Fifty years ago, pre-registration nursing education in Aotearoa New Zealand moved from a hospital-based apprenticeship model of nurse training to the tertiary education sector. The move began in 1973 when two experimental programmes at Wellington and Christchurch polytechnics were approved by Cabinet to begin offering a new type of ‘comprehensive’ nursing registration that incorporated the previously separate general, obstetric, psychiatric, and psychopeadic training into a polytechnic diploma. No longer employed and paid by the hospitals, nursing students who enrolled in the diploma were eligible for the government’s universal student allowance. By 1989, all hospital schools of nursing had closed. By 1999, in line with the international movement, entry to the register of nursing was by undergraduate degree only and diploma programmes were no longer offered. The requirement for a degree later paved the way for masters-level education and the advanced nursing practice roles we have today (Wilkinson, 2007).

My own training took place at Dunedin Hospital in the last class of the Dunedin School of Nursing. I registered in May 1986 as a general and obstetric nurse. During my three years as a student nurse I was a paid employee of the hospital. Along with other more senior student nurses, we comprised a significant part of the nursing workforce. I was rostered full time on rotating shifts, with rostered days to attend class. Clinical rotations were every six to eight weeks through medical, surgical, obstetric and paediatric areas, as well as mental health and district nursing. On reflection, I knew the ward routines very well, and developed good inter-personal and hands-on skills. However, I had only a rudimentary understanding of basic anatomy and physiology, and little knowledge of pathophysiology or pharmacology despite caring for some very unwell people and administering their medicines. Having subsequently taught both pathophysiology and pharmacology, I am still queasy about the ten minutes of class time we spent learning about the pancreas! It was clear that my student role was a service role and my learning was incidental to my service.

In the lead-up to the move of nursing education to the tertiary sector, a number of reports published in the 1960s were highly critical of the hospital apprenticeship model, suggesting that it no longer served the needs of hospitals, nor the needs of student nurses (Department of Health, 1969; Reid, 1965a, 1965b; Salmon, 1968, 1969/1982; World Health Organization, 1966). These reports pointed out that the method of training was failing to keep pace with an increasingly complex medico-technological environment,^[1] together with a shortage of tutors, often inadequately prepared to deliver education in such environments, and a high student attrition rate. For example, in the year ending 31 March 1970 the proportion of students who withdrew from their training was 45 percent (Department of Health, 1988).

In reponse to these concerns, Dr Helen Carpenter, a World Health Organization consultant and Director of the School of Nursing at Toronto University, was appointed by the Government to study the country’s nursing education system and report her findings and recommendations. The report (Carpenter, 1971) identified the need to shift nursing education away from the fiscally driven apprenticeship model of cheap hospital service delivery. Carpenter noted the increasingly complex needs of patients and thought it inappropriate to have under-prepared student nurses ‘in charge’ of a ward of 30 to 40 medical or surgical patients during afternoon or night shifts when supervision was minimal. She recommended that nurses be academically prepared in the tertiary education institutions, under the control of the Department of Education rather than the hospitals. Further, a shift to the tertiary sector would enable new curricula, such as the inclusion of broadly-based health-orientated education more appropriate to community contexts, with reduced emphasis on illness and medically-oriented training. The move was strongly opposed by the New Zealand Hospital Boards Association who resisted any change that would remove students from the workforce, and many individuals, including nurses and doctors, who were dismayed at the prospect of over-educated nurses (Shadbolt, 1983).

Another significant change to the status of nursing education came around 20 years later through legislative changes to the Education Act 1989 and the Education Amendment Act 1990. Respectively, the legislation established the New Zealand Qualifications Authority (NZQA) and allowed polytechnics to confer baccalaureate degrees at level 7 of the NZQA framework. The opportunity was seized upon by the Auckland Institute of Technology, Wellington Polytechnic, and Otago Polytechnic. In 1992, they became the first institutions in Aotearoa to begin offering a pre-registration Bachelor of Nursing (BN) degree (Wood & Papps, 2001). Coincident with these changes, payment of the universal allowance to students ceased and a means-tested student loan scheme was introduced under the Student Loan Scheme Act 1992.

After seven years in practice as a registered nurse (RN), I quickly realised that the introduction of the Bachelor of Nursing meant that my hospital nursing certificate would be inadequate in comparison. At the time, I was a nurse educator on the surgical floor at Dunedin Hospital and I took the opportunity to invite Alison Dixon from Otago Polytechnic to speak to the nurses about transitioning to a Bachelor degree. Along with many others, I enrolled in the part-time ‘RN to BN’ programme, had the honour of Irihapeti Ramsden, Pamela Wood, Elaine Papps, and Joce Parkes as lecturers, and graduated in 1996 with a Bachelor of Nursing.

Looking back now at a review of submissions made to the Department of Health in 1986 (the year I registered as a nurse) about the preparation and initial employment of nurses, I am struck by the similarity of concerns raised by submitters at that time about the diploma with those of today’s Bachelor of Nursing programmes. A sample of issues raised include the inadequacy of clinical experiences; poor standardisation of courses throughout the country; the need for greater awareness of traditional Māori, and Pacific, health practices and perspectives; the cost of training, particularly for Māori, and Pasifika, students who often have families to support; students taking on part-time work while studying; and using students to help meet the service needs of the hospitals due to inadequate staffing. It was clear then, as it is now, that more financial support for students was needed, and suggestions were made that clinical agencies could employ students during semester breaks, and that students could be reimbursed their costs associated with clinical placement.

It is indeed remarkable that so much, and at the same time, so little has changed in nursing Aotearoa during the last 50 years. A report prepared in 2021 for the pre-registration pipeline working group about Māori student nurse attrition rates also identified financial hardship as a key contributor. The authors note that “the impacts are especially evident for Māori students who have to work to self-fund study-related costs at the same time as studying to sustain themselves and support whānau” (Barton et al., 2021, p. 3). The media has recently highlighted the financial pressures on student nurses (Taylor, 2022). The suggestion to pay students for their work during clinical placements has been made via a consumer-led petition (Change.org, 2022) and the Minister of Health has commended the idea (Dahmen, 2022).

Paying pre-registration students during their clinical placements seems like an obvious solution. There are some parallels with the Earn As You Learn (EAYL) scheme and the enrolled nurse (EN) diploma (Wiapo et al., 2023). The scheme is for existing kaimahi (unregulated employees, for example health care assistants) working with health providers, the majority of whom are Māori. The health providers are funded to release the kaimahi to study enrolled nursing, with no loss of income, while they maintain their relationship with the provider and community with the purpose of being employed as an EN on completion. A smiliar idea was suggested to the Department of Health in 1986 and EAYL could be applied to pre-registration students now. Clinical agencies would need to employ students as health care assistants, and the separation between service and learning maintained.

As we reflect on 50 years of nursing education in the tertiary sector this year, another change is upon us that will further transform the majority of pre-registration education programmes. Under the auspices of the Te Pūkenga network of technical institutes and polytechnics, a unified national curricula for the Bachelor of Nursing programmes (BN, BN Māori, BN Pacific) will begin roll out in 2023 (pending approval). Central to the new curricula is the mana of Te Tiriti o Waitangi and the management of nursing care grounded in mātauranga Māori (Māori knowledge). These curricula go far further than the 1986 concern to “increase awareness of traditional Māori and Pacific health practices and perspectives”, to preparing our future registered nurses to be culturally responsive to the needs of tangata whenua, whilst growing the Māori, and Pasifika, nursing workforce. According to Gray (2021), an environment that supports and ‘interweaves’ mātauranga Māori throughout the degree, engages and retains Māori students.

The transformation of the nursing workforce will only come into effect, however, through nursing faculty who are able and committed to privileging indigenous ways of knowing and being, ensuring, as Smith, Le Grice, Fonua and Mayeda (2022) insist, these are visible and valued. Indeed, this is their wero, a challenge, laid down to everyone working in higher education: “[for] colleagues to move beyond their pedagogical comfort zones by learning and incorporating Indigenous knowledges into their teaching beyond surface level” (p. 1). It is a wero that applies to undergraduate and postgraduate nursing education, in both Te Pūkenga and the universities, and to Māori and non-Māori nurse educators. The most recent workforce data available states that of the 1,244 nurses working in an education institution, only 102 are Māori (Nursing Council of New Zealand, 2019). Such a wero is therefore collective – the responsibility cannot rest on Māori nurse educators alone.

The challenge to move pre-registration education to the tertiary sector 50 years ago is as significant as the move to Te Pūkenga’s unified national curricula. Nurse leaders took up the challenge then; ours is to do likewise now. Notwithstanding the operational challenges that loom large, we each have a role in supporting the kaupapa (the programme), the akōnga (the students) in their studies and clinical placements, and the kaiako (the teachers). There were good reasons to move nursing education to the tertiary sector then and there are good reasons now to support this kaupapa.