It is widely recognised that an ageing nursing workforce and difficulty in attracting new staff are major reasons for the critical shortage of registered nurses (RN) in regional areas of Australia1-4. The authors believe that regional universities are a critical element in developing a skilled nursing workforce sensitive to the needs of rural and remote communities. The regional Charles Sturt University (CSU) offers courses in campuses throughout diverse regions of New South Wales (NSW), Australia.
Due to a critical shortage of regional RNs, a bachelor of nursing by distance education (DE) was conceived of and designed at CSU. This enabled rural and remote enrolled nurses (ENs) with NSW Department of Technical and Further Education (TAFE) qualifications to upgrade their qualification to RN without having to leave families and communities to study. However, many rural and remote ENs faced significant barriers to participation in this course5,6.
The authors recognised that prospective nursing students from rural and isolated areas were non-traditional learners5,7 and that flexibility in the mode of study was not sufficient to address their unique needs. Experience suggested that the barriers such students face affect not only their transition to and success in further studies, but also their access to higher education. This is significant when rural background has been established as the most influential factor in shaping health professionals' decision to practise in regional areas8,9.
Among ENs studying the bachelor of nursing by DE, many are mature age and have not studied for many years, are first generation university students, may not have completed secondary school education, have no idea of what university study entails and are poorly prepared for university study. They hold the view that university is only for elite students, and are in awe of the people and processes they will encounter5,6. Overcoming the barriers these individuals face is important for regional communities that need the skilled, professional workforce of their metropolitan counterparts.
The outreach model developed recognised the barriers to commencing RN studies faced by rural and remote ENs, and importance of supporting them within their regional communities. The model that included a consecutive two-day Academic Preparation Workshop reflected the research relating to rural issues and the learning needs of this group. The pilot workshop was held in Dubbo in 2003, followed by workshops in Orange (2004), Broken Hill (2005), Lightning Ridge (2005), Dubbo (2007), and Wagga Wagga (2006, 2007, 2008), making eight Academic Preparation Workshops held throughout rural and remote NSW with a total of 168 participants.
The theoretical vehicles of social capital and transformative learning informed the development of this model and the manner in which the specific needs of the students were addressed. Theories of social capital10,11 provided an understanding of the informal rules that shape behaviour and potentially provide greater access to information, support and opportunities. Social capital theories not only informed the understanding of how potential support in rural communities can be activated, but it also underpinned an understanding of why students had not successfully negotiated support for themselves. In particular, Bourdieu's notions of 'habitus' provided the means to understand the reluctance of these new students to seeing themselves as suitable for university studies because most lived and worked in a setting where this was not an expectation. Further, they were not members of social networks that knew about universities and their role as a collective resource.
A transformative learning pedagogy12 was adopted to support participants through this change process. Central to this approach is the individual becoming aware of their 'meaning schemes' (beliefs, attitudes and emotional responses to situations) and being given trustworthy new knowledge and encouragement. This enabled participants to rationally transform their perspectives and understandings and subsequently make conscious decisions and develop strategies based on this new understanding. This transformative framework underpinned the processes of the model.
The work of Yarrow, Herschell & Millwater13 influenced the decision to provide a face-to-face outreach model. This was because their research indicated that rural communities have strong verbal communication practices, and the validity of a message is established more by knowledge of and personal connection to the messenger than by the content of the message. We believed, therefore, that a lack of personal connection for learners from such communities created a 'disconnection'. This was increased by limited 'knowledge capital' in rural and isolated communities, the perception of universities as foreign places suited to a different social class, and limited activation of potential social capital to support these participants.
Through information, practical understanding and personal connection, knowledge was built of what was involved in undertaking the Bachelor of Nursing studies. In this way the ENs developed a perception of themselves as university students, and also came to understand that academic success is not just an individual endeavour, but is enabled by support during their studies. The academic preparation workshop was held least 6 months prior to a bachelor of nursing by DE intake. This allowed each participant time to build personal capabilities and networks of support, based on their new perception of university study. Four presenters were used in the pilot model but by streamlining this to two presenters (a nursing academic and a learning and teaching adviser) the sustainability of the workshops has increased.
The program included the following elements14:
- an introduction to CSU and the bachelor of nursing course: course progression, residential schools, clinical placements, costs and scholarships
- the CSU application process
- a panel of current students and graduates
- expectations of university studies
- learning in an online environment
- assessment of personal preparedness for tertiary study
- an overview of TAFE, area health services (AHS) and CSU preparation programs and support people
- understanding yourself as a learner
- staying motivated and in control of your studies
- planning for tertiary study.
Understanding enrolment processes and course progression is challenging for prospective students. The nursing academic was able to provide an overview of the course, explain requirements for attendance at residential schools and clinical placements, and to talk participants through the application process. The opportunity to do this face-to-face and to share personal experience of teaching DE students built a personal connection between participants and university staff.
Staff from the university, AHSs and TAFE outlined what university study entails, and the supports available to students in their own communities and the university. Wherever possible staff who would be delivering the service were included. Participants frequently commented that confidence in these supports was a critical factor in their decision to enrol. The inclusion in the workshop of a nurse educator employed by the AHS created an important bridge between participants and the university after the workshop. This educator could provide additional support and advice to participants prior to and during enrolment, and the course lecturer was able to address issues as they arose.
The 'hands on' session 'learning in an online environment' was valuable for many participants who were already familiar with email and general web searching but felt anxious about using online learning tools such as forums and navigating the university website. The inclusion of a panel of current students and graduates to talk about their experiences and successes inspired and encouraged participants; this valuable session prompted many participants' question. The closer the background of panel members to the participants' (eg in terms of family, children, work, shift work, newness to study), the greater the degree of rapport and meaningfulness of the session.
Participants were given an opportunity to stop, reflect and share their thoughts, plans and concerns at three key points in the workshop. To do this in an open and non-threatening manner, use was made of a 'learning tree' at the beginning and end of the workshop. The 'learning tree' consists of a diagram of people at different positions on a tree that depicts a variety of emotions. Participants identified the person on the tree who best represented how they were feeling about commencing university (the 'learning tree' also provided an opportunity to gather qualitative pre- and post-workshop data).
The third key point occurred after the provision of information on the initial day when many students felt overwhelmed and isolated. An activity that used a series of black and white photographs allowed participants to share their feelings, and it quickly became apparent that they were not alone in their fears, concerns and questions. Reducing the sense of isolation was particularly important because some participants were moving outside the expected norms of their family and social group, and would need to develop a separate identity. One participant commented:
I could see that if I started the course there would be a fantastic network of support from [other participants] who were like me ... studying and working and we would be there together. Learning would not be competitive.
The strongest theme to emerge from the workshop evaluations was that individuals felt I can do this. While almost all participants reported they had perceived university as a 'foreign' place, and that they doubted their ability to study at a university level, the workshop was seen to build their motivation and incentive to strive towards a new goal. Participants commented that: they were 'encouraged' by the recognition that 'they had some of the skills they needed'; there were established pathways to build around their identified skill deficits; other university students were 'like them'; and the university learning environment would be 'supportive'. Participants' comments indicated that the new information on skill and resource requirements, pre-enrolment courses and scholarship applications evoked conscious planning and, more importantly, the enactment of these plans.
The timing of the workshops also gave participants the opportunity to prepare for study by applying for scholarships and enrolling in 'study link' (pre-enrolment) subjects offered by the university. They also had time to access local support to assist them with their study and to set up their study environment at home, which included having discussions with their family and in the workplace.
Students left the workshop with:
- an understanding of the course requirements
- knowledge of how to complete the application form
- knowledge about how to find and apply for available scholarships
- the opportunity to have met and interacted with university staff and other prospective students
- an assessment of their current and future needs
- an awareness of support available to them prior to and during their studies
- a personal plan to prepare them for their studies
- a certificate of attendance.
The certificate of workshop attendance, in conjunction with other essential prerequisites, enabled them to be ranked in the highest category for a course offer.
The pre-post survey (conducted immediately before and after the workshops) identified a significant increase in confidence to commence university studies and knowledge of the skills and resources necessary for those studies. This newfound knowledge and confidence resulted in a number enrolments from each workshop in the CSU Bachelor of Nursing by DE (63% in total). Enrolment patterns reflected participants' informed decision-making. Some started with a single subject to allow adjustment to university studies; others delayed their enrolment to better prepare for study; while others undertook normal course progression.
A number of Indigenous students participated in the workshops. One male Indigenous participant decided against tertiary study at present, but shared his decision at the end of the workshop to take on the role of encouraging younger Indigenous community members to consider tertiary study. This was a valuable outcome.
At the time of the first Academic Preparation Workshop, CSU School of Nursing and Midwifery entered into partnership with an AHS in northern Victoria and southern NSW to offer the bachelor of nursing by DE to AHS enrolled division 2 nurses. The partnership included the offer by CSU of residential schools in the local area, and an AHS-employed nurse educator to provide local support for participants. Following on this success was a third partnership with an AHS in western NSW. The initial workshops were funded by CSU, but since 2005 the AHS have funded the workshops, providing a financially sustainable model.
In addition to financial support, AHS and TAFE staff members have actively promoted and participated in the workshops. Key health and university managers have been approached to open and close the workshop as a visible demonstration of organisational support. The nurse educator has had a key role in promoting the workshops to enrolled division 2 nurses within the AHS and has actively participated in the delivery of the workshop. Participants have reported more support and encouragement from their workplace peers as the number of ENs studying grows. The Academic Preparation Workshop is now a component of the AHSs' nursing recruitment strategy to target local people likely to work in rural and remote areas. Recognition has also come at state level. The Manager, Aboriginal Nursing Division, NSW Department of Health, opened the Lightning Ridge Workshop in recognition of the workshop's potential contribution to increased access and success for rural, remote and Indigenous students in the bachelor of nursing DE.
The further west we have travelled to more isolated areas, the more flexibility has been needed. When participants' travel times increase, distance becomes a bigger issue. The program needs to be restructured to accommodate remote groups according to the resources available. Participants outside the target group have attended the workshop, for example a paramedic considering a career change and a high school graduate considering university nursing study. Both state they have benefited. We believe flexibility is a major strength of the program.
Nursing and beyond
We believe the model has potential application beyond prospective nursing students, to prospective rural and remote students in other disciplines. The success of working in partnership with government and community organisations is essential to addressing workforce requirements and improving the health and wellbeing of potential students in rural communities. Current further evaluation of the model will assess its success and provide suggestions for improvement and wider application.
The authors acknowledge the contribution made by the industry partners, particularly the nurse educators who carried out targeted recruitment, assisted in running the workshops, and continued to support participants as they enrolled in the course and during their studies. Also acknowledged is the contribution of current and graduate nursing students who were prepared to share their stories. Finally, the initial funding support by the ARC Linkage project under the direction of Professor Heather Gibb is acknowledged.
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