Maranga Mai! Education — what needs to change?

August 24, 2022

About a third of Aotearoa’s nursing workforce is comprised of overseas-trained nurses, nurse vacancies are into the thousands and an estimated one in three nursing students are dropping out — with even higher rates for Māori and Pacific1. In the first of a series exploring Maranga Mai!, NZNO’s campaign to fix the nursing crisis, Kaitiaki looks at what needs to change in nursing education.

Anna Clarke

Nursing student Anna Clarke

They realise they’re not struggling alone.” Culturally safe clinical placements, support for out-of-town learners, mentoring and earning while studying are key to retaining Māori and Pasifika nursing students, says third-year NorthTec bachelor of nursing (BN) student Anna Clarke, (Te Aupōuri, Te Rarawa and the Tongan village of Vaini).

  • Accommodation: The temporary closure of NorthTec’s marae due to COVID was identified by Māori and Pasifika students as the biggest challenge for out-of-town tauira.
  • Mentoring and peer support: NorthTec’s tuakana-teina hui each term provides a supportive space with other students and graduates.  “It gives them the opportunity to open up.  Then we can get in there and help.
  • Culturally safe placements:  “Sometimes a ‘do what we say’ attitude pushes students away and there can be a bit of an issue around cultural safety.”
  • Fees-free: Fees-free study or paid clinical placements would make nurse training more viable.

Pipi Barton

Nursing lecturer Pipi Barton

Grants, earn-as-you learn, an indigenised nursing curriculum and flexiblity for transient students are key to recruiting more Māori into nursing, says NorthTec nursing lecturer and PhD student Pipi Barton, (Ngāti Hikairo ki Kāwhia).

  • Grants: The number one issue is economic hardship particularly for Māori and Pasifika . . . we need to alleviate hardship immediately by giving grants to Māori and Pacific students, introduce earn-as-you-learn, first for Māori and Pacific, then for everybody.”
  • Indigenised curricula: The curriculum is very Euro-centric — polytechs enrol Māori but don’t retain Māori . . . nursing programmes are going to become more indigenised, with Te Pukenga”.
  • A unified curricula across schools: “A unified curriculum so no matter where you are, if you move around, it’s not going to impact on you negatively or have any additional costs”

— Barton is involved with writing the  unified nursing curricula for Te Pukenga  

Tania Mullane

Pacific nursing educator Tania Mullane

Curriculum can be transformational.” An indigenised curriculum, wraparound support and culturally safe placements are crucial to the success of Pasifika students, says Whitireia’s head of Pacific nursing, Tania Mullane.

Curriculum: “An indigenised curriculum reflects the learner. . . and makes sure our grads are able to be culturally competent, confident and able to meet the needs of populations who need it most.”

Wraparound care: “We have more face to face classes, we offer a lot more support. . . we wrap around — we address whatever we need to do to what we think the students are needing to make them successful.”

Culturally safe placements: “We identify places for individuals and we pull them from areas which are not supportive or culturally unsafe for them.”

Financial support, culturally safe environments and flexible nursing study are crucial elements to growing more of our own nurses — especially Māori and Pasifika — into Aotearoa’s nursing workforce, say educators, nurses and tauira (students).

Financial support — paid placements, grants & no fees?

Economic hardship has been identified as the “number one issue” for nursing students, particularly Māori and Pasifika, says NorthTec nursing lecturer Pipi Barton, (Ngāti Hikairo ki Kāwhia). “Māori are often economically disadvantaged anyway, because of the whole system and colonisation, so there’s that inter-generational transfer of poverty and economic hardship.”

Barton’s PhD research is examining the Māori nursing workforce, particularly why it has remained static at 6-7.5 per cent of the registered nurse (RN) workforce for 40 years against a Māori population of 16.5 per cent. She is also involved in nursing pipeline work at Te Whatu Ora.

Barton suggests alleviating hardship “immediately” by giving grants to Māori and Pasifika tauira and introducing “earn-as-you-learn” clinical placements — first for Māori and Pasifika then for everyone. “Our students are having to work long hours, full-time jobs as well as study full-time. Particularly in the economic environment we have at the moment, it’s really hard, particularly if they have families to support and they’re sometimes the only breadwinner in their families.”

NZNO Te Rūnanga Tauira representative Anna Clarke, (Te Aupōuri, Te Rarawa and Tongan), has seen nearly a quarter of her class drop out this year – most of whom were Māori.   “I have seen my classmates struggle and four of them have left the BN altogether – not all of us have support.” Fees-free and earning on clinical placements like a trades apprenticeship would likely make nurse training much more attractive, she says. “No-one here in New Zealand seems to be attracted into becoming a nurse. . . I’m not too sure why nobody wants to be a nurse, it’s an amazing career!”

“It shows that they’re appreciated, they can contribute at a high level. . . and it just seems punitive, almost, to not reward them.”

Karole Hogarth

Karole Hogarth, Otago Polytechnic head of nursing and representative on education leadership group NETS (Nursing Education in the Tertiary Sector), agrees lack of financial support is the “number one” barrier for students. “If you want to increase the workforce, then you have to provide some kind of support for students in health care, when they’re in clinical practice.”

Paid clinical placements, particularly for second and third-years, “had merit”, Hogarth said. “Certainly that big 360-hour placement at the end that all BN students have to do would be the perfect opportunity, as they’re really ready to enter the workforce. It shows that they’re appreciated, they can contribute at a high level. . . and it just seems punitive, almost, to not reward them.”

And with students sent away to placements for up to six weeks, doubling up their accommodation costs and adding transport expenses, “if you could mitigate some of those. . . then that takes a huge amount of pressure off”.

Nursing Council chief executive Catherine Byrne said the council was supportive of “all initiatives that would retain students, particularly Māori and Pacific, in the nursing programmes”, including paid clinical placements, as long as the quality of the placement was maintained. “That’s really our focus, that the clinical placement is a quality experience.”

Tina Smith

Hogarth said fees-free enrolled nurse (EN) training from 2020 had given EN numbers a real boost. “If we could do that with the BN it would be amazing . . . we could do it for five years, get a whole bunch of graduates through over the next decade – that would be amazing for health care.”

Tertiary Education Union (TEU) national president Tina Smith says more student grants or payments would be a “godsend” for nursing. Student teachers could access $16 million in scholarships over five years – more than $3 million per year. “That would be an absolute godsend to our nursing students who spend a huge amount of time on practicum.”

Particularly in their second year, students “really struggle to balance home, study commitments, being in practicum, having no money and trying to do some paid employment. So having some funding would be so much better”.

Accommodation support

NorthTec’s campus in Whangārei provided accommodation on its marae to students, some of whom traveled from as far afield as Kaitāia – 150km away, student Anna Clarke says. However, that had closed since the COVID pandemic – a loss identified by Māori and Pasifika students at a recent hui as the biggest challenge for out-of-town tauira. Work was now underway to have it re-opened.

Mentoring support and ‘wraparound’ care
Tania Mullane

NorthTec’s tuakana-teina hui each term was compulsory, giving tauira the chance to mix with other students as well as graduates, says Clarke. “It makes the students realise they’re not the only ones who are going through it, that everyone in their study journey have gone through it too and they can give advice. . . ‘don’t give up, you’ll get through it, you can graduate and go to work . . . you don’t  have to just give up just because things are hard at the moment’.”

Whitireia’s head of Pacific nursing Tania Mullane says the BN Pacific enjoys higher than average graduation rates – almost 80 to 90 per cent compared to around two-thirds nationally — to which Mullane attributes a “wraparound” approach. “We do things differently – we have much more face-to-face classes, we offer a lot more support, even on non-teaching days we offer tutorials – we wrap around,” she says. “We know that for half the class, English won’t be their first language – it’s a double whammy.”

NZNO professional nurse advisor Sandie Bayliss, who spent 18 years in nurse education, says mentorship – including study groups or tutorials — is really important to help students connect and clarify material.

An indigenised curriculum
Pipi Barton

The mainstream nursing curriculum is very “Eurocentric” says Barton, who is also involved with writing the three new unified nursing curricula for new mega-polytech Te Pukenga – bachelors of nursing (BN), nursing Māori (BNM) and nursing Pacific (BNP). “Te Pukenga identified that the polytechs are not meeting the needs of Māori – they enrol Māori but don’t retain Māori,” says Barton. “So nursing programmes are going to become more indigenised  and the hope is we’re going to see Māori retention improved because their programmes are more reflective of them.”

“If a student’s coming back and saying ‘as soon as they heard I was from the BN Pacific, their attitude changed’. . . we know what that is, and it’s not for us to fix it.”

Barton said the new mainstream BN – due to be launched mid-2023 — would use more local models and more Māori content such as te Tiriti, cultural safety and kawa whakaruruhau.

Whitireia’s Tania Mullane — also working with Te Pukenga on the new unified BNP — due to unroll in 2024 — agrees. “We have a programme that meets their needs, so they’re able to see themselves in the curriculum.” A big part of students’ first year is finding out who they are, then their relationship to their community, then their relationship to the profession of nursing, she says. “Individual to whānau to professionalism, then back again.”

National nursing curricula & flexible study

Having unified nursing curricula nationally would help Māori, who tend to be more “transient”, says Barton. Currently it costs “a whole lot of money” to have prior learning recognised. “So Te Pukenga is unifying curriculum, so no matter where you are, if you move around, it’s not going to impact on you negatively or have any additional costs.”

Sandra Bayliss

Barton would also like to see the BN Māori and BN Pasifika programmes (currently only delivered at a handful of sites) more widely available. “So that means that Māori will have access to a programme that’s very much about being Māori within the BN.”

Hogarth agrees that “streamlined” nurse education would allow more people to qualify. “It would be great to look at nursing as a whole, from level 4/5 up to post-grad, and being able to step in and out of programmes at whatever point you need to, dependent on your life, abilities and the like. . . There would have to be some boundaries put in but it’s not an impossible scenario and would actually work quite well.”

Extending the time limit for students to complete their BN from five to six years would also be helpful to keep those who need to study part-time or take a break, Hogarth says.

“You can feel when someone really wants to support you and someone doesn’t.”

Only about a quarter of first-year nursing students were school leavers — most were older and had “complex lives” with families, overheads, and needed flexibility, says NZNO’s Bayliss. “So I think part-time options are really important.”

Barton says the problem begins early, with schools not serving Māori well, meaning they tend not to come out with the same qualifications. “So Māori are so disadvantaged in so many different ways and this contributes to our ability to recruit and retain Māori in nursing education.”

Quality, culturally safe clinical placements

Culturally safe placements are crucial for students to thrive, says Mullane, and Whitireia immediately pulls them out if this is not the case. “We identify best places for not only the BNP but individuals and we pull them from areas which are not supportive or culturally unsafe for them. If a student’s coming back and saying ‘as soon as they heard I was from the BN Pacific, their attitude changed’. . . we know what that is, and it’s not for us to fix it.”

Anna Clarke

Student Anna Clarke says some clinical placements can be “alienating”, particularly for tauira Māori. “Sometimes a ‘do what we say’ attitude pushes students away and there can be a bit of an issue around cultural safety. . . You can feel when someone really wants to support you and someone doesn’t.”

TEU’s Smith says accessing consistently high quality clinical placements had always been a struggle “across the rohe”. Models varied wildly, from dedicated education units to staff juggling precepting alongside other demands, “so students are occasionally seen as an added burden, rather than, as they should be, a future asset for nursing and health”.

Robert Reid

Teachers successfully fought for an allowance to mentor students and new graduates, while nurses get “nothing. . . it is considered part of their professional responsibility”, says Smith.

Co-chair of Auckland’s regional skills leadership group, Robert Reid asked nursing schools if they could increase their intake. “They said they would love to but they can’t find enough practicums for the students they have now.”

A blockage in getting more clinical placements “really needs to be addressed, and that is not addressed by getting more funding from the Tertiary Education Commission, but from getting better systems in the DHBs/Health NZ to ensure those places exist,” Reid said.

Train up COVID vaccinators & testers

Those who stepped up to become COVID vaccinators and testers could be supported into nursing if there was some financial support, says Reid.

“We now have through the testing and vaccination, literally hundreds – particularly in Auckland — of young Māori and Pasifika rangatahi and older people too who would never in their wildest dreams think they’d have a job in health, but have,” he said. “We need to work with them, whether it is more of an EN nurse model, or even if it is a BN model, they will only pick that up on an earn-while-you-learn model.”

Niuean health workers at an Auckland vaccination drive in 2021.
Nursing pipeline programme

The national nursing pipeline programme is looking into ways of better matching nurse numbers to need, across all areas, “with a particular focus on growing workforce diversity, Māori and Pacific nurses,” Margaret Dotchin, who co-chairs the group with Nadine Gray, told Kaitiaki.

It is investigating how to:

  • Support Māori and Pacific nursing students to complete their nursing studies and thrive in the early years of their nursing career.
  • Develop a nationally consistent process for staircasing, recognition of prior learning and support, for example from HCA to EN to RN.
  • Develop an early career framework (years one to three post-registration) to support growing new graduates into advance practice roles.
  • Improve clinical placement access, co-ordination and experience for all nursing students.

A Te Whatu Ora spokesman could not put a time on any of the initiatives, but hoped to in the “near future”.

Margaret Dotchin

Nadine Gray

References

  1. The Nursing Pre-Registration Education Pipeline