FUNDING MASTER OF NURSING (Clinical) PROGRAMS

A paper prepared by the College of Nurses, Aotearoa, Inc

November 2006

Executive summary

The excess of labour demand over supply in the health sector is estimated to increase to a level between 28% and 42% of the 2001 workforce by 2021. (NZIER 2004). The College notes that the production of a skilled nursing workforce is a critical component of addressing that challenge.

Nurse Practitioners, nurse specialists and nurse leaders are a critical component of necessary workforce development.  Developing the specialist skills of nurses has been identified in many documents as critical to the sector’s ability to deliver safe and effective health care and disability services, given the increasingly complex needs of an ageing population and the prevalence of chronic conditions.

To assist with meeting these needs, the College urges the Tertiary Education Commission (“the TEC”) to recognise through its funding mechanisms, the distinctive characteristics of clinically focused Masters in Nursing (“MN”) programs, including the Post-graduate Certificate and Diploma steps towards MN.  It is of crucial importance for New Zealand’s future that there is an increasing number of post-graduate and MN graduates.

The problem is that present funding levels are drastically and unworkably low, because decision-making is based on a concept that all training is uniform.  In other words, using the uniform Equivalent Full-time Student (EFTS) based approach as a formula for funding MN programs is inappropriate.

The essential course work for a clinically focused MN includes advanced clinical assessment and diagnostic reasoning, advanced patho-physiology, advanced pharmaco-therapeutics, clinical specialty course, research theory and design, and advanced practicum.  The level of academic, clinical and research expertise required to support such programs is not able to be met through existing funding.

Masters of Nursing programs are at risk both in quality and sustainability under the current funding regimen and this is at odds with sector goals to build a well-educated health workforce to cope with current and predicted demand.

Glossary of terms

The College of Nurses, Aotearoa (NZ)  Inc.   (“the College”)
The College is a professional organisation for registered nurses.  It addresses professional nursing issues for the purpose of improved practice and health outcomes, through forging closer links between research, education, policy and practice.

Nurse practitioner
Nurse Practitioners (NP) are registered nurses who work at an advanced level of practice and are specifically registered as Nurse Practitioners by the Nursing Council of New Zealand. Nurse Practitioners practise both independently and in collaboration with other health care professionals to promote health, prevent disease and to diagnose, assess and manage people’s health needs. They provide a wide range of assessment and treatment interventions, including differential diagnoses, ordering, conducting and interpreting diagnostic and laboratory tests and administering therapies for the management of potential or actual health needs. They work in partnership with individuals, families, whanau and communities across a range of settings. Nurse Practitioners may choose to prescribe medicines within their specific area of practice. They can act as the regular health care provider for their client group, and their practice emphasises the direct provision of clinical care with health education and maintenance and disease prevention as core activities.

Nurse Specialist
A more diverse term applied to nurses with advanced education and training providing specialist services.

Programs
            Masters of Nursing (MN) (Clinical) 
Considered as a taught masters program. This program may have different titles in some organisations.
Master of Arts/ Master of Philosophy (Nursing)
Considered as a research masters program
Postgraduate certificate and postgraduate diploma
Comprised of papers selected from the MN program and supporting the development of clinical practice

PBRF

Performance based research funding

Introduction

The excess of labour demand over supply in the health sector is estimated to increase to a level between 28% and 42% of the 2001 workforce by 2021. (NZIER 2004). The College notes that the production of a skilled nursing workforce is a critical component of addressing that challenge.

Although health and disability service workforce development forecasting is neither foolproof nor at this stage well-developed in New Zealand, it is nevertheless critical to adopt a dynamic approach to health workforce planning and development, producing health professionals who are fit for purpose, in the right numbers and in the right place at the right time (Health Workforce Advisory Committee 2005).  While it is anticipated that the Health Information Workforce Program will ultimately improve forecasting ability, the Program will not be implemented in time to address, in the short to medium term, the issues raised in this paper.

Developing the specialist skills of nurses has been identified in many documents as critical to the sector’s ability to deliver safe and effective health care and disability services, given the increasingly complex needs of an ageing population and the prevalence of chronic conditions.

To assist with meeting these needs, the College urges the Tertiary Education Commission (“the TEC”) to recognise through its funding mechanisms, the distinctive characteristics of clinically focused Masters in Nursing (“MN”) programs, including the Post-graduate Certificate and Diploma steps towards MN.  It is of crucial importance for New Zealand’s future that there is an increasing number of post-graduate and MN graduates.

Clinically focused MN programs currently classified as “taught post-graduate” programs, are designed to prepare advanced nurses to be Nurse Specialists, Nurse Practitioners, clinical managers and nurse leaders.  These advanced nurses will form a key part of the future health care and disability service workforce.  Well-funded post-graduate nursing programs, and particularly clinically focused MN programs, are essential for producing a capable future health workforce.

The problem is that present funding levels are drastically and unworkably low, because decision-making is based on a concept that all training is uniform.  In other words, using the uniform Equivalent Full-time Student (EFTS) based approach as a formula for funding MN programs is inappropriate.

The College calls for an urgent change to the EFTS funding formula for MN programs and a review of Performance Based Research Funding (PBRF) for MN programs. It is recognised that a review of PBRF funding for applied disciplines is underway but it will not be reported until 2008 and changes will only be implemented after that.  If there is no change to the funding formula and to funding decision-making, the five Tertiary Education Organisations (TEOs) currently delivering the MN Program, may be unable to continue to deliver or to deliver to an adequate standard.  The consequences of this for the health care and disability service delivery for New Zealanders will be significant.

There is a need for sound analysis to be used as the basis for decision-making about

1. the amount of funding for MN programs; and
2. the equitable distribution of funding between the various clinical disciplines such as nursing, dentistry, pharmacy, midwifery, medicine and veterinary science as currently there are major and inexplicable anomalies.

What the College wants to see is equitable and realistic funding of post-graduate nursing education, based on the actual costs of delivering such programs and aligned with predicted workforce requirements and predicted demand for services.

The purpose of this paper

The purpose of this paper is to

• set out concerns regarding the level and fair distribution of the funding of clinically focused MN programs;
• discuss the immediate and longer-term strategic relevance of MN programs; and
• urge Government, through the TEC, to address issues in funding level and fairness, as a matter of urgency. 

Background

The nature of the MN has meant that alongside the traditional masters degree with a significant research component, typically MA or M.Phil, there is now, in addition, a more clinically focused masters degree (MN), comprising primarily taught courses with a much smaller research component.  The development of such a degree has been in direct response to the need to prepare advanced clinicians in nursing to meet the need for such services.  Whilst both masters degrees attract students and have relevance to the discipline the majority of students are enrolled in the MN rather than the MA degree

MN programs are designed to meet the need for practitioners with advanced knowledge and skills, including research.  The range of advanced knowledge and skill required to be taught in the degree (diagnostic reasoning, patho-physiology, pharmaco-therapeutics clinical specialty knowledge and prescribing) precludes a thesis of more then 0.5 EFTS and indeed it is more often 0.25 EFTS.

Who funds training for advanced / specialist nursing?

Clinical training is generally funded through the Ministry’s Clinical Training Agency (“the CTA”), but at present the CTA do not fund post-graduate nursing training, with the exception of some specific specialty papers which can be used as a component of the MN degree.  A very small pool of approximately $7m is disbursed by the CTA through direct purchase of some programs and a historical entity called deficit switch funding.  This disbursement process is currently under review.

The education sector is responsible for funding health workforce education through the TEC.  Currently, the TEC categorises and funds two types of post-graduate nursing programs – “taught” and “research-based” using an EFTS funding formula.

Funding issues
a.         Student component funding (EFTS funding by category)

The Working Party on Nurse Practitioner Employment and Development (“the Working Party”) looked during 2006 at the TEC funding process and identified some areas in which change is urgently needed.  It is not clear what analytical process, if any, was used by the TEC to assess the cost of clinical programs.  Some of the issues that have been identified are already being considered as part of the Tertiary Education Funding Review and as a result of the Working Party’s paper prepared for the CTA.  (Nurse Practitioner Employment and Development Working Party, 2006.)

If the current EFTS funding formula continues to be applied as it is for nursing it is likely that TEOs will be unable to deliver the programs that are required to meet immediate and longer-term health and disability sector workforce demands.  If  a gap between workforce supply and demand of as much as 28% to 42% of the 2001 workforce by 2021, as predicted by NZIER is allowed to develop, the impact will be serious, on not only the health of the country but also on its social and economic development.

The College calls for an urgent change to the EFTS funding formula for post-graduate nursing for the following reasons:

1          There has been a decrease in funding for taught MN programs
The funding for taught post-graduate programs has been steadily and dramatically decreasing.  By the College’s calculations, there will be a decrease of 20% in the amount of each EFTS payment between 2005 and 2007.

The TEC funding per EFTS for taught post-graduate nursing programs decreased from $11,852 in 2005, to $10,190 in 2006. (TEC, 2006)

For 2007 the funding for an applied post-graduate program with the three critical components of theory, clinical practice and research will decrease further to $9469.

2          Funding is inadequate to cover course costs
            The essential course work for a clinically focused MN includes advanced clinical assessment and diagnostic reasoning, advanced patho-physiology, advanced pharmaco-therapeutics, clinical specialty course, research theory and design, and advanced practicum.  The level of academic, clinical and research expertise required to support such programs is not able to be met through existing funding.

3          There are insufficient funding categories
The two designations of taught post-graduate and research post-graduate do not recognise the uniqueness of a program that includes theory, research and clinical practice components.

4          Clinical supervision costs
EFTS-based funding does not provide for clinical supervision costs for the prescribing practicum and clinical mentoring, nor does it provide for clinical release time or clinical rotation.  The costs associated with clinical education and training have been assessed for many under-graduate programs, e.g. under-graduate programs with high clinical education-related costs and these have received TEC “add-on” funding, for example:

            All figures are GST excl

            Despite the recognition given to all other under-graduate programs with a high clinical component, clinical MN programs have not received any “add-ons”.  This anomalous situation, which significantly undervalues the taught post-graduate clinically focused MN programs, is set to worsen in 2007.

For 2007, the add-on rates shown above have been added to the base rates and new funding categories created as a consequence, eliminating clinical add-ons.  The TEC proposes in 2007 to move nursing to funding category “L” in which under-graduate and all post-graduate programs, whether taught or research, funded at the same level, namely $9469/EFTS.  (Category L funding also includes agriculture, and horticulture non-degree programs and osteopathy.)

Research post-graduate programs will increasingly receive “top-up” funding via PBRF, once more undervaluing taught post-graduate programs.

5          There are anomalous funding schedules across disciplines
The funding allocated to nursing programs, as compared with relevant medical and dental training is illustrated below: 

TEC 2007 funding:

           
These figures illustrate, in particular, lack of recognition of the comparative level at which nurse practitioners in particular contribute to health service delivery and health sector outcomes.  In addition it indicates:

• the lack of recognition of the complexities and costs of nursing education and training and consequently the low level of funding given to nursing training;
• the lack of recognition of the need for an increase from under-graduate to post-graduate nursing training;
• the lack of understanding of the costs of clinical supervision and other costs associated with a post-graduate nursing Program; and
• that post-graduate nursing is funded at half the level of post-graduate dentistry which is anomalous given the clinical supervision component of both.  Moreover, given the proven effectiveness of Nurse Practitioner services in the USA (National Nursing Centres Consortium, 2005) it is difficult to justify continuing the anomalous funding regime that applies to advanced nursing when compared with medicine and dentistry.

If we are investing in a health workforce that can provide seamless, integrated services for primary health care, rehabilitation and older people’s health services, to ensure that people are supported to live independently in their own home/community, the inadequate level of funding of post-graduate nursing training must be addressed.

b.         PBRF issues
            The College calls for an urgent or earlier review of PBRF for post-graduate nursing training for the following reasons:

1          PBRF discriminates against taught post-graduate programs
The TEC, through PBRF, provides financial rewards which are for completion of research based programs, i.e. the MA, MPhil, PhD.  TEOs which apply for PBRF receive some of their PBRF funding for Research Degree Completions.  Up to 25% of the total funds ($20m) allocated through PBRF is allocated on the basis of Research Degree Completion.  However, only those theses of 0.75 to 1.0 EFTS may be counted.

The clinically focused MN, structured to meet the Nursing Council’s advanced practice competencies, does not attract PBRF funding for research degree completions.  The required clinically focused course work, outlined above, equates to six or seven papers, or ¾ of a two-year full-time equivalent MN.  Therefore a research project which equates to one or two papers is the largest research component which can be included.  This is a further disincentive for tertiary education providers to offer a MN Program.

2          PBRF tends to favour larger research projects
Research project completions are valued for PBRF purposes primarily on the basis of their size.  As the research projects in a clinically focused MN Program have the potential to inform health care practice significantly, the College considers that value should be added to them.  An equitable system of recognising the costs and value of research would see some system of funding for research that is of the order of 0.25 EFTS through 1.0 EFTs and greater.

3          PBRF discriminates against clinical and taught programs
Whilst nurses value traditional post-graduate degrees as preparation for teaching and research work, the majority now want to do the clinical MN in order to become senior clinicians.  These students require research based clinical knowledge delivered in a taught masters.  However, TEOs offering taught post-graduate nursing programs rather than research based programs have been doubly disadvantaged.  Not only has the base funding declined but also PBRF discriminates against such programs

4   Burden on non-administrative, non clinical staff
The onus of generating PBRF generated income for the TEO falls unfairly on a small number of non-administrative / non clinical nursing faculty, while the onus of administration and clinical practice competence assessment falls on others.  

Nursing programs, as in other clinical disciplines need a proportion of faculty who are clinical experts and therefore ideally will be in joint teaching and practice roles.  Managing clinical practice programs produces administrative demand not experienced by schools and departments with no such component.  The administrative load of faculty who are involved with taught and clinically focused MN programs includes spending considerable time meeting the requirements of the Nursing Council of NZ for accreditation and re-accreditation.

Nursing’s scores in the first PBRF round demonstrated the consequences of this, leading to significant funding reductions.  

Conclusion

Government plans for workforce development need are at odds with the TEC funding policy.  The TEC funding is inequitable and levels are too low for MN programs to be sustainable.  Funding levels are seriously compromising the development of advanced nursing knowledge and skills, undermining TEOs’ capacity to respond to regional educational needs and nationally-identified priorities.  This threatens future workforce capability.

There is no incentive for TEOs to support programs to prepare Nurse Practitioners or Nurse Specialists, or to train nurses to be leaders.  There is a double-edged sword with undue pressure to deliver training programs within the current funding regime and also a lack of opportunity for clinically focused taught MN programs to attract PBRF funding.  The College considers that TEOs could be forgiven for assigning low priority to offering approved MN courses and for showing little interest in developing new ones.

In order to address the risk of having tertiary education organsations not being able to teach MN programs in future, the TEC needs to recognise the significance of having advanced nurses in the future health and disabilty service workforce.  It is the College’s fundamental concern that the TEC does not recognise this.

Once they have put advanced nurses in the right context, the TEC will need to address the following key issues:

• The way in which post-graduate nursing is being inappropriately categorised into only two categories (taught and research) for funding purposes;
• The impact of the 20% decrease in EFTS funding from 2005 -7;
• What is the basis for  assigning nursing to new category “L”;
• Whether it is appropriate to fund under-graduate and post-graduate nursing at the same level;

5  The inequitable amounts of funding for other clinical programs as compared with amounts for nursing programs given that nurse practitioners function at a comparative level with medical staff at registrar and more senior level.

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References

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Acknowledgement

Authors of this document were Fellows of the College.

Professor Julie Boddy (Massey University)
Professor Jenny Carryer (Massey University)
Dr Susan Jacobs (Eastern Institute of Technology)
Asst Prof Judy Kilpatrick (Auckland University)
Mary MacManus (Auckland University of Technology)