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Australian Health Review, 2015, 39, 595–599 http://dx.doi.org/10.1071/AH14258

Development, implementation and evaluation of an interprofessional graduate program for nursing–paramedicine double-degree graduates Julie Considine1,3 RN, PhD, FACN, FFCENA, Professor of Nursing Tony Walker2 BparamedStud, GDipEmergHlth(MICA), MEd, General Manager Regional Services Debra Berry1 RN, GDipAdvNurs, MN, Research Fellow 1

School of Nursing and Midwifery, Deakin University, 221 Burwood Highway, Burwood, Vic. 3125, Australia. Email: [email protected] 2 Ambulance Victoria, Building 1, 41–47 Joseph Street, Blackburn North, Vic. 3130, Australia. Email: [email protected] 3 Corresponding author. Email: [email protected]

Abstract. Over the past decade, several Australian universities have offered a double degree in nursing and paramedicine. Mainstream employment models that facilitate integrated graduate practice in both nursing and paramedicine are currently lacking. The aim of the present study was to detail the development of the Interprofessional Graduate Program (IPG), the industrial and professional issues that required solutions, outcomes from the first pilot IPG group and future directions. The IPG was an 18-month program during which participants rotated between graduate nursing experience in emergency nursing at Northern Health, Melbourne, Australia and graduate paramedic experience with Ambulance Victoria. The first IPG with 10 participants ran from January 2011 to August 2012. A survey completed by nine of the 10 participants in March 2014 showed that all nine participants nominated Ambulance Victoria as their main employer and five participants were working casual shifts in nursing. Alternative graduate programs that span two health disciplines are feasible but hampered by rigid industrial relations structures and professional ideologies. Despite a ‘purpose built’ graduate program that spanned two disciplines, traditional organisational structures still hamper double-degree graduates using all of skills to full capacity, and force the selection of one dominant profession. What is known about the topic? There are no employment models that facilitate integrated graduate practice in both nursing and paramedicine. The lack of innovative employment models for double-degree graduates means that current graduate program structures force double-degree graduates to practice in one discipline, negating the intent of a double degree. What does this paper add? This is the first time that a graduate program specifically designed for double-degree graduates with qualifications as Registered Nurses and Paramedics has been developed, delivered and evaluated. This paper confirms that graduate programs spanning two health disciplines are feasible. What are the implications for practitioners? Even with a graduate program specifically designed to span nursing and paramedicine, traditional organisational structures still hamper double-degree graduates using all their skills to full capacity, and force the selection of one dominant profession. Received 20 December 2014, accepted 17 February 2015, published online 13 April 2015

Introduction Over the past decade, several Australian universities have offered a double degree in nursing and paramedicine. Key drivers of double-degree programs were recognition of escalating health workforce pressures and projected workforce shortages, and a desire to improve the productivity, effectiveness and responsiveness of the health workforce though multiskilled health workers.1 The first cohort of nursing–paramedic double-degree graduates in Victoria entered the workforce in 2011. At the time of writing this paper, double degrees in nursing and paramedicine were Journal compilation Ó AHHA 2015

offered at two Australian universities. The graduates of these 4-year double degrees hold dual qualifications as Registered Nurses and Paramedics. Following completion of a double degree, completion of a Graduate Ambulance Paramedic (GAP) program is mandatory for independent paramedic practice in Victoria; however, a graduate program is desirable but not mandatory to practice as a Registered Nurse. Students choose to enrol in double degrees to acquire a broad skill set, explore two disciplines of interest, improve employment prospects and have open career options.2 The intent of a double www.publish.csiro.au/journals/ahr

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degree is that that graduates will practice across both professions, in this case nursing and paramedicine. However, there are currently no mainstream employment models that facilitate integrated graduate practice in both nursing and paramedicine, and current graduate programs lack flexibility and are still discipline specific. In order to complete a formal graduate program, doubledegree graduates must choose to practice in one discipline, negating the intent of a double degree and resulting in suboptimal use of graduates’ skills and knowledge. Outdated views and traditional graduate program structures constrain both nurses and paramedics, hampering their capacity to practice as graduates outside traditional employment models.3,4 These constraints occur in a landscape where a multiskilled health workforce is a key strategy to meet evolving health care demands.3,4 Further, inflexible graduate programs and employment models for double-degree graduates exacerbate the risk of graduates seeking full-time employment in one discipline, thereby being lost to the other profession for which they are qualified.3,5 The only Australian study of employment outcomes of double-degree graduates (nursing–paramedicine) working in a system where cross-disciplinary professional practice was not possible, showed that at the beginning of the first year following graduation (n = 16), 44% of graduates were working in paramedicine and 56% were working in nursing.6 By the end of their second year following graduation (n = 10), 60% were working in paramedicine and 40% in nursing.6 To date, published literature related to nursing and paramedic roles has focused on the movement of nurses to paramedicine,3,7 the use of paramedics to staff emergency departments (EDs)8 and the use of nurses in prehospital care.9 Historically in Australia, the most common ‘merger’ of nursing and paramedicine is the movement of experienced nurses out of nursing into paramedicine.3 Registered Nurses, particularly specialist intensive care and emergency nurses with postgraduate qualifications, are actively recruited by ambulance services across Australia. As a group of professionals with highly sought-after skills and knowledge, active recruitment and advanced standing has made the transition of nurses to paramedicine relatively easy.3 Although the move to paramedicine provides new career opportunities, the movement of experienced specialist nurses out of the nursing further exacerbates well-documented workforce shortages and skill mix issues in emergency and critical care nursing.3,5 Several authors have explored the use of paramedics to staff EDs, citing nursing shortages as the rationale for this workforce redesign.8,10 These studies focus on the assessment and triage skills and procedural capability of paramedics, with little attention to the discipline-specific skills and knowledge required by expert emergency nurses through specific educational preparation and experiential learning.8,10 Nurses have been used in prehospital care in many European countries, but nurses working in prehospital care is not the norm in Australia given the specific educational preparation of Australian paramedics.9

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qualifications as Registered Nurses and Paramedics. In 2011, Australia’s first graduate program for double-degree graduates in nursing and paramedicine, called the Interprofessional Graduate program (IPG), occurred as a joint venture between Northern Health, Melbourne, Australia and Ambulance Victoria. The aim of the present study was to detail the development of the IPG, the industrial and professional issues requiring solutions, outcomes from the first pilot IPG group and future directions for graduate programs spanning two health disciplines. The first conversations regarding whether the IPG was feasible occurred in August 2008 between two ED nurse educators from Northern Health, the General Manager of Quality and Education Services and the Manager of Graduate and Vocational Education from Ambulance Victoria. A steering committee was convened comprising representatives from Northern Health and Ambulance Victoria, and an Advisory Group assembled with representation from the then Nurses Board of Victoria and the Nurse Policy and Ambulance and Acute Care Branches of the Victorian Government Department of Human Services. From the outset, all key stakeholders agreed on the following aims of the IPG: (1) to provide supported transition from students to competent novice practitioners in both disciplines; (2) to ensure that graduate requirements of regulatory authorities of both disciplines were met; (3) to enable informed decisions about ongoing employment and career planning; and (4) to foster interprofessional relationships and enhance collaboration between industry partners. The perceived advantages of the IPG were to provide participants with graduate experience in both disciplines, enabling them to consolidate skills and knowledge in both nursing and paramedicine, increase collaboration between Ambulance Victoria and the ED at Northern Health and optimise workforce capacity by supporting the best use of clinical skills and knowledge, increasing capacity to respond to workforce shortages in either discipline and increasing job satisfaction. IPG model The IPG was an 18-month program where IPG participants would work in a ‘Northern Health–Ambulance Victoria’ hub. Participants were split into two groups, with half working as graduate nurses in the ED at Northern Health and the other half working as graduate paramedics with Ambulance Victoria at any one time. Ideally, those working as graduate paramedics would be rostered to Ambulance Victoria branches local to Northern Health to enable ongoing contact with the ED during their ambulance placement. Rotations were initially planned for every 4–6 weeks to minimise skills attrition in each discipline; however, the final IPG resulted in 3–4-monthly rotations in order to meet the rostering requirements of both organisations and the clinical needs of the participants. All IPG participants completed a 4-week structured induction program with Ambulance Victoria and then completed 4-week cycles paired with a dedicated Paramedic Educator on an emergency ambulance.

Interprofessional Graduate Program Despite the growth of double degrees in nursing and paramedicine, there have been no initiatives aimed at providing concurrent nursing and paramedic experience for graduates with dual

Content The IPG content was drawn from Ambulance Victoria’s GAP program and Northern Health’s Supported Transition to

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Emergency Practice (STEP) program. In both disciplines, IPG participants were integrated with ‘traditional’ single-degree graduates undertaking GAP and STEP programs to foster interprofessional learning. A combination of core and discipline-specific competencies were developed and mutual recognition of competency completion was agreed in order to decrease duplication. Participants completed clinical hurdles in patient assessment (adults and paediatrics), 12-lead electrocardiogram interpretation while working in emergency nursing, basic life support and manual defibrillation while working in paramedicine and a medication safety hurdle requirement in both disciplines. Industrial issues The first barrier was one of industrial relations and how to employ a graduate nurse–paramedic across two employers. Ideally, it was felt that a single employment model would be preferred whereby IPG participants had one main employer, Employer A, and were seconded to Employer B during their rotations. Salaries would be recovered by Employer A invoicing Employer B periodically throughout the program. The first industrial challenge was equity of award entitlements. Nurses work a rotating roster of day, evening and night shifts whereby shifts are variable from week to week. Ability to request specific shifts or days off adds to variability in rostering patterns. Nurses are paid a base rate salary with shift penalties for evening, night, weekend and public holiday shifts according to the shifts actually worked, so their fortnightly salary fluctuates. Nurses are provided with employer-paid superannuation of 9.5% according to the Australian Superannuation Guarantee. In contrast, paramedics work a 4 days on–4 days off roster consisting of two 10-h days shifts and two 14-h night shifts. Paramedics are paid an annualised salary whereby all penalty entitlements for weekends, night shifts and public holidays are spread across the year and their fortnightly pay does not fluctuate. They also participate in a Government Defined Benefit Superannuation Scheme common to all emergency services workers in Victoria. At the time of development of the IPG, a graduate nurse in Victoria was paid A$66 403–68 630 (with an increase in 12-monthly increments) and graduate paramedics were paid A$68 195–70 769 inclusive of shift penalties (with increases in 6-monthly increments). The leave entitlements (sick leave and annual leave) were equitable. Both unions (i.e. the Victorian Branches of the Australian Nursing Federation (now the Australian Nursing and Midwifery Federation) and the Ambulance Employees Association) were supportive of the intent of the program but, reasonably, wanted to make sure that participants were not disadvantaged and received all their award entitlements. The Australian Nursing Federation was not supportive of Registered Nurses being employed by Ambulance Victoria under a paramedicine award and the Ambulance Employees Association was not supportive of paramedics being employed by a health service under a nursing award. The discrepancies in salaries, rostering practices, how to manage annual leave and sick leave and ensuring compliance with respective awards were insurmountable, so a dual employment model was negotiated. Therefore, the IPG participants were provided with the award conditions (salary, roster, leave entitlements) of the organisation in which they were working and were on leave without pay from the other organisation. This meant they

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had two separate accruals of annual leave, sick leave, superannuation and salary sacrifice benefits. The dual employment model also raised issues related to lines of reporting. Participants were answerable to the line manager in the setting in which they were working; however, informationsharing clauses were added to both employment contracts should there be a performance management issue. It was felt that if there were performance issues in one setting (nursing or paramedicine) then it would be a matter of time before those issues impacted on the other setting. There also needed to be capacity to have a joint approach to performance management processes with input from educators from both disciplines and scope to renegotiate rotations should a participant require extra clinical exposure in one discipline. Professional issues There were several professional challenges that required solutions in order for the IPG to occur. The first was blending one registered profession (nursing) with an unregistered profession (paramedicine), and although both professions have codes of conduct and practice standards, Registered Nurses are also bound by regulatory requirements, such as recency of practice, hours of continuing professional development, indemnity insurance arrangements and two levels of mandatory reporting. The Australian Health Professional Registration Agency (AHPRA) requires nurses to notify when another registered practitioner has: (1) practiced while intoxicated by alcohol or drugs; (2) engaged in sexual misconduct; (3) placed the public at risk of substantial harm because the practitioner has an impairment; or (4) placed the public at risk of harm because the practitioner has practiced in a way that constitutes a significant departure from accepted professional standards.11 In addition, State legislation in Victoria since the early 1990s requires that doctors, nurses, midwives, teachers and principals and police are mandated to report if they believe, on reasonable grounds, that a child is in need of protection from physical and/or sexual abuse.12 The second challenge was enabling both disciplines, nursing and paramedicine, to come to terms with a graduate practitioner that had a scope of practice different to previous single-degree graduates. For example, IPG participants graduate with skills such as intravenous cannulation and manual defibrillation. These are not skills typically held by a single-degree graduate nurse. Similarly, skills such as administration of blood products and planning and managing care for multiple patients over many hours are not usually seen in graduate paramedics. The other major scope of practice issue was differences governing each profession in the Drugs, Poisons and Scheduled Substances Act and Regulations.13,14 Registered Nurses are authorised to initiate and administer several Schedule 2 and 3 medications if supported by the organisations’ nurse-initiated medication policy; all other medications require a prescription from a medical officer or nurse practitioner. Paramedics employed by Ambulance Victoria are authorised to initiate and administer several Schedule 2, 3, 4 and 8 medications in accordance with Clinical Practice Guidelines approved by the Ambulance Victoria Medical Advisory Committee. One of the challenges for IPG participants was practicing under two different legislative frameworks depending on the discipline in which they were practicing. For example,

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when practicing as a paramedic, administration of intravenous morphine for pain relief guided by clinical practice guidelines is an accepted part of paramedic practice. When practicing as a Registered Nurse, administration of intravenous morphine for pain relief can only occur under a prescription from a medical officer or nurse practitioner. Third, the IPG challenged the traditional notions of graduate programs in both nursing and paramedicine. A graduate program is preferred but not mandatory in order to practice as a Registered Nurse; however, in paramedicine, completion of the GAP program is mandatory for independent practice as a paramedic with Ambulance Victoria. Traditionally, graduate programs in both nursing and paramedicine are of 12 months duration; there was concern that an 18-month program would not enable enough clinical experience. Educators from both disciplines perceived participants would only have 9 months experience, not readily recognising the synergies between nursing and paramedicine and that some skills (e.g. patient assessment and basic life support) were the same in both settings. Nursing graduate programs tend to have between one and three rotations. Programs with one rotation tend to place graduate nurses in medical or surgical wards. Graduate experience in speciality areas such as emergency nursing tends to occur during placements and it is not usual practice for the entirety of graduate nursing experience to occur in a setting like the ED. There was concern from educators that IPG participants would not ‘consolidate basic nursing skills’ without a medical or surgical ward placement. Again, Registered Nurses have a generic skill set that is fundamental to nursing practice and can be applied in any context: washing a patient, undertaking advanced health assessment or administering pain relief are the same skills regardless of the environment in which those skills are used. Finally, because the IPG sat outside the usual graduate nurse program structure, there was no dedicated funding to support IPG participants. In Victoria, the nursing and midwifery component of the Victorian Government-funded Training and Development Grant supports the delivery of nursing and midwifery graduate programs and the clinical components of postgraduate nursing and midwifery education.15 Using current figures, the Training and Development Grant provides A$17 162 per graduate nurse place for graduates employed at 0.8–1.0 full-time equivalent. In order to facilitate the IPG, the Victorian Government Department of Health Nursing & Midwifery Policy Branch provided funding for the nursing component of the IPG to support 2 weeks supernumerary time during initial orientation and two supernumerary days when IPG participants rotated back to Northern Health, after their first rotation to Ambulance Victoria. Results and Discussion The first IPG was an 18-month program that ran from January 2011 to August 2012 with 10 participants. All 10 IPG participants were invited to participate in a survey administered in March 2012 (T1; 6 months before IPG completion), March 2013 (T2; 6 months after IPG completion) and March 2014 (T3; 18 months after IPG completion) that detailed their employment details: main employer details (name, hours of weekly employment, role title) and whether they were undertaking postgraduate studies. In the T1 survey, participants were also asked to compete a section on

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demographics (age, gender, country of birth, languages spoken, previous experience in healthcare and high school completion score). The survey was approved by the Human Research and Ethics Committees at Deakin University and Ambulance Victoria. Nine of the 10 IPG participants completed all three surveys. Two were male, the other seven were female, and all participants were born in Australia. The mean ( s.d.) age of participants at the commencement of the IPG was 23.7  1.3 years. Two participants spoke second languages: one spoke Greek and the other Norwegian. Prior to joining the IPG, two participants had no previous experience in healthcare, three participants worked as paid carers, two participants worked as Enrolled Nurses and two participants worked in clerical positions in hospitals. At the end of the period studied, all participants nominated Ambulance Victoria as their main employer and five participants were working casual shifts in nursing. No participant reported undertaking or completion of postgraduate studies in either nursing or paramedicine. The tendency to full-time paramedic employment has several possible explanations. At the conclusion of this first IPG, full-time or casual employment were the only employment options in paramedicine. There was uncertainty among IPG participants about their capacity to work as a casual paramedic and later reinstate full-time paramedic employment in a location of their choice. There was also concern about restricted access to casual shifts, thereby limiting the ability to continue consolidation of paramedicine skills. Conversely, there were opportunities to work full time, part time or casual in nursing, and specifically in emergency nursing. The relatively easy movement between these employment conditions may have influenced employment choices. A second IPG ran in 2012–13 with four participants. The IPG then stopped because of a lack of nursing vacancies in the ED at Northern Health and employment overestablishment was not a financially viable option for the health service. Further, given that none of the first IPG participants was working full time in nursing, there were perceptions that the IPG had limited advantages for nursing. The benefits and detriments of double degrees in nursing and paramedicine to the Australian healthcare system are unknown, as is the full potential of graduates’ unique scope of practice for patient care and health workforce. In order to examine long-term outcomes, programs such as the IPG need to be viewed as potentially adding value to the healthcare system rather than introspection driven by vested interests of siloed organisations. In the absence of graduate programs such as the IPG and the development of subsequent workforce models to accommodate clinicians with dual qualifications and skill sets, it will be impossible to fully understand the impact of double-degree graduates on the Australian health workforce. Conclusion Alternative graduate programs that span two disciplines are feasible and can be successful, but are hampered by rigid industrial structures and professional ideologies. Even with a ‘purposebuilt’ graduate program that spanned two disciplines, traditional organisational structures still prevent double-degree graduates

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using all their skills to full capacity, and force the selection of one dominant profession. If multiskilled clinicians are the future of the Australian health workforce and double degrees continue to be offered as the pathway to multiskilling, there is an urgent need to develop graduate programs and employment models that are enabling rather than disabling for graduates. If healthcare organisations are unwilling or unable to allow double-degree graduates to practice in their chosen professions, then the future of double degrees must be called into question.

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Competing interests None declared. Acknowledgements This study was generously funded by the Victorian Government Department of Health, Nursing and Midwifery Policy Branch. The authors thank all the key stakeholders at Northern Health and Ambulance Victoria who made the Interprofessional Graduate Program possible. Special thanks go to Tina Ivanov, Danielle Waddell and Bart Wunderlich for their contribution to the development and delivery of the IPG. Thanks also go to the participants of the study for their continued support of this work.

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Development, implementation and evaluation of an interprofessional graduate program for nursing-paramedicine double-degree graduates.

Over the past decade, several Australian universities have offered a double degree in nursing and paramedicine. Mainstream employment models that faci...
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