of Flinders University, School of Nursing and Midwifery who gave their time to share their knowledge and experience. RESEARCH TEAM Chief Investigator Professor Paul Arbon RN, BSc, Grad Dip Ed, Grad Dip Health Ed, MEd Studies, PhD, FRCNA. Investigators Dr Lynette Cusack RN, PhD, MHA, BN, Dip Applied Science (Nursing), MRCNA. Dr Alison Hutton RN, BN, MN, PhD, Dip App Sci (Nursing), Paed Cert. MRCNA. Associate Professor Linda Starr RN, RPN, Dip App Sci (Nursing), BN (Ed), Grad Dip Ed (Dist Ed), LLB, LLM, Grad Dip Legal Practice, FRCNA. Ms Naomi Verdonk (Research Assistant).
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CONTENTS
Page
ACKNOWLEDGMENTS AND INVESTIGATORS
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GLOSSARY
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EXECUTIVE SUMMARY
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MAIN REPORT Introduction Background Literature review
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METHODOLOGY Aims Objectives Ethics Design
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DATA COLLECTION Online survey Focus groups
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DATA ANALYSIS Online survey Focus groups
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RESULTS Online survey Focus groups
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DISCUSSION
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LIMITATIONS
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CONCLUSION
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RECOMMENDATIONS
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REFERENCES
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APPENDICES Appendix A. Data analysis from Section one of the online survey Appendix B. Data analysis from Section two of the online survey Appendix C. Data analysis from Section three of the online survey
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GLOSSARY Australian Health Practitioners Regulation Agency (AHPRA) The Australian Health Practitioners Regulation Agency (AHPRA) was formed by an Act of Parliament and is bound by the Health Practitioner Regulation National Law as in force in participating jurisdictions, and its Regulations. AHPRA supports the 10 National Health Practitioner Boards in implementing the National Registration and Accreditation Scheme. Health Practitioner National Law Act 2009 The National Registration and Accreditation Scheme (the National Scheme) for health professionals in Australia commenced on 1 July 2010 under the Health Practitioner Regulation National Law Act (the National Law) as in force in each state and territory. Health Practitioner National Law Act 2010 (SA) As at July 1st 2011, Australian nursing and midwifery students are required to register with the Nursing and Midwifery Board of Australia under this national legislation. Nursing and midwifery students are regulated in relation to impairment. impairment, in relation to a person, means the person has a physical or mental impairment, disability, condition or disorder (including substance abuse or dependence) that detrimentally affects or is likely to detrimentally affect— (a) for a registered health practitioner or an applicant for registration in a health profession, the person’s capacity to practise the profession; or (b) for a student, the student’s capacity to undertake clinical training— (i) as part of the approved program of study in which the student is enrolled; or (ii) arranged by an education provider (s5). NMBA Nursing and Midwifery Board of Australia (National Board). NMBSA Nursing and Midwifery Board of South Australia (State Board).
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Nursing and Midwifery Practice Act 2008 (SA) Prior to July 1st 2011, South Australian nursing students were required to register with the Nursing and Midwifery Board of South Australia under this State legislation. Nursing and Midwifery students were regulated in relation to both unprofessional conduct and Medical fitness. Unprofessional conduct includes: (a) improper or unethical conduct in relation to nursing or midwifery practice; and (b) incompetence or negligence in relation to the provision of nursing or midwifery care; and (c) a contravention of or failure to comply with (i) a provision of this Act; or (ii) a code of conduct or professional standard prepared or endorsed by the Board under this Act; and (d) conduct that constitutes an offence punishable by imprisonment for 1 year or more under some other Act or law. (Part 1(3)). Note: Student clinical competence is not regulated within the Act. Medical fitness to provide nursing or midwifery care: A person or body must, in making a determination under Nursing and Midwifery Practice Act 2008 (SA) as to a person's medical fitness to provide nursing or midwifery care, have regard to the question of whether the person is able to provide such care personally to another without endangering the other's health or safety. (Part 1 (4))
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EXECUTIVE SUMMARY Introduction This study focuses on Flinders University undergraduate nursing students’ understanding of their professional responsibilities following the introduction and implementation of legislation in South Australia to formally regulate nursing and midwifery students. The Nurses Memorial Foundation of South Australia Inc funded the Nursing Student Regulation study. The research investigates nursing students’ understanding of their accountability to maintain the standards of the profession under the former Nursing and Midwifery Practice Act 2008 (SA). Under the Act students are regulated in relation to their medical fitness and propriety; and, are expected to conform to accepted standards of fitness and professional behaviour. Student clinical competence is not regulated as students’ are acknowledged within the Act as beginning practitioners. The objective of this research is to ascertain: a. To what extent nursing students understand the requirements imposed by student registration, including the implications of signing the Board’s self-declaration form. b. What regulation means to these nursing students at this developmental stage of their career. c. How nursing and midwifery students manage their accountability for medical fitness and professional behaviour related to student regulation under the Nursing and Midwifery Practice Act 2008 (SA) (The Act). d. To identify strategies needed to support nursing students’ transition to meet their formal regulatory obligations. This study is important because it investigates a significant development in our nursing history; the implementation of nursing and midwifery student registration. The research takes advantage of the unique opportunity to investigate the early stage of a significant regulatory change, that is, the registration and regulation of students in nursing programs. It explores the introduction of this new regulatory structure from the students’ perspective identifying their understanding(s) of accountability under the legislation, and provides insight into their understanding of the meaning of being regulated. The research findings will help to inform nursing student regulation across Australia which commenced in March 2011.
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Design An exploratory descriptive approach was used to undertake this study. Nursing students at Flinders University School of Nursing and Midwifery were recruited as participants in the study. The study consisted of two phases: Phase 1 was an online survey of first, second and third year undergraduate nursing students. Phase 2 utilised semi-structured focus groups of first, second and third year undergraduate nursing students. Findings The research has identified that overall the participants demonstrated little understanding of regulation and the impact regulation had on them as nursing students. There was however, evidence that second and, more so, third year students had a better understanding of what regulation meant to their practice. Nursing students in this study articulated their understanding of regulation under five different categories. Nursing student participants identified that being regulated meant: 1. a boundary for practice; 2. increased accountability; 3. protection of the public, themselves and the profession; 4. an opportunity to monitor the nursing student workforce; and, 5. that nursing student regulation is about becoming part of the profession. The research identified that overall the nursing students had a fairly clear understanding of the term ‘professional conduct’. ‘Fit to Practice’ was understood mainly in relation to physical health problems; very few identified mental health issues. There was poor understanding from participants in both the survey and focus groups on how nursing students should apply the fitness to practice requirements of the legislation to their practice as a student within the education sector and while on clinical placement. This finding raises some concern regarding the participants’ awareness of the potentially serious consequences they could face in relation to managing issues of fitness to practice. At present there seems to be no opportunity to actively engage the students in a forum designed to inform them of the impact this Act could have on their practice. Conclusion This research has shown that nursing student participants across the three years have not fully understood what regulation of their practice means and how it applies to them. This understanding includes how regulation works, what their obligations are under the Act, the role of the State Board and the education sector, and any potential consequences of breaching the legislation. Ignorance of the issue would not be an excuse acceptable to either the public or the State Board. This report identifies that education providers with the regulation authority should consider a strategy to develop nursing students’ understanding of their responsibility as a regulated health professional. 6
Recommendations Nursing Education Providers Education providers establish a process to engage with students on a continuous basis that enables them to explore the application of professional regulation to their nursing student role. Among the steps that could be considered are: • The initial registration of first year students as an ‘event’ that impresses itself on the new student. • Re-emphasis of their regulation responsibilities prior to first clinical placement, including regulation scenarios into curriculum-orientation package. • Engage the Clinical Coordinators (who support students in clinical venues) to discuss regulation issues relevant to the clinical context of the clinical placement. This would be supported by an information/discussion session with Clinical Coordinators to enable a consistent approach. • Develop two e-learning resources o An on-line module that includes regulation scenarios on both fitness to practice and propriety issues and is required of all students o A blog with a designated coordinator, that enables students in any year to discuss practice regulation issues on-line. The coordinator could be supported by a team of third year nursing students and interested lecturers, who assist with the development of scenarios for the on-line course, as well as answer questions raised in the discussions. Nursing Regulators Regulators need to consider how they can work in partnership with Nursing Education providers to engage with nursing students to make the most of this opportunity to educate students about being regulated. Many of the nursing participants in the study felt more connected to the profession by being registered and receiving their certificate of registration. This enthusiasm about belonging to the profession could be harnessed by regulators to promote the role of regulation well before the student is registered as a nurse or midwife. The regulatory board could consider developing an electronic newsletter that is sent to all registered students quarterly, re-emphasizing key issues in regulation and providing case studies of regulatory action.
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MAIN REPORT Introduction This study focused on Flinders University undergraduate nursing students’ understanding of their professional responsibilities following the introduction and implementation of legislation in South Australia to formally regulate nursing and midwifery students under the former Nursing and Midwifery Practice Act 2008 (SA). This study is important because it investigates a significant development in our nursing history; the implementation of nursing and midwifery student registration. The research takes advantage of the unique opportunity to investigate the early stage of a significant regulatory change, that is, the registration and regulation of students in nursing programs. It explores the introduction of this new regulatory structure from the students’ perspective identifying their understanding(s) of accountability under the legislation, and provides insight into their understanding of the meaning of being regulated. The research findings will help to inform nursing student regulation across Australia which commenced in March 2011. Background The Nursing Student Regulation study was funded by the Nurses Memorial Foundation of South Australia Inc and was researched over a period of twelve months. The study focuses on Flinders University undergraduate nursing students’ understanding of their professional responsibilities, following the introduction and implementation of legislation in South Australia to formally regulate nursing and midwifery students. In particular, the research investigates nursing and midwifery students’ understanding of their accountability to maintain the standards of the profession under the former Nursing and Midwifery Practice Act 2008 (SA) (the Act). Under this Act, nursing students were regulated in relation to their medical fitness and propriety; and are expected to conform to accepted standards of fitness and professional behaviour. Student clinical competence is not regulated, as students’ were acknowledged within the Act as beginning practitioners. On the 1st of July 2010, South Australian nursing students’ registrations transferred to the national Nurses and Midwives Board Australia. Regulation of nursing students now continues under the Health Practitioner Regulation National Law Act 2009 (the National Law) as in force in each state and territory, for South Australia, the Health Practitioner National Law Act 2010 (SA). On 4 August 2009, the Nursing and Midwifery Practice Act 2008 (SA) was enacted and provided for undergraduate nursing and midwifery students to be regulated. The Nurses and Midwives Board of South Australia (NMBSA) was the first nursing and midwifery regulatory authority to implement the process of formally registering students (Hutt 2010). This legislation aligned nursing and midwifery with other professional groups, as well as paving the way for national regulation.
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Formal regulation of nursing and midwifery students through legislation raises the expectation that nursing and midwifery students are fully cognisant of their obligations under the Act. The Act regulates students’ professional behaviour and medical fitness to practice, not their competence. Regulation in such a formal way must be accompanied by an understanding of one’s own accountability to the standards set by law and by the profession. Accountability in this context requires registered nurses, registered midwives and enrolled nurses to ensure they are practising to acceptable standards, are medically fit and conduct themselves in an ethical and proper manner. For example, activities related to their responsibilities under regulation could include monitoring any chronic, physical or mental health conditions with their medical practitioner, keeping up to date with clinical developments and working within the regulatory framework of legislation, standards, policies, procedures, including the nursing and midwifery code of conduct and ethics. To register, all students were required by the NMBSA (the State Board) to complete a self-declaration form. On this form they were required to make a declaration in relation to: • medical fitness; • any findings of guilt recorded against them of any offence by any Court; • any investigation and/or disciplinary action by a nursing and midwifery authority. Students can be reported to the State Board for issues related to medical fitness and/or unprofessional conduct that may place the publics’ health or safety at risk. A report to the State Board may involve investigation and sanction by that Board in relation to their student registration and authority to practise as a student. This study is important because the findings inform and document: • a significant development in the history of the nursing profession in Australia; • ascertain the professional development needs of nursing students and identify supportive strategies; • an important baseline for future studies on national student regulation. This information will be used to inform the development of national regulation policy and procedures for nursing and midwifery students. It will also be used to assist providers of education for students of nursing and midwifery.
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Literature review A literature search was undertaken using both the ProQuest and CINAHL nursing research databases. The key words were ‘nursing’, ‘student’, ‘regulation’, legislation’, ‘law’, ‘understanding’, ‘knowledge’ and ‘confidence’. No articles were found regarding nursing students’ understanding of being regulated in Australia or overseas, which exposed a significant gap in nursing student regulation research in Australia. The results revealed three international journal articles that consider the benefits of regulating nursing students and support registration in the interest of public safety (Sin and Fong 2008; Tate and Moody 2005; Tee and Jowett 2009). Therefore this research is important in commencing the discourse on the emerging issue of nursing students’ understanding of regulation in Australia.
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METHODOLOGY Aim The aim of this research was to explore nursing students’ understanding of their professional responsibilities following the introduction and implementation of legislation in South Australia to legally regulate nursing and midwifery students. Objectives 2. The objective of this research was to ascertain: a. To what extent nursing students understand the requirements imposed by student registration, including the implications of signing the Board’s self-declaration form. b. What regulation means to these nursing students at this developmental stage of their career. c. How nursing and midwifery students manage their accountability for medical fitness and professional behaviour related to student regulation under the Nursing and Midwifery Practice Act 2008 (SA) (The Act). 3. To identify strategies needed to support nursing students’ transition to meet their formal regulatory obligations. Ethics Ethics approval was obtained through the Flinders University Social and Behavioural Research Ethics Committee, South Australia. All participants were 18 years and above and able to give informed consent. No ethical issues or episodes of misadventure occurred during the conduct of this study. Design An exploratory descriptive approach was used to undertake this study of two phases. The first phase consisted of an online survey of first, second and third year undergraduate nursing students to identify key issues of students’ understanding and knowledge of their responsibilities. The second phase utilised semi-structured focus groups of nursing students from the same year levels, which complement and extend the examination of these key findings by exploring the survey results in greater depth.
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Phase One A pilot survey was essential to this study to ensure that the questions were reliable, validated and user friendly. This was prepared by entering the proposed questions into the Remark Web Survey® Version 4 software which provided online confidential data collection. The researchers distributed a hard-copy of the prepared online pilot survey to 10 students from each year level (n=30), together with an information sheet about the research. The students were asked to comment on the ease of completion, vocabulary issues, mixed or difficult questions, ease of use, overall format and flow, any cultural barriers, the language used and the time taken to complete. Feedback was noted and minor changes regarding question phrasing and answer options were made. The survey was made available online and all undergraduate students enrolled in Pre-registration, graduate entry, graduate-entry (registered nurse entry), graduate re-entry, double degree - bachelor of health sciences and nursing courses were invited to participate via university email (n=1800). Consent of the participants was assumed when the anonymous survey was submitted online through the confidential Remark Web Survey® software system. Phase Two At the end of the online survey, participants were asked if they would be interested in attending a focus group. The focus group was an opportunity for participants to discuss their understanding of regulation and to identify strategies that would support their transition to formal registration as a student. In conjunction with this process, posters outlining information regarding the focus groups were situated around the School of Nursing and Midwifery to further advertise the study. All participants were asked to email the research team to volunteer if they were interested in attending the focus groups.
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DATA COLLECTION Online survey Remark Web Survey® software system was utilised for online confidential data collection and PASW Statistics 18.0®computer program was used for statistical analysis and data storage. Focus groups Brief notes of the discussed concepts were taken during the focus groups, and then summarized at the end of session in order for participants to validate the discussion. The focus groups were audiotaped and transcribed verbatim prior to analysis.
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DATA ANALYSIS Online survey Descriptive statistics such as frequencies and percentages were used to summarise the quantitative data of sections one and two of the online survey. Section one referred to the participants’ demographic information and section two consisted of a quiz relating to their knowledge about nursing student regulation requirements. The quiz was analysed and the correct responses were identified. The open-ended questions were reviewed to identify themes in the data. Participants’ confidence levels regarding various nursing student regulation requirements were explored in section three, as students were asked to rank their confidence levels on a Likert scale; ranging from not confident (1) to very confident (5). Relationships between the non-parametric data were analysed and determined using the Kruskal-Wallis test followed by pair-wise comparisons and spearman correlation. Focus groups Thematic analysis is a widely used method in qualitative research (Braun and Clarke 2006) and provides ‘a detailed and systematic recording of themes and issues’ that are found in the interview data (Burnard 1991). This validated process was used to analyse the responses to the focus group questions by following six steps: Step 1 – Familiarity with the data, transcribing the data and reading and re-reading Step 2 – Identifying initial codes within the data Step 3 – Generating themes from initial codes Step 4 – Reviewing and refining themes Step 5 – Defining and naming themes Step 6 – Final analysis and write up. The endpoint of this analysis occurred at thematic saturation.
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RESULTS Online Survey 1. Section one of the online survey: Demographic information Year level The demographic information of the online survey participants (n=220) included differing genders and ages, as well as students from both domestic and international origins (refer to Appendix A). By utilising the PASW Statistics 18.0® software, descriptive analysis revealed that 36.1% of the participants were from first year (n=79), 37% from second year (n=81) and 26.9% from third year (n=59) of the Flinders University undergraduate nursing programs. Enrolment 71.8% of students were enrolled in the Bachelor of Nursing (Pre-registration) course (n=158). 85.9% of participants were studying full time (n=189); 91.1% of first year students (n=72), 88.9% of second year students (n=72) and 74.6% of third year students (n=44). Age and gender Overall, 31.4% of participants were between the ages on 21-25 (n=69) and 13.3% of all participants were male (n=29). Enrolled nurses Of all the online survey participants, 10.1% were enrolled nurses (n=22); 3.8% first year students (n=3), 16.3% second year students (n=13) and 10.3% of third year students (n=6). International students In addition, the overall percentage of international students was 19.2% (n=42); 12.7% of first year (n=10), 25% of second year (n=20) and 20.3% of third year (n=12).
2. Section two of the online survey: Testing the participants’ knowledge of nursing student regulation requirements The correct responses to section two related to the processes established by the NMBSA, relevant to South Australian nursing students at the commencement of 2010 (refer to Appendix B).
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2.1 When are nursing students required to register in South Australia? The correct response to this question is ‘prior to commencement of the course’. 5.5% of all participants answered this question correctly (n=12); including no first year students, 7.4% of second year students (n=6) and 10.2% of third year students (n=6). 18.2% of students who are enrolled nurses answered this question correctly (n=4). 2.2 When registering, what evidence are you meant to provide? The correct response could include: a) Passport and evidence of enrolment in a Bachelor of Nursing degree or Diploma in Nursing b) Passport, drivers license and evidence of enrolment in a Bachelor of Nursing degree or Diploma in Nursing c) Drivers license, evidence of enrolment in a Bachelor of Nursing degree or Diploma in Nursing and other valid evidence. Only 2.3% of all participants answered this question correctly (n=5). 2.5% of the first year students (n=2), 2.5% of the second year students (n=2) and 1.7% of the third year students (n=1) responded correctly. No enrolled nurses answered this question correctly. 2.3 Are nursing students required to renew their registration annually? The correct response is ‘yes’. 24.2% of participants answered this question correctly (n=53). 23.1% of first year students (n=18), 18.5% of second year students (n=15) and 32.2% of third year students responded correctly (n=19). In addition, 31.8% of enrolled nurses answered this question correctly (n=7). 2.4 Did you know the reasons why you needed to register with the Nursing and Midwifery Board of Australia? Please explain the reason... 32.4% of all participants answered this question correctly (n=69). 31.1% of first year students (n=23), 32.1 % of second year students (n=26) and 35.1% of third year students (n=20) responded correctly. In addition, 45.5% of enrolled nurses answered this question correctly (n=10). The reason for registering was due to a legislative requirement under the Nursing and Midwifery Practice Act 2008 (SA), for nursing and midwifery students to be regulated in relation to unprofessional conduct and fitness to practice. The nursing students provided a range of reasons why they thought they had to register with the NMBSA. These are summarised below: Accountability There were a significant number of comments that attributed the reason for registering to ensuring that students became more accountable for their practice. This was particularly related to their time on clinical placements.
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So that students could be accountable for their practices because as students we are under registered nurses in the clinical setting so we tend not be accountable in that respect. In my opinion, the reason for registration is that: The students cannot start work without registration and have to be responsible for their behaviour during clinical placement. As being a nursing student, we will be dealing with a real clinical environment. Registering in NMBSA can make us aware about our accountability as well as consequences that might happen if somebody breaches the rules. Many identified registration to mean that they were now accountable to practice under nursing specific professional guidelines and codes of conduct and ethics. To be accountable to the same guidelines as enrolled and registered nurses with regards to the code of ethics, code of professional conduct and National competency standard. Because even as a student there are guidelines that must be followed when on clinical placement and responsibilities that you have as a nursing student. Patient safety A few participants identified their accountability to patient safety as a reason to be registered. In order to work in clinical placement one has to be registered so one has permission to be licensed to work as a student nurse in dealing with other peoples’ lives and not harm anyone. ….It helps students to be aware as to how nurses are accountable for their actions. Regulation There were a few who understood that registration was linked to being regulated. Regulation and to protect patients. Registration allows the Nursing and Midwifery Board to regulate any achievements or take disciplinary action. NMBSA will over the education process to be accountable for practice. By signing to NMBSA we are saying we will follow safe practice according to training and nursing regulations 17
A small number of these students recognised that they were registered because it was a requirement under regulation legislation. It has been legislated, and allows for accountability. Teaching Institutions and Hospitals now have a pathway of recourse should unsafe practice occur. A legal requirement - confidentiality issues – suitability, responsibility and accountability. I believe it is for legal reasons when we are on placement and to ensure that we are fit to undertake a nursing position both academically, physically and legally. Protection Many of the participants identified the registration process as some form of protection. Protection for themselves as a means of personal insurance, occupational health and safety cover or if something goes wrong with a patient Insurance safety for students, schools and patients …for legal cover and... To ensure the health and safety of the public I think for my protection as a student and for public protection as well So you are covered when you are out on clinical placement So we are accounted for on a register as nursing students and I assume for insurance, statistical and OHS&W purposes A few thought that it protected the nursing profession from unsuitable students. To ensure that only people who are trusted enter a facility on clinical placement. To protect the staff and residents/patients of the facility when on clinical placement. I think because it can identify people who are not appropriate to be nursing e.g. criminal history. NMBSA can keep track of everyone in the nursing field for things like conduct
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Workforce Monitoring There were a few nursing students who understood the register to be mainly for administrative purposes, keeping track of the nursing student numbers and to assist with health workforce planning. It is a way to administer the nursing students. To have a record of all nursing students doing placements So they know how many students will be graduating. For identification and information Summary for Section 2.4 Over all there were a range of views expressed as to why nursing students thought they needed to register. The main reason given by nursing students for registering was to increase the accountability of students to meet professional nursing standards and codes whilst on clinical placement. The next was to provide some form of insurance cover and/or legal protection; either to the nursing student, patients, hospital or university should something go wrong. Only a few appeared to fully understand that it was a legislative requirement under the Nursing and Midwifery Practice Act 2008 (SA) to regulate nursing and midwifery students for fitness to practice and professional conduct in the public interest. The students’ comments support the overall survey response, which identified a limited understanding by nursing students of the purposes of regulation. 2.5 Which behaviours are not ‘fit and proper’? Incorrect responses include: a) Failure to pay University fees b) Constant overdue library books c) Failure to attend lectures / tutorials Correct responses include: a) Breach of academic integrity b) Social security fraud c) Any violent behaviour d) Any conviction of a criminal offence - including minor offences e) Misusing internet technology f) Driving without a license 22.3% of all participants answered this question correctly (n=49). 19% of first year students (n=15), 25.9% of second year students (n=21) and 20.3% of third year
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students (n=12) responded correctly. In addition, 27.3% of enrolled nurses answered this question correctly (n=6). 2.6 What would happen if you provided incorrect information to the Nursing and Midwifery Board of SA? The correct response is ‘you would be involved in an inquiry’. 5% of all participants answered this question correctly (n=11). 2.5% of first year students (n=2), 3.7% of second year students (n=3) and 10.2% of third year students (n=6) responded correctly. In addition, 4.5% of enrolled nurses answered this question correctly (n=1). 2.7 Which issues should the School of Nursing and Midwifery report to the Nursing and Midwifery Board of SA? The correct response is ‘Medical unfitness and Unprofessional/Unfit behaviour’. 8.6% of all participants answered this question correctly (n=19). 3.8% of first year students (n=3), 9.9% of second year students (n=8) and 13.6% of third year students (n=8) responded correctly. In addition, 4.5% of enrolled nurses responded correctly (n=1). Overall analysis Section two was assessed and marked out of a possible 17 points. Overall, mean score was 12.9% for all participants (n=220). First year students achieved a mean score of 9.1% (n=79), second year students 14.4% (n=81) and third year students 17.4% (n=59). In addition, enrolled nurses averaged 18.7% (n=22). 3. Section three of the online survey: Analysing participants’ confidence levels regarding nursing student regulation requirements All nursing students were asked to rank their level of confidence on a scale of 1 (Not confident) to 5 (Very confident) regarding 8 different topics. The questions were: 1. Their knowledge of the nurse's professional code of conduct. 2. Their knowledge of the nurse's professional code of ethics. 3. Their knowledge of where to access the Health Practitioner Regulation National Law Act 2009. 4. Their understanding of what fit to practice means as a nursing student. 5. Their understanding of the term professionalism. 6. Their knowledge of the role of the NMBSA. 7. Their knowledge of the role of the Australian Health Practitioners Regulation Agency. 8. Their knowledge of where to access information about nursing and midwifery regulation in Australia.
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Reliability The Cronbach’s Alpha for the responses to these questions is 0.874 (˃0.7), which provides good support for internal consistency and reliability. Analysis of mean values The overall confidence level means increased from first to third year, indicating that as the students progressed through their degree program, their confidence levels improved. Enrolled nurses were present in the second and third year student samples and were found to have a higher mean value.
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Kruskal-Wallis test The Kruskal-Wallis test was used to compare the mean ranks of student confidence for the three year levels. A high Mean Rank indicates a high confidence level. The test showed that there was a general trend of increased confidence in nursing students’ understanding of regulation, as they progressed through their tertiary studies (Refer to Table 1). Table 1: Kruskal- Wallis Ranks- Comparing the mean ranks for the three year levels.
Ranks Year level 1. Your knowledge of the nurse's First year professional code of conduct. Second year Third year Total 2. Your knowledge of the nurse's First year professional code of ethics. Second year Third year Total 3. Your knowledge of where to First year access the Health Practitioner Second year Regulation National Law Act 2009. Third year Total 4. Your understanding of what fit First year to practice means as a nursing Second year student. Third year Total 5. Your understanding of the term First year professionalism. Second year Third year Total 6. Your knowledge of the role of First year the NMBSA. Second year Third year Total 7. Your knowledge of the role of First year the Australian Health Practitioners Second year Regulation Agency. Third year Total 8. Your knowledge of where to First year access information about nursing Second year and midwifery regulation in Third year Australia. Total *High mean ranks indicate high confidence levels.
N 79 81 59 219 77 81 59 217 79 80 59 218 79 80 59 218 79 80 59 218 77 80 58 215 79 81 59 219 79 81 59 219
Mean Rank* 97.62 107.48 130.03 96.08 109.60 125.03 95.35 111.73 125.43 107.33 98.53 127.29 115.92 94.28 121.54 97.90 110.78 117.59 100.36 114.15 117.20 105.03 103.78 125.19
Questions 6, 7, and 8 do not demonstrate an overall difference between the responses of the three year levels (i.e. p ˃ 0.05). However, the Kruskal-Wallis analysis of variance indicated that the confidence levels differed significantly for questions 1, 2, 3, 4 and 5. Question 1: X2 (2, n=219) = 10.010, p = 0.007 Question 2: X2 (2, n=217) = 8.060, p = 0.018 Question 3: X2 (2, n=218) = 8.317, p = 0.016 Question 4: X2 (2, n=218) = 7.898, p = 0.019 Question 5: X2 (2, n=218) = 8.449, p = 0.015
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Pair wise comparison The Kruskal-Wallis analysis is supplemented with a pair wise comparison, where the p value of critical difference is 0.017 (Bonferonni adjustment involves dividing the alpha level of 0.05 by 3, adjusted to 0.02 by PASW Statistics 18.0®). Question 1 Null hypothesis is rejected. Asymptotic significances are observed between the first and third year students, as the significant value is 0.002. The mean rank of third year students (130.03, n=59) is significantly higher than the first year students (97.62, n=79). Question 2 Null hypothesis is retained, therefore there are no significant differences observed between the year levels. Significant value is 0.018. Question 3 Null hypothesis is rejected. Asymptotic significances are observed between the first and third year students, as the significant value is 0.004. The mean rank of third year students (125.43, n=59) is significantly higher than the first year students (95.35, n=79). Question 4 Null hypothesis is retained, therefore there are no significant differences observed between the year levels. Significant value is 0.019. Question 5 Null hypothesis is rejected. Asymptotic significances are observed between the second and third year students, as the significant value is 0.008. The mean rank of third year students (121.54, n=59) is significantly higher than the second year students (94.28, n=80). These results indicate that the general trend is that the confidence of Flinders University undergraduate nursing students increases as they progress through their degree. Correlation To investigate if there is a statistically significant association between individual students’ scores from section two and their confidence levels of section three, a correlation was computed. The Spearman correlation is based on ranking the nonparametric data and is significant at the 0.05 level (2-tailed). The Spearman's rho statistic r(218)=0.31, p=0.07, therefore the correlation between the total score and confidence levels is not statistically significant and there is no systematic association.
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RESULTS Focus Groups Focus group participant demographic information Year level Two sessions were held for first year students (n=2 and n=5), one session for second year students (n=3) and one session for third year students (n=2). Enrolment 75% of students were enrolled in the Bachelor of Nursing (Pre-registration) course (n=9) and the remaining 25% were undertaking a graduate entry course (n=3). All students were studying full time. Ages and gender 50% of participants were aged 21-25 (n=6), with 33.3% aged 26-30 (n=4). 25% of all participants were male (n=3) Enrolled nurses Of all the focus group participants, only one undergraduate nursing student (n=1) was an enrolled nurse. International students The overall percentage of international students participating in the focus groups was 58.3% (n=7); 41.7% of the first year participants (n=5) and 16.7% of the second year participants (n=2). This study focused on students’ understanding of their responsibilities in relation to the introduction of legislation in South Australia to formally regulate nursing and midwifery students. The focus groups were conducted with nursing students from the same year (first, second and third year) using semi-structured questions, which were informed by the survey results. The questions explored, in more detail, the nursing students’ understanding of being regulated and their accountability under the Nursing and Midwifery Practice Act 2008 (SA). Each of the three groups findings are analysed in five main categories identified from the series of questions explored during the focus groups. The categories are: • Meaning of regulation to nursing students. • Why regulate nursing students? • Putting your name on the Student Register: what did it mean to you? • Meaning of ‘Fit to Practice’ and ‘professional conduct’ for nursing students. • Understanding the consequences of being regulated. The specific issues discussed under each of the five categories are derived from the participants.
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RESULTS Focus Groups Focus groups thematic analysis Meaning of regulation to nursing students First Year The first year participants described the meaning of regulation as something to do with standards related to the discipline of nursing, or to do with law or organisational policies related to clinical placements. In each of the meanings they identified that they had a responsibility guided by legislative frameworks to abide by these: The standards of the discipline ... like nursing discipline Something about rules Or laws Policies in the institutes [hospitals] Second Year The second year students did not relate the meaning of regulation to any legislative framework. The participants understood the term regulation to mean conduct of a nurse related to standards of behaviour or rules, as expressed by this participant: Regulation means, according to me, it’s working under the rules, some rule, some protocols... We need to obey those rules. Third Year Some of the participants in this group indicated that they had not thought much about regulation and what it meant to them as a nursing student, though considered it was to do with some form of guide: I haven’t actually thought that much of it, it’s more like I guess, guiding would be probably good, just that you have a set that you have to follow, like everything’s supposed to be the same it doesn’t matter where you are. Other participants in third year viewed regulation as meaning clear levels of accountability for nursing students by defining what they can and cannot do when they are on clinical placement: It gives us accountability we are responsible for our actions. Limiting what we can do and what we can't. That's regulation. 25
A few understood it to be related to legislation: I think of law when I think of regulation. I think of your legal responsibilities and the things that you can do and the things that you can't do. So, when I think of regulation I think about law and your rights and responsibilities. Summary A number of participants across the three groups acknowledged that they had not really thought about regulation and its relationship to them as nursing students. There was an overall understanding that regulation set in place some form of boundary around their practice as nursing students, although most were unable to clearly articulate this from a legislative perspective. Looking across the three years, the first year students did not expand on their use of the words, law, discipline and policies, whereas the second and third year participants explored the meaning in more depth, demonstrating a better understanding of the meaning of regulation. Why regulate nursing students? First Year The first year participants had a number of reasons as to why they thought that nursing students were regulated. The main reason was to provide more control over students while on clinical placements: I think, even though we are only students, but we need to do placement in the hospital/aged care place. That means we need to be regulated to obey their principles and policies. To reduce patient errors by following the regulations of the hospital... Some other participants considered the reason for nursing student regulation in a more positive light, to prepare nursing students for the future. They explained that by regulating student nurses when it came to registering as a Registered Nurse they would have a good understanding of regulation: Prepare nursing students for the future... If a student does become an RN… To understand regulation at this moment will - in the future, as Registered Nurses follow these regulations for the rest of their life. Second Year The participants from the second year group thought that there were a number of reasons why it was decided to regulate nursing students. The first reason was as a means to monitor nursing students with the intention to protect patients when going on clinical placement: 26
It's easier for the Board to monitor the students' performance, both in academically in the school and on placement. Sometimes we're doing placements; we're working with the patients in hospital. Something may happen... with the patients. If something happens, that is not good then we need to change this to avoid certain things happening again in the future. One participant thought that it was to promote patient trust in nursing students by the public, because they are taking on more responsibility while on clinical placement: Help the society to trust the nursing students. Because nursing students - we are dealing with the patient, and the health of the patients... Taking on more responsibility. Third Year The third year participant group also thought that regulation was instigated to protect the patients when they went on clinical placement: I think because they think we don't have any idea of what we're doing and we haven't had much knowledge as fourth year [School] students to be able to do things or have the skills or take care of people. So they are regulated to make sure that a first year student coming out of high school or coming out from a job, don’t decided the things they can do. So as to prevent any damages or life threatening stuff happening. To monitor and raise the level of accountability of nursing students: Just to make us more accountable for the things that we're doing so we can be aware of, you know, we can't just get out there and do what we want. There's someone looking on us and you just have to do this right. One participant explored the notion that regulation supported the nursing student because by being regulated they were able to refuse to undertake tasks, delegated to them by nurses, which they felt unprepared for: I'd say maybe they noticed that when we go out on placement, they [Nurses] allow you to do stuff that you've not been taught... I'm just thinking there are students that might have done it wrong and caused harm... So if - the responsibility would be on the student to say no, I can't do this... Because when there wasn't any regulation they [Nurses] just say it's good when you come back next year, you'll be able to do it
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because you've done it now. So [regulation] is better there's the limit to what can be done and what can't be done. Summary There was a view across all three groups that the main purpose of regulating nursing students was to protect the public from harm when they went out on clinical placement. There were also views expressed in a more positive light that saw regulation as protecting students from undertaking tasks they felt they were unprepared for. Participants expressed that regulation meant they now had a reason for saying ‘no’ to undertaking nursing tasks that they felt was above their level of competency. Through being regulated students said that they now felt they were able to say ‘no’ to a request. The reason given was that through being regulated, the nurse requesting the task would understand their point of view and not perceive them to be ‘difficult’. The students claimed the registered nurse would understand the student thinking about their own registration just as the Registered Nurses has to consider their registration. Each group stated that being regulated raised the level of accountability upon them to perform safely, because they were being more closely monitored. Putting your name on the Student Register: what did it mean to you? In 2010 nursing and midwifery students were required, before they commenced their Tertiary Advanced Further Education (TAFE) or University nursing course, to contact the NMBSA to register their name and to make certain declarations about fitness and propriety. This action of formally registering with the State Board was explored with the participants to find out if they understood the process and what it meant to them. First Year Not all of the participants in this group recalled undertaking this action and indicated that they did not remember registering. Those that did remember indicated that it was just a matter of ‘signing a piece of paper’. There was no discussion about the process and any meaning it had for them: Just signed and handed it in. They [TAFE] assigned us the paperwork, and we just needed to sign the name on it and then they posted them to the Nursing Board. Second Year Most remembered registering with the Board, by signing a form and receiving a registration card to show staff when they went on clinical placement. The participants viewed the receipt of a ‘registration card’ very positively:
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Yeah, we got a registration card. I think, for me, it felt like I have been registered now. As a student, I have some responsibilities for study, for placements, to learn things like that. Registering made them feel part of the profession, verified their identity as a nursing student and made them feel legitimate: We are student nurses, so we are part of the Health Department now. I think our identity has been confirmed... as a nursing student... Not nurses but just nursing students. It also clarifies our duties with the other students... We cannot do things above the nursing students’... scope of practice. All participants expressed a view that very little information was provided to them about regulation and the implications for them when their name went onto the register: When we register with the Nursing Board, we think, oh I need to comply with some principles, something like that, but actually, we cannot imagine what things will happen. What's the difference between you registering with the Board or not, we're not really clear about it, what's the difference? So we need to get more information. I read some of the obligations but I think there should be more information to have in the class or on orientation, some session, so that everyone knows. Some people, they don't read and they just sign. ...Some of my friends, they ask why are we doing that? Why do we need to register as a student? We are not nurses yet. Third Year The views expressed by the third year participants were similar to those of the second year students. Most remember signing something, as it was part of the enrolment process. They did not think to question what it was about. It was something they had to do to be a nursing student: No information and no-one told me that this is why you've been - they just said everyone has to be. So I didn't really know what's going on. So it didn't really change anything for me; just carried on normally. Yeah just a name on the list... I didn’t think about it much, it’s just a requirement we had to do to be a student doing the course and that’s as far as I took it pretty much. 29
We kind of just signed the papers and handed them in, cause it was like if you don’t, you don’t get to be a student. Students expressed a view that very little information was provided to them about student regulation and the purpose of placing their name on the register: I think it was put into one of the lectures or something in the beginning of the year. It might have been in the orientation sessions about why we had to be registered or something. For some of the participants receiving their registration card from the NMBSA was important. It gave them an identity and they felt that they had become part of the profession and expressed feeling of pride about this: It made me feel more important as if I was part of something... We had the student group in school for midwives and nursing but this was more, I don't know, legitimate. Professional. More professional. I had a little card and my number on it. So that was, you know... Made me feel good? That made you feel more important?... It made me feel part of the nursing profession. So people out there, looking out for me. So I could easily go to be out there - the website had a little section about students. So that was really good. Summary Most of the participants across the three groups did not have a clear memory of registering with the NMBSA. Any process of registration was seen as part of the enrolment process. Most participants did not remember receiving information written or verbal about registering and what relationship this process established between them and the regulator. If it was received it was not read. There was a very positive aspect to registering that the second and third year students discussed; this was receiving their registration card from the NMBSA. Most considered this as an important moment as it signified their entry into the profession and the start of a career. Registration legitimised their place within the profession.
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Meaning of ‘Fit to Practice’ and ‘Professional Conduct’ for nursing students First Year The participants understood the term ‘Fit to Practice’ was some form of physical injury carried by a nurse whereby they may not be able to carry out their nursing care safely: Like disabilities. For example, if we have an accident and we have a broken leg and we can't go to work... Because I can't nurse the patient properly may accidentally knock someone with our crutches, those things. ‘Professional conduct’ was discussed as following procedures, having a caring attitude and being knowledgeable about your work practices, though not necessarily in relation to regulation: I think it means when we do anything with a patient, we need to do it in an appropriate way. It means use the right nursing skill, which you learn from university, and to treat the patient properly. A nurse must have a good attitude because if they are like - if someone like a gangster, we act like them... Like a gangster... Then the patient will be scared of us. Neither of the terms ‘Fit to Practice’ or ‘Professional Conduct,’ when explored by the participants, were discussed within a regulation framework. This finding would indicate that this part of regulation and their responsibilities is not well understood by the first year nursing students. Second Year The participants in this group all recognised that ‘Fit to Practice’ was about both the physical and mental health of a nurse that may affect their patient care. As a nursing student, we need sound health to work. We need a sound mind and sound body to work properly. In nursing, we care for the patients. If we are not physically well or if we are mentally not there, we can't learn on placement or in the uni, we can't concentrate. The second year participants were less confident about the term ‘Professional Conduct’ and said it was about not making mistakes such as drug errors.
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Third Year ‘Fitness to practice’ was identified more succinctly by this group of participants: So in my opinion it’s something along those lines where you’re able to do the very basic core responsibilities of your role and you’ve got to be able to be healthy enough to do them in both body and mind. You are fit and able to perform the tasks demanded from you or expected from you. If you’ve got physical injuries... Like they say in the workplace if you’re injured you shouldn’t be working really. The same should apply to students. Unprofessional conduct was much more clearly articulated and well understood by participants within this group.: That they act and dress appropriately, they answer to people in a mature and respectful way and they know their scope of practice, they take responsibility for their own actions, they’re willing to seek help in areas where they don’t have enough knowledge and they actively seek new information and keep up to date and are willing to teach others their knowledge. Summary There was a consistent understanding across all three years that ‘Fit to Practice’ was related to nursing students’ physical ability to work safely. The mental health of nursing students was not well recognised as a component of ‘Fit to Practice’. ‘Professional conduct’ was poorly understood within the first year group of participants. The second year participant group had a better understanding of the term and the third year participants articulated the meaning well. Understanding the consequences of being regulated First Year Some of the first year participants when discussing ‘Fit to Practice’ did realise that they could be reported to the NMBSA. This was particularly the case if they did something that affected patient safety. For example: Reported to the Nursing Board. When discussing consequences of being regulated more broadly there was discussion about meeting specific codes of conduct and ethics and following guidelines: Must follow the codes, which tell you what you can and can’t do.
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Second Year The participants in the second year group identified in their discussion a link between patient safety and registration. There was no discussion on how the process of reporting to the Board would actually happen and what formal consequences there could be for nursing students: So you put the person in danger. Obviously, you may cause something - like you may lose your registration. If something goes wrong you get struck off and lose registration. Third Year The third year group instigated more discussion on the consequences of regulation on nursing students. In particular how regulation raised the level of ‘consequence’ to very serious, because there was now the potential for them to be removed from their chosen path of study, if their registration was cancelled: I’m just saying now that’s it’s regulated it’s more of a serious matter I think than it probably used to be. You could sort of, how do I put it, you could sort of go under the radar before because you’re not - there’s no regulating body for students... The participants also explored how the NMBSA would not accept ignorance of the consequences of regulation as an excuse, not to remove their registration: The other thing too is that the Nurse’s Board is not going to look at the fact that we didn’t know that we were regulated - if being ignorant to the law is not going to - at the end of the day is not going to hold up with the Nurse’s Board if we’re doing something wrong and we didn’t know. No they’re not going to say, oh you didn’t know that’s fine then it’s all okay kind of thing. We’re still going to be held accountable even though we didn’t know... There were a few participants who had never considered the consequences of regulation: No I didn't know that [I could be reported to the NMBSA]. This is the first time I heard that or know of the seriousness of the consequences. What I thought was we had to go to a, you know, topic coordinator if something went wrong. Or a clinical facilitator. I did not know you could face the disciplinary board. I only thought it was the uni. I didn't know once you get registered with the board you could also - I thought - I didn't know that. 33
This was something that had not been discussed between themselves as students: Not talked about. One participant who had thought about the consequences of regulation reflected on this: I was a bit worried, you know, it makes you more accountable for your actions. But it's part of the challenge of being a student also; wanting to be a registered nurse later on. So that was all right... I had to rise up to the challenge. So it was good. But I was worried a bit, you know. You get worried if you did something wrong. I became more careful of what I was doing. It was like at the back of my mind. Summary The consequence to nursing students of being reported to the NMBSA was not well understood across all of the three years. Second and third year students explored this concept more than the first year students in the focus groups, which demonstrated different levels of understanding of the reasons and processes involved in reporting nursing students to the NMBSA. Very few indicated that they had actually given this matter some serious thought before hand although it had been there at the back of their mind. Participants’ Recommendations At the end of the focus groups the participants were asked to reflect on the discussion they had just undertaken in the focus group and to identify any recommendations that they thought would assist nursing and midwifery students to better understand regulation in the future. This is a summary of their suggestions; • Provide education sessions at university or some material before clinical placement – Regulators please come to talk to us. • It's better not to have information to read, we get so much at the start of the year. A tutorial would be better with scenarios. • I think issues of law and ethics should be moved to first semester in a first year subject. This would seriously help because it gives you the definition of your job under the law as well. You could look at your ethical responsibilities and where they fit into regulation. The other thing too, is by bringing law and ethics into the first semester I think would aid the international students. • There should be more discussion about physical and mental health issues. Letting students know before we start this course.
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DISCUSSION The purpose of this section of the report is to summarise and discuss the most significant points that have come from this study. The aim of this study was to explore nursing students’ understanding of their professional responsibilities following the introduction and implementation of legislation in South Australia to formally regulate nursing and midwifery students. The study set out to ascertain several issues related to nursing students:a) understanding the requirements of registering, b) what regulation means, and c) how nursing students manage fitness and professional behaviour. Understanding the Requirements of Registering Engagement in the process of registering There were only a few nursing students who remembered and were familiar with the requirements for student registration. The results of section two of the online survey questionnaire revealed that participants had a limited understanding of the procedural requirements leading to registration, demonstrated by the average student score of 12.9% (pg 20). This finding was further supported during the focus groups when it was discovered that most participants did not remember receiving information about nursing student regulation and the purpose of placing their name on the register. The focus groups also revealed that a number of participants across the three year levels had no clear memory of registering with the Nursing and Midwifery Board of South Australia (NMBSA) and perceived the process to be an adjunct to university enrolment. The NMBSA required nursing and midwifery students to complete and submit an ‘Application for Student Registration’ form along with compulsory supporting documents to be lodged with the application, including proof of personal identity and evidence of confirmation of enrolment. An information sheet was available to students containing the details about the registration process. This minimal recollection of the registration requirements by nursing students across all years is important for regulation authorities to note. Especially as there was a formal process required by the NMBSA at the commencement of the 2010 academic year in which students were required to undertake a number of actions, as described above. The new process for nursing and midwifery student registration under the Health Practitioner National Law Act 2010 (SA), commencing 2011, requires no engagement by the student to register. These circumstances create an even greater risk of students being unaware of their regulation responsibilities. Due to the recent change in this process this study raises a number of questions:
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Given the minimal recollection of the requirements by nursing students during an active process of registration, will an inactive process exacerbate a lack of understanding? In addition who is now responsible for ensuring students do understand their legislative obligations? Is it the regulation authority, the education provider or both and how will this be successfully achieved? What Regulation Means to Nursing Students A major component of this study was to explore what regulation meant to nursing students. By exploring the meaning of being regulated with nursing students it has assisted the researchers to gain an understanding of how nursing students view regulation and the ways in which regulation may apply to them. Five meanings for nursing students of being regulated were identified from this study. Nursing student participants identified that being regulated meant a boundary for practice; increased accountability; protection of the public, themselves and the profession; an opportunity to monitor the nursing student workforce and that nursing student regulation is about becoming part of the profession. Regulation is a boundary for practice Overall, the nursing students understood that regulation provided some form of boundary that framed their practice as students, especially while on clinical placement. Most students however, from both the focus groups and survey were unable to clearly articulate this understanding from a legislative perspective and could not name the relevant Act. The majority of students participating in the focus groups indicated that they did not necessarily understand how the regulation legislation applied to them as students. This is a very important finding for both the regulatory bodies and education providers to consider, because it indicates that a different strategy is required to better inform students about the impact regulation has on them. There was evidence of a slightly better understanding of the application of regulation to students in second and, more so, third year students as well as those who were enrolled nurses. Increased Accountability A significant number of participants indicated that due to being regulated they need to be more accountable for their behaviour when they are on clinical placement. This was because they understood that through regulation they are subject to specific professional guidelines that whilst developed for the registered nurse, such as codes of conduct and ethics, may now apply to them. Protection of the public, themselves and the profession The majority of participants recognised that student regulation was there for the protection of the patient. Overall, it was understood that by regulating nursing students the public would be protected from harm when students are on clinical
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placement. It was also considered that regulation is in place to protect students from undertaking tasks that they are not prepared for. Other participants held the view that by regulating students, new graduates would have a greater understanding of their regulatory responsibilities and scope of practice by the time they actually come to register as a nurse. Therefore more informed and responsible beginning registered nurses would lead to better patient protection from unprofessional conduct and impaired practice. Interestingly, many participants were under the impression that regulation is a form of protection for the student, relating to personal indemnity and occupational health and safety work-cover insurance. Some participants thought that regulation protects the nursing profession from unsuitable student candidates by using the education process to identify those who failed to abide by the rules or laws for the profession. Monitoring the workforce Some participants viewed student registration as a method of workforce monitoring by the government, which served administrative purposes. Becoming part of the profession Some of the second and third year student participants mentioned that when they received their registration card from the NMBSA, it signified their entry into the profession and the start of their career. This event was viewed very positively and was clearly a point in the registering process they remembered and valued. With the changes to National Regulation, AHPRA are currently not providing students with a registration number or certificate. This change to the process misses the opportunity for the regulation authority to connect with students and is an issue that should be considered by the National Board. How Nursing Students Manage ‘Fit to Practice’ and Professional Behaviour The findings from this research indicate that the majority of participants were poorly informed on what constitutes unfit/unprofessional behaviour as well as unaware of the possible consequences of any regulatory breach. Professional conduct was poorly understood within the first year group of participants, whereas the second year participants had a better understanding of the term and the third year students articulated the meaning well. The focus groups identified that a number of participants across the three year levels had not thought about regulation and its relationship to nursing students since signing the Nursing and Midwifery Board of South Australia (NMBSA) self-declaration form as part of their application to register. Self-declaration A number of participants did not have a clear recollection of the self-declaration section of the application form related to any medical conditions that may impact on their ability to provide nursing care or may endanger the health of others. The 37
nursing students were also required to declare if they had been convicted or had a finding of guilt recorded against them in relation to any offence by any Court. This self-declaration was an important part of the registration process with the NMBSA because it focused the student on two key areas related to protection of the public, the nursing students’ ability to physically and mentally perform nursing care safely and their previous behaviour in relation to meeting societal expectations. It is of concern that many of the nursing student participants did not recollect this critical reflection related to their fitness and propriety because these two aspects are at the heart of the profession. This study highlights an area of regulation that requires a better understanding of its importance by nursing students, even though they are still undertaking their degree, because they do provide care at the patients’ bedside. Understanding ‘Fit to practice’ is more than physical disability Participants across all three years consistently demonstrated their understanding of ‘Fit to Practice’, as being the nursing students’ physical ability to work safely, few recognised mental health as a component of ‘Fit to Practice’. In addition, the consequence of nursing students being reported to the NMBSA was not well understood across all three year levels. Therefore, there is little evidence from this study to support that the nursing students have implemented strategies to ensure they are accountable for their medical fitness and professional behaviour. Understanding the consequences The focus group discussions raised a question on how reasonable it is for the regulatory authority to have an expectation that nursing students understood the meaning of being regulated and the consequent implications. Several participants in their third year recognised that the NMBSA would not accept ignorance of the consequences of regulation as an excuse not to remove their registration. In law, the standard of reasonableness is what the practitioner/student ought to have known and done according to accepted professional standards of another peer professional with the same level of skills, knowledge and expertise. It is therefore important that nursing students have this knowledge prior to commencing their studies to ensure they are fully informed about the expectations regulation places on them as students of nursing. Given that the South Australian Tertiary Assessment Guide (SATAC 2010), (which is available to every student) and the NMBSA both provided information to students about registering with the NMBSA it could be argued that students were informed about their registration requirement, but does it mean that they understood what this meant within a regulation context?
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This study raises questions, which regulation authorities should consider: When registering, what obligation does the student have to find out more about regulation and the potential consequences for them? This research has shown that the student participants have not fully understood what registration means, how it works and what their obligations are under the Act. This potentially places the student in a vulnerable position; given that ignorance of the issue would not be a mitigating factor should any complaint regarding the student be laid at the State Board. Why does regulating students matter? It could be argued that it does not really matter if nursing students do not fully understand the meaning of being regulated. Is patient safety really at risk? This argument is explored further taking into account a number of factors. Students are at the bedside The first factor is that student nurses are at the bedside, though supervised, and they do provide hands-on care to patients, including the most vulnerable people in the community. Therefore by being regulated, their public accountability is increased. This may encourage more reflection on patient safety on the part of the nursing student while on clinical placement. Physical and mental impairment The second factor is the nature of both a physical and mental impairment and the risks in the workplace to the nursing students, colleagues and patients, which may not be fully understood by the student new to the context of nursing practice. This is particularly the case if the student has a physical condition, which prevents them from assisting patients with their physical care, or has a blood borne virus, which restricts them to certain areas of practice where they are not at risk of contaminating patients. Another major consideration is those students with mental health disorders who are newly diagnosed and are in the early stages of learning to manage their condition, in particular understanding the side-effects of their medication. It is important for nursing students to have good insight into their mental well-being and manage their clinical placement accordingly, so that they do not put themselves and patients at risk. Regulation clearly places the accountability to actively manage any known health risk on the student, but in partnership with their treating medical officer and education provider. Enables Independent external investigation into complaints of ‘Fit to Practice’ The third factor in considering why regulating nursing students matters is that regulation provides an avenue for the education provider to seek an external investigation into any serious issues around fitness to practice. Regulation takes any complaint by an education provider, about a student, out of the potential discrimination box and places it clearly into the box for public protection. This is particularly in situations when the student is non-compliant with their ‘disability 39
action plan’, which the education provider has developed with the student and their treating medical officer. A complaint to the regulation authority enables a confidential external review of the facts and the matter can then be managed and monitored externally in partnership with the student, their medical officer, and the education provider to ensure that the nursing student is supported and the public remains protected. Supports students welfare The fourth reason for supporting students’ understanding of regulation relates to their welfare. Student regulation enables those who do have a physical or mental disability that may seriously affect their practice to decide prior to completing their degree if they will be capable of gaining a license to practice. For those who choose to continue their course they have the opportunity to learn how to manage their health condition before they enter the workplace as a registered nurse. The first year as a registered nurse can be potentially stressful and includes adapting to regular shift work, new environments and a greater level of accountability and decisionmaking. By being fully aware of their regulation responsibility nursing students can be prepared to manage their health issues and continue to practice safely. The knowledge they will acquire over the 3 years on the meaning of regulation will equip them as registered nurses to manage their eligibility in all spheres under the Act. Public safety taken seriously by profession Finally, from the public’s perspective, student regulation is an additional signal that the health profession does take patient safety seriously. Patients need to be assured that they have an appropriate person in this trusted carer role. This is by recognising fitness to practice as an area of potential risk with students, who are in the workplace, providing patient care. Summary The research has identified that overall the participants demonstrated little understanding of regulation. This finding raises some concern regarding the participants’ awareness of the potentially serious consequences they could face in relation to managing issues of fitness to practice. At present there seems to be no opportunity to actively engage the students in a forum designed to inform them of this. The participants indicated that at the time of their first enrolment they are overwhelmed by information making this time unsuitable to impress upon them the importance of regulation. Many participants indicated that the best time would be just before they embark on their first clinical placement, when they are more receptive to thinking about practice issues. The students also indicated that they would value an opportunity to really discuss what regulation means because it is a new concept to them and to consider scenarios especially around ‘Fit to Practice’ and how they apply this to their decision-making and role.
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The discussion also considered whether a lack of understanding about regulation by nursing students really does matter. It was argued that it did matter for several reasons. It mattered for nursing students’ welfare, for protection of the public and to support education providers. The question remains as to what responsibility the students, education providers, the employers and regulation authorities have to ensure that the students are fully informed about regulation and the implication it has on them personally. A good knowledge base about the regulatory framework for registered nurses and midwives should be developed prior to their first registration as a nurse. It is hoped that nursing students will gain this knowledge during the course of their degree as part of meeting the competency standards (Australian Nursing and Midwifery Council, 2006). This study suggests that the pieces of the puzzle around regulation, registration and professional standards of practice may not all come together, given all the other learning priorities the nursing students have.
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LIMITATIONS This research is limited to the undergraduate nursing students of the Flinders University School of Nursing and Midwifery. The number of online survey participants (n=220) represents approximately 12.8% (n=1707) of the Flinders University onshore undergraduate nursing student population. In addition, the number of students who volunteered to attend the focus group discussion was low (n=12). Nevertheless, these limitations were considered when undertaking the analysis.
42
CONCLUSION This research has shown that nursing student participants across the three years have not fully understood what regulation of their practice means and how it applies to them. This understanding includes how regulation works, what their obligations are under the Act, the role of the State Board and the education sector, and any potential consequences of breaching the legislation. Ignorance of the issue would not be an excuse acceptable to either the public or the State Board. This report identifies that education providers with the regulation authority should consider a strategy to develop nursing students’ understanding of their responsibility as a regulated health professional. RECOMMENDATIONS Nursing Education Providers Education providers establish a process to engage with students on a continuous basis that enables them to explore the application of professional regulation to their nursing student role. Among the steps that could be considered are: • The initial registration of first year students as an ‘event’ that impresses itself on the new student. • Re-emphasis of regulation responsibilities prior to first clinical placement, including regulation scenarios in a curriculum- orientation package. • Engage the Clinical Coordinators (who support students in clinical venues) to discuss regulation issues relevant to the clinical context of the clinical placement. This would be supported by an information/discussion session with Clinical Coordinators to enable a consistent approach. • Develop two e-learning resources o An on-line course that includes both regulation scenarios on both fitness to practice and propriety issues and is required of all students o A blog with a designated coordinator, that enables students in any year to discuss regulation issues on-line. The coordinator could be supported by a team of third year nursing students and interested lecturers, who assist with the development of scenarios for the on-line course, as well as answer questions raised in the discussions. Nursing Regulators Regulators need to consider how they can work in partnership with Nursing Education providers to engage with nursing students to make the most of this opportunity to educate students about being regulated. Many of the nursing participants in the study felt more connected to the profession by being registered and receiving their certificate of registration. This enthusiasm about belonging to the profession could be harnessed by regulators to promote the role of regulation well before the student is registered as a nurse or midwife. The regulatory board should consider developing an electronic newsletter that is sent to all registered students quarterly, re-emphasizing key issues in regulation and providing case studies of regulatory action. 43
REFERENCES Australian Nursing Midwifery Council (2006), National Competency Standards for Registered Nurses, 4th Edition; Endorsed by the Nurses Midwives Board Australia 2009. Braun, Virginia and Clarke, Victoria (2006), 'Using thematic analysis in psychology', Qualitative Research in Psychology, 3 (2), 77 - 101. Burnard, Philip (1991), 'A method of analysing interview transcripts in qualitative research', Nurse Education Today, 11 (6), 461-66.
Health Practitioner Regulation National Law Act 2010 (the National Law), Queensland Government, Australia.
Hutt, Di (2010), 'Reflections and Celebrations of Nursing and Midwifery in South Australia', in Nursing & Midwifery Board of South Australia (ed.), Bulletin (30; South Australia), 1317. Nursing and Midwifery Practice Act 2008 (SA) South Australian Government, Australia. Sin, Chih Hoong and Fong, Janice (2008), 'Do no harm’? Professional regulation of disabled nursing students and nurses in Great Britain', Journal of Advanced Nursing 62 (6), 642-52. Tate, Ellienne T. EdD R. N. and Moody, Karen PhD R. N. C. (2005), 'The Public Good: Regulation of Nursing Students', SO - JONA's Healthcare Law, Ethics, & Regulation April/June 2005;7(2):47-53. Tee, Steve R. and Jowett, Rosalynd M. (2009 ), 'Achieving fitness to practice: Contributing to public and patient protection in nurse education', Nurse Education Today, 29, 43947.
44
APPENDICES Appendix A Data analysis from Section one of the online survey: Demographic information Valid
Missing Total
First year Second year Third year Total -1.00
All participants’ year level Frequency Percent 79 35.9 81 36.8 59 26.8 219 99.5 1 .5 220 100.0
Valid Percent Cumulative Percent 36.1 36.1 37.0 73.1 26.9 100.0 100.0
18 - 20 21 - 25 26 - 30 31 - 35 36 - 40 41 - 45 46 - 50 51 - 55 55 Total
All participants’ age Percent Valid Percent Cumulative Percent 38 17.3 17.3 17.3 69 31.4 31.4 48.6 27 12.3 12.3 60.9 20 9.1 9.1 70.0 24 10.9 10.9 80.9 20 9.1 9.1 90.0 9 4.1 4.1 94.1 7 3.2 3.2 97.3 6 2.7 2.7 100.0 220 100.0 100.0
18 - 20 21 - 25 26 - 30 31 - 35 36 - 40 41 - 45 46 - 50 51 - 55 55 Total
First year participants’ age Frequency Percent Valid Percent Cumulative Percent 22 27.8 27.8 27.8 20 25.3 25.3 53.2 8 10.1 10.1 63.3 5 6.3 6.3 69.6 11 13.9 13.9 83.5 8 10.1 10.1 93.7 3 3.8 3.8 97.5 1 1.3 1.3 98.7 1 1.3 1.3 100.0 79 100.0 100.0
18 - 20 21 - 25 26 - 30 31 - 35 36 - 40 41 - 45 46 - 50 51 - 55 55 Total
Second year participants’ age Frequency Percent Valid Percent Cumulative Percent 14 17.3 17.3 17.3 26 32.1 32.1 49.4 11 13.6 13.6 63.0 6 7.4 7.4 70.4 7 8.6 8.6 79.0 9 11.1 11.1 90.1 1 1.2 1.2 91.4 3 3.7 3.7 95.1 4 4.9 4.9 100.0 81 100.0 100.0
Frequency Valid
Valid
Valid
45
Valid
Valid
Missing Total
Valid
Valid
Missing Total
Valid
18 - 20 21 - 25 26 - 30 31 - 35 36 - 40 41 - 45 46 - 50 51 - 55 55 Total
Male Female Total -1.00
Male Female Total
Male Female Total -1.00
Male Female Total
Third year participants’ age Frequency Percent Valid Percent Cumulative Percent 2 3.4 3.4 3.4 22 37.3 37.3 40.7 8 13.6 13.6 54.2 9 15.3 15.3 69.5 6 10.2 10.2 79.7 3 5.1 5.1 84.7 5 8.5 8.5 93.2 3 5.1 5.1 98.3 1 1.7 1.7 100.0 59 100.0 100.0 All participants’ gender Frequency Percent Valid Percent Cumulative Percent 29 13.2 13.3 13.3 189 85.9 86.7 100.0 218 99.1 100.0 2 .9 220 100.0 First year participants’ gender Frequency Percent Valid Percent Cumulative Percent 12 15.2 15.2 15.2 67 84.8 84.8 100.0 79 100.0 100.0 Second year participants’ gender Frequency Percent Valid Percent Cumulative Percent 11 13.6 13.9 13.9 68 84.0 86.1 100.0 79 97.5 100.0 2 2.5 81 100.0 Third year participants’ gender Frequency Percent Valid Percent Cumulative Percent 6 10.2 10.2 10.2 53 89.8 89.8 100.0 59 100.0 100.0 All participants’ enrolment
Valid Bachelor of Nursing (Pre-registration) Bachelor of Nursing (Graduate entry) Bachelor of Nursing (Graduate entry – registered nurse only) Bachelor of Nursing (Graduate re-entry) Bachelor of Health Sciences / Bachelor of Nursing Other Total
Frequency Percent 158 71.8 39 17.7 4 1.8 1 16 2 220
.5 7.3 .9 100.0
Valid Percent 71.8 17.7 1.8
Cumulative Percent 71.8 89.5 91.4
.5 7.3 .9 100.0
91.8 99.1 100.0
46
First year participants’ enrolment
Valid Bachelor of Nursing (Pre-registration) Bachelor of Nursing (Graduate entry) Bachelor of Nursing (Graduate entry – registered nurse only) Bachelor of Nursing (Graduate re-entry) Bachelor of Health Sciences / Bachelor of Nursing Other Total
Valid Percent 84.8 3.8 1.3
Cumulative Percent 84.8 88.6 89.9
1.3 7.6 1.3 100.0
1.3 7.6 1.3 100.0
91.1 98.7 100.0
Frequency Percent 50 61.7 24 29.6 2 2.5
Valid Percent 61.7 29.6 2.5
Cumulative Percent 61.7 91.4 93.8
4.9 1.2 100.0
4.9 1.2 100.0
98.8 100.0
Frequency Percent 40 67.8 12 20.3 1 1.7
Valid Percent 67.8 20.3 1.7
Cumulative Percent 67.8 88.1 89.8
10.2 100.0
100.0
Frequency Percent 67 84.8 3 3.8 1 1.3 1 6 1 79
Second year participants’ enrolment
Valid Bachelor of Nursing (Pre-registration) Bachelor of Nursing (Graduate entry) Bachelor of Nursing (Graduate entry – registered nurse only) Bachelor of Nursing (Graduate re-entry) Bachelor of Health Sciences / Bachelor of Nursing Other
4 1 81
Third year participants’ enrolment
Valid Bachelor of Nursing (Pre-registration) Bachelor of Nursing (Graduate entry) Bachelor of Nursing (Graduate entry – registered nurse only) Bachelor of Health Sciences / Bachelor of Nursing Total
Valid
Missing Total
Valid
Valid
Missing Total
Yes No Total -1.00
Yes No Total
Yes No Total -1.00
6 59
10.2 100.0
All participants’ who are enrolled nurses Frequency Percent Valid Percent Cumulative Percent 22 10.0 10.1 10.1 196 89.1 89.9 100.0 218 99.1 100.0 2 .9 220 100.0 First year participants’ who are enrolled nurses Frequency Percent Valid Percent Cumulative Percent 3 3.8 3.8 3.8 76 96.2 96.2 100.0 79 100.0 100.0 Second year participants’ who are enrolled nurses Frequency Percent Valid Percent Cumulative Percent 13 16.0 16.3 16.3 67 82.7 83.8 100.0 80 98.8 100.0 1 1.2 81 100.0
47
Valid
Missing Total
Valid
Valid
Valid
Valid
Valid
Missing Total
Valid
Valid
Missing Total
Valid
Yes No Total -1.00
Third year participants’ who are enrolled nurses Frequency Percent Valid Percent Cumulative Percent 6 10.2 10.3 10.3 52 88.1 89.7 100.0 58 98.3 100.0 1 1.7 59 100.0
Full-time Part-time Total
All participants’ enrolment Frequency Percent Valid Percent Cumulative Percent 189 85.9 85.9 85.9 31 14.1 14.1 100.0 220 100.0 100.0
Full-time Part-time Total
First year participants’ enrolment Frequency Percent Valid Percent Cumulative Percent 72 91.1 91.1 91.1 7 8.9 8.9 100.0 79 100.0 100.0
Full-time Part-time Total
Second year participants’ enrolment Frequency Percent Valid Percent Cumulative Percent 72 88.9 88.9 88.9 9 11.1 11.1 100.0 81 100.0 100.0
Full-time Part-time Total
Third year participants’ enrolment Frequency Percent Valid Percent Cumulative Percent 44 74.6 74.6 74.6 15 25.4 25.4 100.0 59 100.0 100.0
Yes No Total -1.00
Yes No Total
All participants who are international students Frequency Percent Valid Percent Cumulative Percent 42 19.1 19.2 19.2 177 80.5 80.8 100.0 219 99.5 100.0 1 .5 220 100.0 First year participants who are international students Frequency Percent Valid Percent Cumulative Percent 10 12.7 12.7 12.7 69 87.3 87.3 100.0 79 100.0 100.0
Second year participants who are international students Frequency Percent Valid Percent Cumulative Percent Yes 20 24.7 25.0 25.0 No 60 74.1 75.0 100.0 Total 80 98.8 100.0 -1.00 1 1.2 81 100.0
Yes No Total
Third year students who are international students Frequency Percent Valid Percent Cumulative Percent 12 20.3 20.3 20.3 47 79.7 79.7 100.0 59 100.0 100.0
48
Appendix B Data analysis from Section two of the online survey: Testing participants’ knowledge of nursing student regulation requirements 2.1. WHEN ARE NURSING STUDENTS REQUIRED TO REGISTER IN SA? ANSWER: Prior to enrolment.
Valid
Valid
Valid
Valid
Valid
correct incorrect Total
All participants’ responses to section 2.1 Frequency Percent Valid Percent Cumulative Percent 12 5.5 5.5 5.5 208 94.5 94.5 100.0 220 100.0 100.0
incorrect
First year participants’ responses to section 2.1 Frequency Percent Valid Percent Cumulative Percent 79 100.0 100.0 100.0
correct incorrect Total
Second year participants’ responses to section 2.1 Frequency Percent Valid Percent Cumulative Percent 6 7.4 7.4 7.4 75 92.6 92.6 100.0 81 100.0 100.0
correct incorrect Total
Third year participants’ responses to section 2.1 Frequency Percent Valid Percent Cumulative Percent 6 10.2 10.2 10.2 53 89.8 89.8 100.0 59 100.0 100.0
correct incorrect Total
Enrolled nurses’ responses to section 2.1 Frequency Percent Valid Percent Cumulative Percent 4 18.2 18.2 18.2 18 81.8 81.8 100.0 22 100.0 100.0
2.2. WHEN REGISTERING, WHAT EVIDENCE ARE YOU MEANT TO PROVIDE? ANSWER: a) Passport & evidence, or b) Passport, drivers license & evidence, or c) Drivers license, evidence & other
Valid
Valid
Valid
correct incorrect Total
All participants’ responses to section 2.2 Frequency Percent Valid Percent Cumulative Percent 5 2.3 2.3 2.3 215 97.7 97.7 100.0 220 100.0 100.0
correct incorrect Total
First year participants’ responses to section 2.2 Frequency Percent Valid Percent Cumulative Percent 2 2.5 2.5 2.5 77 97.5 97.5 100.0 79 100.0 100.0
correct incorrect Total
Second year participants’ responses to section 2.2 Frequency Percent Valid Percent Cumulative Percent 2 2.5 2.5 2.5 79 97.5 97.5 100.0 81 100.0 100.0
49
Valid
correct incorrect Total
Third year participants’ responses to section 2.2 Frequency Percent Valid Percent Cumulative Percent 1 1.7 1.7 1.7 58 98.3 98.3 100.0 59 100.0 100.0
Enrolled nurses’ responses to section 2.2 Frequency Percent Valid Percent Cumulative Percent Valid incorrect 22 100.0 100.0 100.0 2.3. ARE NURSING STUDENTS REQUIRED TO RENEW THEIR REGISTRATION ANNUALLY? ANSWER: Yes
Valid
Missing Total
Valid
Missing Total
Valid
Valid
Valid
Yes No I don’t know Total -1.00
Yes No I don’t know Total -1.00
All participants’ responses to section 2.3 Frequency Percent Valid Percent Cumulative Percent 53 24.1 24.2 24.2 97 44.1 44.3 68.5 69 31.4 31.5 100.0 219 99.5 100.0 1 .5 220 100.0 First year participants’ responses to section 2.3 Frequency Percent Valid Percent Cumulative Percent 18 22.8 23.1 23.1 44 55.7 56.4 79.5 16 20.3 20.5 100.0 78 98.7 100.0 1 1.3 79 100.0
Yes No I don’t know Total
Second year participants’ responses to section 2.3 Frequency Percent Valid Percent Cumulative Percent 15 18.5 18.5 18.5 36 44.4 44.4 63.0 30 37.0 37.0 100.0 81 100.0 100.0
Yes No I don’t know Total
Third year participants’ responses to section 2.3 Frequency Percent Valid Percent Cumulative Percent 19 32.2 32.2 32.2 17 28.8 28.8 61.0 23 39.0 39.0 100.0 59 100.0 100.0
Yes No I don’t know Total
Enrolled nurses’ responses to section 2.3 Frequency Percent Valid Percent Cumulative Percent 7 31.8 31.8 31.8 10 45.5 45.5 77.3 5 22.7 22.7 100.0 22 100.0 100.0
50
2.4.DO YOU KNOW THE REASONS WHY YOU NEEDED TO REGISTER WITH THE NMBSA? Correct responses of this open- ended question were marked by researchers with nursing regulation experience.
Valid
Missing Total
Valid
Missing Total
Valid
Valid
Missing Total
Valid
correct incorrect Total -1.00
correct incorrect Total -1.00
correct incorrect Total
correct incorrect Total -1.00
correct incorrect Total
All participants’ responses to section 2.4 Frequency Percent Valid Percent Cumulative Percent 69 31.4 32.4 32.4 144 65.5 67.6 100.0 213 96.8 100.0 7 3.2 220 100.0 First year participants’ responses to section 2.4 Frequency Percent Valid Percent Cumulative Percent 23 29.1 31.1 31.1 51 64.6 68.9 100.0 74 93.7 100.0 5 6.3 79 100.0 Second year participants’ responses to section 2.4 Frequency Percent Valid Percent Cumulative Percent 26 32.1 32.1 32.1 55 67.9 67.9 100.0 81 100.0 100.0 Third year participants’ responses to section 2.4 Frequency Percent Valid Percent Cumulative Percent 20 33.9 35.1 35.1 37 62.7 64.9 100.0 57 96.6 100.0 2 3.4 59 100.0 Enrolled nurses’ responses to section 2.4 Frequency Percent Valid Percent Cumulative Percent 10 45.5 45.5 45.5 12 54.5 54.5 100.0 22 100.0 100.0
2.5. WHICH BEHAVIOURS ARE NOT FIT & PROPER? INCORRECT ANSWERS: Failure to pay University fees, constant overdue library books, failure to attend lectures/tutorials
Valid
Valid
Valid
correct incorrect Total
All participants’ responses to section 2.5 Frequency Percent Valid Percent Cumulative Percent 49 22.3 22.3 22.3 171 77.7 77.7 100.0 220 100.0 100.0
correct incorrect Total
First year participants’ responses to section 2.5 Frequency Percent Valid Percent Cumulative Percent 15 19.0 19.0 19.0 64 81.0 81.0 100.0 79 100.0 100.0
correct incorrect Total
Second year participants’ responses to section 2.5 Frequency Percent Valid Percent Cumulative Percent 21 25.9 25.9 25.9 60 74.1 74.1 100.0 81 100.0 100.0
51
Valid
Valid
correct incorrect Total
Third year participants’ responses to section 2.5 Frequency Percent Valid Percent Cumulative Percent 12 20.3 20.3 20.3 47 79.7 79.7 100.0 59 100.0 100.0
correct incorrect Total
Enrolled nurses’ responses to section 2.5 Frequency Percent Valid Percent Cumulative Percent 6 27.3 27.3 27.3 16 72.7 72.7 100.0 22 100.0 100.0
2.6. WHAT WOULD HAPPEN IF YOU PROVIDED INCORRECT INFORMATION TO THE NMBSA? ANSWER: You would be involved in an inquiry
Valid
Valid
Valid
Valid
Valid
correct incorrect Total
All participants’ responses to section 2.6 Frequency Percent Valid Percent Cumulative Percent 11 5.0 5.0 5.0 209 95.0 95.0 100.0 220 100.0 100.0
correct incorrect Total
First year participants’ responses to section 2.6 Frequency Percent Valid Percent Cumulative Percent 2 2.5 2.5 2.5 77 97.5 97.5 100.0 79 100.0 100.0
correct incorrect Total
Second year participants’ responses to section 2.6 Frequency Percent Valid Percent Cumulative Percent 3 3.7 3.7 3.7 78 96.3 96.3 100.0 81 100.0 100.0
correct incorrect Total
Third year participants’ responses to section 2.6 Frequency Percent Valid Percent Cumulative Percent 6 10.2 10.2 10.2 53 89.8 89.8 100.0 59 100.0 100.0
correct incorrect Total
Enrolled nurses’ responses to section 2.6 Frequency Percent Valid Percent Cumulative Percent 1 4.5 4.5 4.5 21 95.5 95.5 100.0 22 100.0 100.0
2.7. WHICH ISSUES SHOULD THE SCHOOL OF NURSING AND MIDWIFERY REPORT TO THE NMBSA? ANSWER: Medical unfitness & Unprofessional / Unfit behaviour
Valid
correct incorrect Total
All participants’ responses to section 2.7 Frequency Percent Valid Percent Cumulative Percent 19 8.6 8.6 8.6 201 91.4 91.4 100.0 220 100.0 100.0
52
Valid
Valid
Valid
Valid
correct incorrect Total
First year participants’ responses to section 2.7 Frequency Percent Valid Percent Cumulative Percent 3 3.8 3.8 3.8 76 96.2 96.2 100.0 79 100.0 100.0
correct incorrect Total
Second year participants’ responses to section 2.7 Frequency Percent Valid Percent Cumulative Percent 8 9.9 9.9 9.9 73 90.1 90.1 100.0 81 100.0 100.0
correct incorrect Total
Third year participants’ responses to section 2.7 Frequency Percent Valid Percent Cumulative Percent 8 13.6 13.6 13.6 51 86.4 86.4 100.0 59 100.0 100.0
correct incorrect Total
Enrolled nurses’ responses to section 2.7 Frequency Percent Valid Percent Cumulative Percent 1 4.5 4.5 4.5 21 95.5 95.5 100.0 22 100.0 100.0
OVERALL KNOWLEDGE SCORE USING SCALE Question 1: 3 points Question 2: 1 point Question 3: 2 points Question 4: 2 points Question 5: 3 points Question 6: 3 points Question 7: 3 points TOTAL POSSIBLE MARKS = 17 points All participants’ scores Percent Valid Percent Cumulative Percent 68 30.9 30.9 30.9 61 27.7 27.7 58.6 43 19.5 19.5 78.2 15 6.8 6.8 85.0 16 7.3 7.3 92.3 4 1.8 1.8 94.1 4 1.8 1.8 95.9 6 2.7 2.7 98.6 1 .5 .5 99.1 1 .5 .5 99.5 1 .5 .5 100.0 220 100.0 100.0
Frequency Valid
.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00 12.00 Total
(68x0 + 61x2 +43x3 + 15x4 + 16x5 + 4x6 + 6x8 + 1x9 + 1x10 + 1x12) / (220x17) = (0 + 122 + 129 + 60 + 80 + 24 + 48 + 9 + 12) / 3740 = 484 / 3740 = 0.129 = 12.9%
53
First year participants’ scores Frequency Percent Valid Percent Cumulative Percent Valid .00 27 34.2 34.2 34.2 2.00 30 38.0 38.0 72.2 3.00 13 16.5 16.5 88.6 4.00 3 3.8 3.8 92.4 5.00 4 5.1 5.1 97.5 6.00 1 1.3 1.3 98.7 7.00 1 1.3 1.3 100.0 Total 79 100.0 100.0 (27x0 + 30x2 + 13x3 +4x5 +1x6 +1x7) / (79x17) = (0 +60 + 29 + 20 + 6 + 7) / 1343 = 122 / 1343 = 0.091 = 9.1% Second year participants’ scores Frequency Percent Valid Percent Cumulative Percent Valid .00 29 35.8 35.8 35.8 2.00 16 19.8 19.8 55.6 3.00 14 17.3 17.3 72.8 4.00 5 6.2 6.2 79.0 5.00 8 9.9 9.9 88.9 6.00 3 3.7 3.7 92.6 7.00 2 2.5 2.5 95.1 8.00 4 4.9 4.9 100.0 Total 81 100.0 100.0 (29x0 + 16x2 + 14x3 + 5x4 + 8x5 + 3x6 + 2x7 + 4x8) / (81x17) = (0 + 32 + 42 + 20 + 40 + 18 + 14 + 32) / 1377 = 198 / 1377 = 0.144 = 14.4% Third year participants’ scores Frequency Percent Valid Percent Cumulative Percent Valid .00 12 20.3 20.3 20.3 2.00 15 25.4 25.4 45.8 3.00 16 27.1 27.1 72.9 4.00 7 11.9 11.9 84.7 5.00 3 5.1 5.1 89.8 7.00 1 1.7 1.7 91.5 8.00 2 3.4 3.4 94.9 9.00 1 1.7 1.7 96.6 10.00 1 1.7 1.7 98.3 12.00 1 1.7 1.7 100.0 Total 59 100.0 100.0 (12x0 + 15x2 + 16x3 + 7x4 + 3x5 + 1x7 + 2x8 + 1x9 + 1x10 + 1x12) / (59x17) = (0 + 30 + 48 + 28 + 15 + 7 + 16 + 9 + 10 + 12) / 1003 = 175 / 1003 = 0.174 = 17.4%
54
Enrolled nurses’ scores Percent Valid Percent Cumulative Percent Valid .00 4 18.2 18.2 18.2 2.00 6 27.3 27.3 45.5 3.00 3 13.6 13.6 59.1 4.00 3 13.6 13.6 72.7 5.00 3 13.6 13.6 86.4 6.00 1 4.5 4.5 90.9 8.00 2 9.1 9.1 100.0 Total 22 100.0 100.0 (4x0 + 6x2 + 3x3 + 3x4 + 3x5 + 1x6 + 2x8) / (22x17) = (12 + 9 +12 + 15 + 6 +16) / 374 = 70 / 374 = 0.187 = 18.7% Frequency
55
Appendix C Data from Section three of the online survey: Analysing participants’ confidence levels regarding nursing student regulation requirements Reliability Statistics Cronbach's Alpha Based on Cronbach's Alpha Standardized Items .874 .877
N of Items 8
Descriptives Confidence
Mean 95% Confidence Interval for Mean
Statistic 3.1641 3.0642 3.2641 3.1755 3.1250 .566 .75224 1.00 5.00 4.00 1.00 -.194 -.201
Lower Bound Upper Bound
5% Trimmed Mean Median Variance Std. Deviation Minimum Maximum Range Interquartile Range Skewness Kurtosis
Std. Error .05072
.164 .327
Custom Table- Comparing confidence level means
Year level
Year level
First year Second year Third year First year
4. Are you an enrolled nurse? Please tick a box.
Second year
4. Are you an enrolled nurse? Please tick a box.
Third year
4. Are you an enrolled nurse? Please tick a box.
Yes No Yes No Yes No
Mean 3.05 3.10 3.41 3.96 3.02 3.63 2.99 3.63 3.37
Confidence Standard Deviation .62 .86 .72 .40 .60 .76 .85 .71 .72
56
Total N 79 81 59 3 76 13 67 6 52
Test Statisticsa,b
1. Your 2. Your knowledge knowledge of the of the nurse's nurse's professiona professiona l code of l code of conduct. ethics. 10.010 8.060
Chisquare df 2 2 Asymp .007 .018 . Sig. a. Kruskal Wallis Test b. Grouping Variable: year_level
3. Your knowledge of where to access the Health Practitione r Regulation National Law Act 2009. 8.317 2 .016
8. Your knowledge of where to 7. Your access knowledge informatio 4. Your of the role n about understandin of the nursing g of what fit 5. Your 6. Your Australian and to practice understanding knowledg Health midwifery means as a of the term e of the Practitioner regulation nursing professionalism role of the s Regulation in student. . NMBSA. Agency. Australia. 7.898 8.449 3.973 3.157 4.944 2 .019
2 .015
2 .137
2 .206
2 .084
57
Scatterplot shows the best fit for a straight linear regression line as well as a quadratic curve. The points do not fit the linear line very well, hence the quadratic curve may be better. The linear assumption is likely to be violated and therefore a Pearson correlation may not be the most appropriate statistic.
Total Score Confidence
Descriptive Statistics Mean Std. Deviation 2.3727 2.22218 3.1641 .75224
N 220 220
Correlationsa Spearman's rho
total_score Confidence
Correlation Coefficient Sig. (2-tailed) Correlation Coefficient Sig. (2-tailed)
total_score 1.000 . .068 .314
Confidence .068 .314 1.000 .
a. Listwise N=220
58
