One Profession, Two Ways of Thinking: Challenges in Developing Australia's Nursing Workforce

ABSTRACT

Professional education for licensed nurses in Australia is a complicated matter involving two education systems—vocational education and training, and higher education—each characterized by a different curriculum model. The contribution of the two systems follows a division of the workforce into Enrolled Nurses and Registered Nurses, with vocational education serving the first division and higher education the second. Although the systems are intended to provide connecting educational and career pathways, it results in a binary education landscape featuring two distinct forms of curriculum and contrasting assumptions about knowledge. This discursive discussion analyses the impact of the competency‐based curriculum on Enrolled Nurses' education, entry to the profession of nursing, and their aspirational educational pathways towards registered nursing. Many Enrolled Nurses successfully articulate to become Registered Nurses; however, we argue that traversing between the two distinct curriculum approaches creates barriers to these transitions. We also argue that apart from undermining the learning trajectories of nurses, the influence of the competency‐based curriculum model threatens the coherence of the profession at a time when conditions of work are both intensified and globalized, calling for a solution in the form of curriculum harmonization.

1. Introduction

This paper focuses on the complexities of nurse education in Australia produced by its positioning within two disparate education systems. Although the issues are examined from the Australian context and perspective, the discussion is relevant to the contemporary global discourse which calls for greater harmonization of nurse education to sustain an appropriately educated and skilled nursing workforce worldwide (World Health Organisation [WHO] ²⁰²⁰).

There are three levels of professional registration for nurses in Australia: Nurse Practitioners, Registered Nurses and Enrolled Nurses. Registered Nurses and Enrolled Nurses make up the bulk of the workforce (Schwartz 2019), and this paper focuses on these two groups. Registered Nurses work to a specific scope of practice, as determined by their educational preparation, experience and health service requirements (Nursing and Midwifery Board of Australia ²⁰²⁴). Registered Nurses are considered leaders in the nursing profession and are responsible for the work they complete and the work they delegate. Enrolled Nurses also work to a specified scope of practice, which is, generally speaking, a condensed version of the Registered Nurse's scope of practice. Enrolled Nurses are responsible for their own work, but act under the direct and indirect supervision of a Registered Nurse, who holds overarching accountability (Nursing and Midwifery Board of Australia ²⁰²⁰).

Professional education for Enrolled Nurses and Registered Nurses in Australia involves two systems: vocational education and training (VET) and higher education. Together, these systems comprise Australia's ‘tertiary’ education sector and are intended to provide connecting educational pathways. Movement between the two sectors (i.e. articulation) is common in some occupational areas, including nursing. However, the two systems feature contrasting assumptions about knowledge and approaches to curriculum. These differences are such that commentators have referred to a ‘binary’ of Australian tertiary education (Parker et al. 2018), and researchers have described a range of problems for individuals and occupations that arise from them (Hodge and Knight 2021).

A key factor producing this binary is the adoption of ‘competency‐based training’ as a sector‐wide model of occupational analysis and curriculum in VET. There is no equivalent overarching model to competency‐based training in higher education, and it is this competency‐based model that generates the epistemological and curricular contrasts mentioned. On the higher education side, curriculum is largely derived by experts from their intimate acquaintance with the epistemological and ontological demands of their disciplines and professions. They seek to reproduce their field through education with as few mediating factors as possible (Hodge et al. 2024). When it comes to nursing, higher education curriculum is beholden to the body of knowledge and practice of nursing curated by professional associations, whereas VET curriculum represents that corpus via the rules of competency‐based training which have been characterized as ‘epistemically supplantive’ (Hodge et al. 2016, 5) or imposing assumptions about knowledge and curriculum that are not necessarily consistent with nursing itself. In this article, we examine how the competency‐based model of Australian VET impacts the curricular experience of preparing Enrolled Nurses for the nursing profession. Our examination helps to account for difficulties Enrolled Nurses are reported to experience transitioning to higher education and raises doubts about how well the profession as a whole is served by competency‐based VET.

In our analysis, we acknowledge that Enrolled Nurses and Registered Nurses have different roles in the health system, but presuppose that the nursing body of knowledge and practice as such is holistic, revolving around the human body and its systematic, science‐informed and ethical care. We regard differences in the scope of practice of Enrolled Nurses and Registered Nurses as a division of labour rather than a bifurcation of professional knowledge. We conclude that while VET prepares Enrolled Nurses for technical tasks, other important aspects of the nursing body of knowledge and practice are not visible in VET curricula. While this problem has obvious impact on nursing students moving from VET to higher education, it poses questions for the integrity of professional knowledge within the Australian nursing workforce. We conclude that with respect to nursing, the binary of Australian tertiary education produces two ways of thinking, to the potential detriment of the profession.

To make our case, this article adopts a discursive (critical) discussion format. In doing so, it takes a critical approach to the area of inquiry, and presents important questions to readers for debate, discussion and decision. We begin with an overview of the nursing body of knowledge and practice to establish that the corpus is more than a technical one. We then provide a brief account of how the nursing workforce in Australia was divided into Enrolled Nurses and Registered Nurses and their respective educational paths allocated. We follow this with a description of the binary system of tertiary education in Australia, focusing on differences in epistemic and curricular assumptions between its VET and higher education components. How they each address the nursing corpus is then analysed. The relative shortcomings of the competency‐based VET system become clear, and we elaborate on the issues created.

2. Nurses' Knowledge and Practice

Analysis of the nursing body of knowledge and practice is far from a simple matter of drawing on an agreed set of principles. We do not try to make a statement on the ultimate parameters of the nursing corpus. Rather, for the purpose of this paper, we limit ourselves to differentiating technical practice from other parts of the corpus to scaffold our analysis. Apart from technical skills, nursing researchers distinguish bodies of theory, professional identity and ways of thinking.

In terms of technical skills, nursing has always been a technical practice, embedded in specific knowledge and technology (Weller‐Newton and McCormack ²⁰²⁰). Nursing practice requires nurses to work directly with patients, technology and materials (such as medications), and within the environment of health facilities. As such, there are a range of technical requirements that nurses need to understand and employ in highly proficient ways (Crisp et al. 2021). Nurses must work with the diverse apparatus of health work, with an expectation of continued practice and ongoing learning once employed in the profession.

Alongside technical skills, researchers distinguish theoretical areas such as anatomy, physiology, psychology and sociology as relevant to the work of nurses. These each present as intricate and often extensive bodies of knowledge to be learned. Each of them incorporates networks of propositional knowledge and theory, each with their own history of development, contemporary debates and areas of growth (Barbagallo et al. 2022). Nurses are required to master a significant quantity of detail as well as representations of how the given body of knowledge coheres. Each field brings with it a perspective on the world, and methods of developing new knowledge (Krishnan 2009). Nurses are expected to navigate disparate conceptual systems, appreciate distinctive ways of conceptualizing and understand how these coalesce with their own discipline's knowledge base (Satoh et al. 2023).

Professional identity is a part of the nursing corpus that is explicitly oriented to the occupation as a historically and societally unique and valued role (Maginnis 2018; Simmonds et al. ²⁰²⁰). Historical exemplars, such as that of Florence Nightingale, are honoured (Beck 2021), and the evolution of nursing into a modern, scientifically informed profession is appreciated (Van der Cingel and Brouwer ²⁰²¹). Institutional expressions of this distinct role, such as scope of practice (including the relations between Registered Nurses and Enrolled Nurses) are learned as part of professional practice. The identity and worth of the nurse are respected and appreciation of associated values is inherent in their professional preparation. These values are implicit in the emerging nurse's identity and are expressed in a holistic commitment to the people they care for and in the capacity to speak out against erroneous practice (Philippa et al. 2021).

In addition to such modes of thinking (relative to the different knowledge areas nurses are exposed to), there are broader ways of thinking that are characteristic of nursing (Epp et al. 2021; Falcó‐Pegueroles et al. ²⁰²¹). Critical thinking is necessary; Registered Nurses and Enrolled Nurses are responsible for their own decisions and for any work they delegate. They need to continuously evaluate options and commit to courses of action, potentially in conflict with other sources of advice (Christianson 2020). These are, to some extent, generic capabilities; however, to be able to effectively demonstrate this ability in any given situation, Registered Nurses and Enrolled Nurses need to have been exposed to the knowledge, assimilate its tenets, and have opportunities to integrate this into their practice. These, then, are ways of thinking specific to nurses and implicit in professional practice.

3. The Division of Nursing Labour and Education in Australia

Nursing, then, involves extensive and entwined domains of knowledge and practice. These domains revolve around the human body and its systematic care and are drawn on in the context of a professional identity that is historically and socially situated and valued. Before the introduction of Enrolled Nurses as ‘nurses’ aides' in the 1960s, those we now term ‘Registered Nurses’ provided all nursing care (Lewis et al. 2020). The Enrolled Nurse workforce model was intended to alleviate workforce shortages, manage labour costs and provide a pathway for Enrolled Nurses to become Registered Nurses. Enrolled Nurses were trained in hospitals, mirroring the apprenticeship‐style Registered Nurse educational model of that period. The Enrolled Nurse's scope of practice was initially limited to providing basic patient care under the supervision of a Registered Nurse but expanded from 1994 in response to Registered Nurse shortages (Lucas et al. 2021).

Higher education programs for Registered Nurses commenced in Australian universities in 1984 following the Sax (1978) inquiry into nursing education. By 1994, all Registered Nurse preparatory programs were conducted within the higher education system, and only Enrolled Nurse education remained as a hospital‐based apprenticeship‐style model. From 1997, Enrolled Nurse education was also transferred out of the hospital setting (Johnson and Preston 2001) following the Reid (1994) review. Instead of replicating the higher education model for Registered Nurse preparation, Enrolled Nurse education was transferred to VET. Price et al. (2001) noted industry stakeholder support for positioning Enrolled Nurse education in the VET system, due to the latter's supposed ‘technical’ focus, in contrast to the emphasis on theory and professional identity that characterized education for Registered Nurses. We return to the question of the appropriateness of this assessment of Enrolled Nurse knowledge and subsequent allocation to VET for professional preparation later.

4. Epistemic and Curricular Differences Between Higher Education and VET

In this section, we analyse the epistemic differences between higher education and VET and contrast the curricular heterogeneity of higher education with competency‐based training, the single curriculum system enforced in VET.

4.1. Knowledge and Curriculum in Higher Education

Australian higher education is generally geared to reproduction of scholarly bodies of knowledge. That is, the epistemic demands of disciplines and professions directly shape curriculum for a given area (Hodge et al. 2024). Although there is a qualifications framework that describes generic outcomes for different levels of study (the Australian Qualifications Framework 2013), and despite the policies and procedures in different institutions that impose overarching ‘graduate outcomes’ statements and course structures and templates, ‘what’ is taught is generally decided by those with expertise in the field. There are necessary decisions to be made in relation to curriculum since not everything relevant to a field of study can be represented, and there may be contention over which paradigm or general interpretation of the field should predominate. But setting these often‐powerful influences aside, what is taught in higher education is more or less expected to reflect the epistemic structure and content of discrete disciplines and professions.

Professional or scholarly associations—including for nurses—exist in part to contemplate what should be included in any program of study and consider paradigms that best serve the field (Klassen 2022), but what is important in this case is that each association (and by extension, each group of academics making curricular decisions) approaches the body of knowledge and practice for its profession or discipline in a way unique to that area (Hodge et al. 2024). These ways are determined by traditions of reflection and scholarship attuned to the epistemic demands of a given field. Whatever statements of standards or capabilities come to be espoused by such associations, they are epistemically distinct as befits the deep‐seated singularity of individual disciplines and professions.

In a sense, then, Australian higher education is characterized by epistemic and curricular heterogeneity. Apart from the generic overlay of Australian Qualifications Framework requirements (e.g. that a bachelor degree be three to four years' duration [Australian Qualifications Framework Council ²⁰¹³]) and institutional policies and procedures (e.g. templates requiring statements of course or unit outcomes), there is little in common among discrete areas of study. Nursing curriculum is not commensurate with those of Engineering or History. How knowledge and practice is conceptualized, structured, proportioned and sequenced in curricula are matters determined in the main by the demands of the discipline or profession as interpreted by experts.

4.2. Knowledge and Curriculum in Vet

The heterogeneity of epistemic and curricular forms in Australian higher education is in stark contrast with its VET system. In the latter, a single curriculum model is enforced—competency‐based training. The history of competency‐based training goes back to the early 20th century (Kliebard 1975). While its roots were in this early period, competency‐based training was implemented as a national Australian model in the early 1990s (Hodge 2007). The rhetoric of the time declared it would bring consistency and a structured framework to the decentralized and industry‐specific curriculum approach employed by Technical and Further Education (TAFE) institutes, Australia's public vocational education colleges (Smith and Keating 1997). The literature discursively suggests that a key improvement was to allow a division of educational labour between industry representatives and training providers, institutionalizing industry ‘leadership’ of the VET sector and its curriculum.

The competency‐based curriculum of VET is encapsulated in ‘Training Packages’, which prescribe the skills and knowledge required for occupational roles that are divided into elementary ‘units of competency’. Education providers and teachers base their programs on what is codified in the units, which are written by industry representatives. Auditing mechanisms, industrial relation pressures and funding policy all serve to focus training provider management on delivering only what is described in the unit content (Hodge et al. 2024). VET teachers are thereby placed in the unenviable position of being disregarded as industry experts (Hodge et al. 2024). Instead, they are required to study and in turn, instruct their students in the content of the units—content that is prone to becoming out‐of‐date and predominantly concerned with procedural skills necessary to undertake well‐known occupational tasks. The limitations of the competency‐based approach are further corroborated by Misko and Circelli (2022) who found Training Packages unsuitable for addressing nontechnical skills and capabilities such as ‘critical thinking, learning from others, collaboration, creativity and innovation, and self‐direction’ (p. 1). They further concluded that the limitations of competency‐based training make it inappropriate for occupations such as nursing, which require learners to acquire ‘complex and extensive bodies of knowledge’ (p. 12).

Early in the era of VET reform, Robinson (1993) described the disorientation and demoralization of teachers under the competency‐based training regime. Her research depicted teachers who could no longer recognize their own expertise in the units. Later, Hodge (2016) reported that many VET teachers found it necessary to actively reinterpret content (including omitting, updating and re‐creating) to overcome limitations and to ethically serve the interests of their students and partner employers. This was seen as necessary as the units of competency were not reflective of their own occupational expertise.

Nevertheless, government and industry have generally regarded competency‐based training as a successful innovation. Some 1500 units of competency representing around 37 industries – about half of all occupations in Australia—were used daily to guide learning, teaching and assessment for the 5.1 million Australians enrolled in VET courses in 2023 (National Centre for Vocational Education Research ^2024a). The Diploma of Nursing, the preparatory qualification for Enrolled Nurses, is one of these courses, with an estimated 26,820 students enrolled Australia‐wide in 2023 (National Centre for Vocational Education Research ^2024b).

5. Australian Tertiary Education and Nurse Professional Education

The Australian tertiary landscape and its contrasting approaches to knowledge and curriculum have been described. We drew attention to the heterogeneous and reproductive logic of curriculum in higher education, and how there are no prior epistemic commitments nor curricular rules specific to higher education that would serve as a generic filter on that knowledge. Experts in each corpus try to reproduce that corpus in their teaching.

Contrary to this, the VET approach includes different forms of occupational expertise served by the system, which are filtered through a single epistemic grid provided by the competency‐based training model. That is, nursing knowledge and practice (like that of the many other occupations served by VET) are selectively disaggregated into units of competency that must be structured to express that corpus in terms of discrete tasks. Knowledge is captured in supplementary assessment requirement documents that list ‘knowledge requirements’ deemed necessary to perform the defined task (Commonwealth of Australia: Department of Employment and Workplace Relations ²⁰²²).

Two features of the VET model of knowledge are of particular significance in this connection. As noted, the system‐wide rules for constructing units of competency emphasize tasks and view knowledge as relevant only insofar as it allows the particular task to be performed. Second, the segmentation of the nursing body of knowledge is itself subjected to boundaries formed between units of competency rather than the way the corpus itself is articulated. We will illustrate some of the problems that arise for the nursing body of knowledge and practice from these rules with reference to units from the Diploma of Nursing, after providing some explanation about the qualification from which these units are drawn.

6. The Australian Enrolled Nurse Curriculum: The Diploma of Nursing

The national rules for the Diploma of Nursing (which must be observed by all providers of the qualification) determine that twenty‐five units of competency must be completed. Of these, twenty are compulsory or ‘core’ units (refer to Table 1) and five are electives (refer to Table 2).

Table 1.

National training package (curriculum) HLT54121 diploma of nursing: Core units.

Core units (all must be selected)
Unit code and title	Discussion points
CHCDIV001 Work with diverse people	These units are imported from the Community Services Training Package (curriculum).
CHCDIV002 Promote Aboriginal and/or Torres Strait Islander cultural safety
CHCPRP003 Reflect on and improve own professional practice
HLTAAP002 Confirm physical health status	These units are nonspecific to enrolled nursing and included in other health and non‐health qualifications.
HLTAAP003 Analyse and respond to client health information
HLTINF006 Apply basic principles and practices of infection prevention and control
HLTWHS002 Follow safe work practices for direct client care
HLTENN035 Practise nursing within the Australian healthcare system	Units with the HLTENN prefix are technical units specific to the enrolled nurse curriculum.
HLTENN036 Apply communication skills in nursing practice
HLTENN037 Perform clinical assessment and contribute to planning nursing care
HLTENN038 Implement, monitor and evaluate nursing care
HLTENN039 Apply principles of wound management
HLTENN040 Administer and monitor medicines and intravenous therapy
HLTENN041 Apply legal and ethical parameters to nursing practice
HLTENN042 Implement and monitor care for a person with mental health conditions
HLTENN043 Implement and monitor care for a person with acute health conditions
HLTENN044 Implement and monitor care for a person with chronic health conditions
HLTENN045 Implement and monitor care of the older person
HLTENN047 Apply nursing practice in the primary healthcare setting
HLTENN068 Provide end of life care and a palliative approach in nursing practice

Source: Adapted from Skills IQ (2023a).

Table 2.

National training package (curriculum) HLT54121 diploma of nursing: Elective units.

Five elective units must be selected, including at least 3 from the list below.
Up to 2 units may be selected from any other Training Package (curriculum).
BSBLDR414 Lead team effectiveness	These units are from the Business Services training package (curriculum).
BSBPEF402 Develop personal work priorities
CHCCCS027 Visit client residence	These units are imported from the Community Services Training Package (curriculum).
CHCCOM005 Communicate and work in the health or community services
CHCLLN001 Respond to client language, literacy and numeracy needs
CHCPOL003 Research and apply evidence to practice
HLTAHA023 Support the provision of basic nutrition advice and education	These units are nonspecific to enrolled nursing and included in other health and non‐health qualifications.
HLTAID011 Provide First Aid
HLTAID014 Provide Advanced First Aid
HLTOHC007 Recognize and respond to oral health issues
HLTOHC008 Inform and support patients and groups about oral health
HLTOHC009 Apply and use basic oral health products
HLTINF007 Implement and monitor infection prevention and control standards, policies and procedures
HLTWHS003 Maintain work health and safety
HLTWHS006 Manage personal stressors in the work environment
HLTENN046 Contribute to maternal and infant healthcare	Units with the HLTENN prefix are technical units specific to the enrolled nurse curriculum.
HLTENN057 Contribute to nursing care of a person with diabetes
HLTENN060 Apply nursing practice in the paediatric care setting
TAEDEL402 Plan, organize and facilitate learning in the workplace	This unit forms part of the Training and Assessment Training Package (curriculum).

Source: Adapted from Skills IQ (2023a).

Table 2 outlines the elective units relevant to the Diploma of Nursing. To comply with the rules for constructing the qualification, the education provider must select five electives in consultation with relevant stakeholders, (Skills IQ ^2023a; Australian Nursing and Midwifery Accreditation Council ²⁰¹⁷). Of the twenty core units, thirteen are directly related to the technical practice of Enrolled Nurse work tasks. Of the remaining seven, three are ‘imported’ from the Community Services Training Package (addressing occupations such as youth work) and four are generalized units from the Health Training Package. These generalized units are included in a number of health‐related occupations including nursing and address topics of anatomy and physiology, infection control practices, and work, health and safety.

There is flexibility in the choice of elective units for the Diploma of Nursing (refer to Table 2). Three of the five electives must be selected from a specified list which includes units from the Business Services Training Package (for occupations such as manager), the Training and Education Training Package (for occupations such as VET trainer), or the Community Services Training Package. The remaining two elective units may be chosen from other qualifications within the Health Training Package, or from any other Training Packages and accredited courses, taking into account the requirements of industry, the job role, and the Australian Qualification Framework level (Skills IQ ^2023a).

The majority of the core units of the Diploma of Nursing (refer Table 1) have a technical focus, such as HLTENN038 Implement, monitor and evaluate nursing care and HLTENN039 Apply principles of wound management. As indicated, the competency‐based training model is not designed to convey theory. Should theory be deemed important to learn, then it would need to be reconstrued in terms of performance. This is the situation in relation to anatomy and physiology in the Diploma of Nursing. These are discrete fields of knowledge and theory outside of Australian VET but become configured as generic tasks common to a number of health occupations and available for inclusion as units of competency within the Diploma of Nursing. So, although there are units such as HLTAAP002 Confirm physical health status (refer Table 1) that address these fields, and although they do include lengthy lists of ‘knowledge evidence’, the unit's emphasis on task performance dominates the presentation of the body of theory. Wheelahan (2007) and others have analysed the way competency‐based training restricts access to theory, even when that theory is a powerful component of a domain of practice and necessary for further professional growth. That scientifically studied and systematically constructed fields of knowledge should be reworked into the mould of tasks is a peculiar situation that denies Enrolled Nurses access to these bodies of theory

When it comes to nurses' professional identity and ways of thinking, the Diploma of Nursing exhibits clear limitations. The thirteen specialized core units of the Diploma curriculum each includes the following statement referring to the work division between Enrolled Nurses and Registered Nurses.

This unit applies to enrolled nursing work carried out in consultation and collaboration with registered nurses, and under supervisory arrangements aligned to the Nursing and Midwifery Board of Australia regulatory authority legislative requirements.

(Skills IQ ^2023a)

This statement refers to the legislative scope of Enrolled Nurses—unquestionably an important feature of the workforce—and the nursing division of labour is in focus here. The statement does not, however, reflect the holistic, intrinsic characteristics associated with the profession of nursing, such as values, beliefs and ethics (Fitzgerald 2020). It may also dilute the Enrolled Nurse's autonomy in working as broader part of the nursing profession and their critical thinking.

Three of the core units from the Diploma of Nursing curriculum deal with the concepts of professionalism and professional practice: CHCPRP003 Reflect on and improve own professional practice; HLTENN035 Practise nursing within the Australian healthcare system; and HLTENN041 Apply legal and ethical parameters to nursing practice. CHCPRP003 was developed for community services qualifications and imported (i.e. included without alteration) as a core unit for the Diploma. It ‘describes the skills and knowledge required to evaluate and enhance [one's] own practice through a process of reflection and ongoing professional development’ (Skills IQ ^2023b, 2), and is seemingly highly transferable, applying to ‘workers in all industry sectors who take pro‐active responsibility for their own professional development’ (Skills IQ ^2023b, 2). CHCPRP003 is deemed sufficiently generalizable to be included unaltered as a specified core or elective unit in three training packages (Community Services, Sport, Fitness and Recreation and Health) and 40 qualifications at varying levels of the Australian Qualifications Framework. As such, the specific nuances of professionalism and practice in nursing are omitted, recognized only as generalized professional behaviour.

The second unit with potential to contribute to the development of professional identity is HLTENN035, which addresses knowledge and skills ‘to practise as a nursing professional within the Australian healthcare system’ (Skills IQ ^2023c, 2). The unit's three broad outcomes (elements) however, emphasize practice: (1) Apply principles and requirements of nursing practice to work in the Australian healthcare system; (2) Identify and respond to factors and issues affecting health in Australia; and (3) Work in the context of professional nursing practice (Skills IQ ^2023c). This focus on practice is also reflected in the ‘required knowledge and skills’ outlined in the unit's performance criteria and knowledge evidence list. To be deemed competent in this unit, students must demonstrate an understanding of the constructs of the Australian healthcare system in which Enrolled Nurses practice, including funding and provision of healthcare, alternative healthcare approaches, health promotion practices, and the regulatory and peak bodies that influence nursing practice, nursing education and care. Although HLTENN035 requires students to ‘Incorporate theoretical concepts of nursing theory in clinical engagement and practice related to nursing care’ (Skills IQ ^2023c, 4), there is no reference to the specific theory or concepts that are supposed to apply.

Likewise, HLTENN041 addresses the legal framework in which enrolled nurses must practice, while offering an opportunity for students to develop nursing‐related ethics, values and beliefs associated with professional practice (Skills IQ ^2023d). It addresses complex topics such as ethical issues; decision‐making; legal concepts including civil, common and statute law; and Commonwealth and State legislation including thirteen specified legislative instruments and Acts (Skills IQ ^2023d). Despite the promise and hefty content of HLTENN041, just 30 ‘nominal hours’¹ are allowed for its delivery (Victoria State Government ²⁰²³). Nominal hours are the ‘anticipated hours of supervised training’, or ‘amount of effort’ required to meet the outcomes of a unit of competency (Naidu et al. 2020, 33). Presumably, given the complex and important content of HLTENN041, Enrolled Nurse students would require significantly more unsupervised hours (i.e. self‐study) to develop the skills and knowledge necessary to achieve the outcomes of this unit.

Notwithstanding differences in scope of practice that separate the Enrolled Nurse's role from that of the Registered Nurse, developing a professional identity as a nurse is as necessary for those studying the Diploma of Nursing as it is for those in a bachelor's program. According to Fitzgerald (2020), a ‘profession’ is most commonly defined by its values, beliefs and ethics, and these characteristics must be internalized to develop a professional identity. Maginnis (2018) argues that professional identity should be a key goal of all pre‐registration nursing education, explicitly embedded into curriculum, and supported by appropriate role models and socialization into the clinical workplace. The Diploma of Nursing appears underserved in this respect, denying Enrolled Nurses equitable access to the underlying philosophy, ontology and epistemology of nursing, posing a risk that the nurses' professional identity and the critical thinking that underpins a nurses' work remain hidden to Enrolled Nurses. They may not ‘see’ the additional training that Registered Nurses undertake in this realm, because they are only trained to view the profession as a series of tasks consistent with the way all competency‐based curriculum is conceptualized.

7. Points of Discussion

Our discursive discussion of the Diploma of Nursing qualification was intended to show how the competency‐based training model ‘filters’ the nursing body of knowledge and practice. This curriculum foregrounds the performance of tasks. Knowledge is referenced, but it is bounded in terms of what is required to competently perform these identified tasks. Competency‐based training rules, reinforced by funding and auditing pressures, limit learning of knowledge to what falls within the boundary of the units of competency, curtailing access to coherent bodies of theory that extend beyond those tasks. The task focus of the units not only limits access to theory but restricts development of professional identity and values as well as ways of thinking specific to nursing. Like knowledge, identity and values are referenced in certain units of competency, but in this case, generic units are ‘imported’ into the curriculum on the assumption that, for example, ‘identity’ in nursing is no different to identity in other occupations. We stress here that there is no systemic intention in VET to distort occupational knowledge, and there is evidence that VET providers and teachers find ways to overcome such distortions (Hodge 2014). However, at least in respect to the nursing corpus, the competency‐based training model serves to create an uneven representation.

It could be argued that competency‐based training aligns with the scope of practice of an Enrolled Nurse, given that they must report to, and work under the supervision of the Registered Nurse. However, the Enrolled Nurse standards of practice mirror that of the Registered Nurse (accounting for the reporting lines and reduced accountability of the role) and expressly require Enrolled Nurses to engage in ongoing professional development (Nursing and Midwifery Board of Australia ²⁰¹⁶). Moreover, Enrolled Nurses are a valuable element of the nursing workforce and considering them only in terms of specific tasks and activities may be a missed opportunity for the nursing profession to represent itself as one entity, collaborating to deliver effective and safe healthcare.

If, as our discussion suggests, student Enrolled Nurses are presented with a narrow view of nursing, what problems ensue? An obvious problem concerns the experience of nurses transitioning from VET to higher education. On enrolling into an accredited undergraduate nursing program, Enrolled Nurses generally receive 12 months credit (approximately one‐third of the degree), in recognition of knowledge and skills acquired in the Diploma of Nursing. Application of credit is at the discretion of the higher education provider but is usually considered equivalent to year one of the accredited degree program, so that Enrolled Nurses commence in the second year.

The transition pathway in each program requires approval by Australian Nursing and Midwifery Accreditation Council. This transition, however, is not necessarily smooth. Articulating Enrolled Nurses are likely to enter an undergraduate nursing program with the benefit of clinical experience but may be disadvantaged in other ways. By commencing the degree in second year, articulating Enrolled Nurses may not have access to the normal supports afforded to first‐year students to assist their transition to university study (Hutchinson et al. 2011) and may commence second year with inadequate academic skills (Craft et al. 2017; Jacob et al. ²⁰¹⁴; Northall, Ramian et al. ²⁰¹⁶; Wall et al. ²⁰²⁰). In addition, Enrolled Nurses have been found to experience difficulties associated with role and identity transition (Cubit and Lopez 2012; Logan et al. ²⁰¹⁷; Wall et al. ²⁰²⁰), along with problems relating to self‐efficacy and potential disengagement from the undergraduate nursing program (Logan et al. 2017; Northall et al. ²⁰¹⁶). Attrition data specific to this cohort are not readily available (Wall et al. 2020); however, Northall et al. (2016) and Doggrell and Schaffer (2016) report poorer academic outcomes and higher attrition rates for VET‐trained nurses articulating into Bachelor of Nursing degrees, compared with non‐articulating students.

Various recommendations have been made to address these transition difficulties, and individual higher education providers have implemented remedial strategies. Wall et al. (2020), for example, recommended that transitioning Enrolled Nurses be provided with enabling programs to support their transition to higher education studies, individualized pathways which recognize their specific prior knowledge and skills, and mentors to provide academic and pastoral assistance. Logan et al. (2017) identified a need to support transitioning Enrolled Nurses to develop the higher level of bioscience knowledge required and reported on the potential benefits of cross‐institutional, open access and online resources to address this gap.

Although the experience of transitioning from Diploma of Nursing to an undergraduate nursing degree has been examined by some researchers, there is little in the literature which discusses the barriers associated with reverse articulation. Attrition in pre‐registration nursing programs is a global issue (Chan et al. 2019; Middleton et al. ²⁰²¹); however, few vocationally relevant exit pathways exist for non‐completing undergraduate nursing students in Australia. Although completing a Diploma of Nursing can provide advanced standing when entering an undergraduate nursing program, the reverse does not necessarily apply due to misalignment between the two forms of curriculum. The prescriptive assessment conditions that must be met to address the training package requirements that underpin the Diploma of Nursing curriculum prevent seamless reverse articulation.

8. Global Nursing Workforce Challenges

Articulation challenges for nurses transitioning between VET and higher education within the Australian tertiary system are an obvious manifestation of the two ways of thinking about nursing fostered by the tertiary education binary. But the bifurcation of images of nursing can impact in other ways that may become evident over time, due to pressures mounting on health systems globally. In this context, calls to enhance mobility within the nursing profession are relevant. The World Health Organisation continues to advocate for a globally mobile nursing workforce, able to adapt to changing community needs through the achievement of the Sustainable Development Goals (World Health Organisation [WHO] ²⁰²⁰). Indeed, the World Health Organisation (WHO) (2020) states that countries must optimize the contributions of nursing practice, strength leadership and governance, and drive nurse education progress in primary and universal healthcare. To do so, nurses need to be educationally prepared to think critically, laterally and holistically, and beyond the tasks and competencies of the technical aspects of the work.

Newer literature has discussed the notion of ‘task‐shifting’ whereby nurses (particularly those in the primary healthcare setting) may assume roles and tasks previously completed by a physician, to better use resources and alleviate the time pressures on the system. For example, primary health nurses in Ghana were trained and supported to manage hypertension in the community as a form of task‐shifting, which met the needs of the community (Gyamfi et al. 2017). Task shifting is supported by the World Health Organisation, as a method of reorganizing and decentralizing health services (World Health Organisation et al. 2007).

Of import, task‐shifting and indeed, the mobilization of nursing to its full potential, relies on a workforce which is appropriated skilled, trained and competent. Appropriate recognition of the value of nurses, and their educational preparation is also essential (Afolabi et al. 2019). To be successful, task shifting requires complex change in the development of technical skill, clinical roles and role identities (Feiring and Lie 2018). Indeed, the nature of the nurse education curriculum is critical to elevating the skill and standing of nurses.

Overall, the binary of Australian nursing education creates dichotomous views from those practicing the profession, and creates broader barriers, such as attrition and challenging articulation which may impede on a nurse's mobility and range of scope of practice. What is clear, is that the VET pathway remains task focused, a paradigm that no nurse can fit within. As such, harmonization across the two models is required. An aligned, harmonized curriculum would facilitate smooth educational and professional transitions for Enrolled Nurses to become Registered Nurses and strengthen the cohesiveness of the nursing professional workforce as one profession, albeit with different scopes of practice.

We emphasize that the issues we have described relate to the competency‐based curriculum and not the educational provider. Increasingly, Enrolled Nurses and Registered Nurses learn within the same educational settings, although with different curricula. A reformed curriculum would extend this provision, affording the two different categories of nurses an opportunity to study shoulder to shoulder, just as they work in industry.

9. Conclusion

Both Registered Nurses and Enrolled Nurses play a vital role in the provision of quality healthcare in Australia. As the nursing profession continues to evolve to reflect societal and industry demands, so too must the way in which we support and educate nurses. In this article, we have raised the issues and implications associated with nurse education in Australia, due to its positioning within two different educational systems, with two different approaches to curriculum. Historical methods of competency‐based training have provided foundations in nurse education; however, despite Registered Nurse education transitioning to the higher education alternative, VET's competency‐based curriculum has remained as the basis for educating Enrolled Nurses.

We have explained the limitations of the competency‐based Enrolled Nurse curriculum, particularly in relation to the development of critical thinking and higher order knowledge which form the basis of the nurse's professional identity and help to prepare them for a future with increasingly complex and changing workforce demands. We have also highlighted the problems that Enrolled Nurses may face when attempting to traverse between the two educational systems and curricula to access intended pathways from Enrolled Nurse to Registered Nurse or reverse. In conclusion, we recommend a reformed curriculum for Enrolled Nurses, one that is in alignment — harmonized — with the curriculum employed in the education of Registered Nurses.

Ethics Statement

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The authors have nothing to report.