Does Australia’s competency-based training meet the mental health training needs of enrolled nurses?

ABSTRACT

Australia’s demand for nurses is exponentially increasing as we are faced with a global pandemic, an ageing population, and an increase in chronic health conditions and mental health issues. This presents a significant challenge for the healthcare system by increasing the absolute number of people needing care. The Enrolled Nursing course can train nurses in 18-24 months and offers a solution to the nursing shortage. This training in Australia is delivered by the Vocational Education Training (VET) system utilizing a competency-based training approach (CBT). However, CBT is often criticised for failing to deliver the essential skills of communication. critical thinking, and clinical reasoning that are fundamental to mental health nursing. This discussion paper explores the current VET system in Australia to determine if it can adequately train Enrolled Nurses with the skills to work with mental health consumers and suggests that simulation-based education using Simulated Persons could provide one solution.

KEYWORDS:

• Vocational education & training
• enrolled nurse
• diploma of nursing
• competency-based training
• healthcare
• nursing
• simulation

Introduction

Australia’s demand for nurses is exponentially increasing as we are faced with an increased ageing population that will see 20% of the population aged over 65 before 2040 (Australian Institute of Health & Welfare [AIHW], 2022). This presents a significant challenge for the healthcare system as it will increase the absolute number of people needing care. In addition, older adults experience a greater number of age-related health problems and disability (e.g. cancer, arthritis, dementia) and as a result tend to be high users of health services (Australian Institute of Health & Welfare [AIHW], 2018; Gibb, 2019; Halcomb et al., 2017; Soleimani et al., 2022). This challenge is compounded by an increasing prevalence of chronic health conditions (e.g. diabetes, hypertension) in all populations due to lifestyle-related behaviours (AIHW, 2018; Miller et al., 2022)

In addition to the ageing population and chronic health conditions, mental health issues are a serious problem among Australians with around 50% of adults reporting a mental health disorder at some point in their lifetime (AIHW, 2018; Fehily et al., 2017; Mitchell & D’Amore, 2021). Heightened psychological distress, sudden loss of employment, decreased social interactions, and the move to remote learning/employment during the COVID-19 pandemic (Joffe, 2021; Wynter et al., 2022) also resulted in increased use of mental health services and the potential to exacerbate long-term mental illness (Blasco-Belled et al., 2022). As a result, more people will need health care in the future, and there is a likelihood of increasingly complex issues that involve mental health issues, as mental health issues are often associated with chronic illness and ageing. This can either be the reason for hospitalisation or an indirect consequence of being admitted to hospital. One of the significant challenges confronting nurses is that they receive little training on how to care for individuals with mental health issues (Australian Institute of Health & Welfare [AIHW], 2016; Hung et al., 2019; Saito & Creedy, 2021).

Currently, less than one in 10 nurses have qualifications specific to mental health as they are only available as postgraduate studies (AIHW, 2016). Furthermore, in many Australian nursing courses mental health skills (i.e. mental state examination and risk assessment) are only scantily covered, especially in VET programs for Enrolled Nurses (ENs). To meet the increasing demand for mental healthcare now and in the future, we need to reconsider existing training approaches.

Australia’s education system

The Australian education system is divided into primary, secondary, and tertiary study with education being compulsory for children aged between six and 17.

Higher Education (HE) is offered by universities and registered training organisations (RTOs) where students complete a bachelor’s degree or above level qualifications with the aim of not only gaining employment but also enhancing scholarship, learning, and research.

In contrast, VET is offered by Technical and Further Education (TAFE), Adult and Community Education (ACE) providers, and Registered Training Organizations (RTOs). These providers deliver training in the skills and knowledge required to be competent in the workplace. VET offers qualifications such as Certificates I-IV, Diplomas, Advanced Diplomas, Institute accredited courses, and skillsets where the main aim is to equip the student with the knowledge and skills to perform competently in the workplace through the application of learning, as well as to provide short courses, foundation education and vocational education in schools (Joyce, 2019; Mulder & SpringerLink, 2017).

In relation to nursing, RNs complete their bachelor’s degree over 3 or 4 years through HE, whereas ENs enrol a Diploma through VET that takes 18–24 months to complete.

VET competency-based training

VET in Australia involves competency-based training (CBT). This type of training was initially designed to align educational programs in VET to workplace needs (Joyce, 2019; Mulder & SpringerLink, 2017; Wheelahan, 2016). CBT has become the dominant trend in VET worldwide and was introduced in Australia in 1992 to make the VET system more flexible and responsive to students and industry (Skiba, 2020). The focus of CBT is on specific skills (usually technical skills) and underpinning knowledge required by industry, where student performance is measured against specified standards and not relative to other students. Students are assessed as either competent or not competent, but the degree of proficiency is not measured or graded. These standards are determined by national training packages (Smith, 2010), which ‘consist of the industry or occupation-based collections of units of competency that are packaged together into qualifications at different levels’ (Smith, 2010, p. 55). Training packages were first introduced in Australia in 1997 to regulate VET and ensure national consistency of vocational qualifications (Smith, 2010).

In contrast to HE, VET and its emphasis on CBT allows learners to receive a qualification if they have the skills that enable them to meet industry requirements, which is not dependent on a minimum duration of time (Wheelahan, 2016). To be deemed competent, the learner must be able to show that they can perform a task, or skill, or demonstrate knowledge at a level expected in the workplace (McGrath et al., 2019). Yet this definition creates a conundrum as there is no standard expectation of the workplace and no standard workplace. These expectations also differ from one workplace to another (McGrath et al., 2019). Several criticisms of CBT have been proposed and are outlined below. In EN training, competency needs to be clearly defined especially when consumers’ lives can be dependent on the outcome of actions. This remains true for training in the area of mental health which needs to be not only clearly defined but its content increased in the curriculum (Schwartz, 2019). EN training is overseen by the Australian and Midwifery Accreditation Council (ANMAC) and VET training by the Australian Skills Quality Authority (ASQA) yet much of the delivery is not subject to intense scrutiny leaving the educational standard of ‘ … .incorporation of simulated learning opportunities’ (Australian Nursing and Midwifery Acreditation Council [ANMAC], 2017) not descripted or defined.

Criticisms of VET competency-based training

The criticisms of CBT tend to reflect inefficiencies in meeting current and future needs of twenty-first-century learners in a changing workforce, assessment deficits, a failure to address academic skills, poor quality teachers, poor quality providers and the inability to develop critical thinking, metacognitive skills, and create life-long learners.

Failure to meet current and future workplace needs

One of the main criticisms of CBT in VET is that it places too much emphasis on technical skills and not enough on twenty-first-century skills, employability, or enterprise skills (Foundation of Young Australians [FYA], 2018). These are the skills that are required to gain employment, progress, and contribute to the enterprise, essentially those generic skills required in the workplace that allow an individual to be flexible and adaptable in the twenty-first century (Smith, 2010). These twenty-first-century skills are like graduate attributes in HE in that both they define qualities and skills that are transferrable between vocations (Payton & Knight, 2018; Seet et al., 2018). Twenty-first-century skills, often synonymous with employability, and enterprise skills are those skills associated with personal, interpersonal, and organizational success and provide for lifelong learning and adaptability to change (Foundation of Young Australians [FYA], 2018). Twenty-first-century skills include problem-solving, creativity, financial literacy, digital literacy critical thinking, presentation skills, communication skills, collaboration, and teamwork (Foundation of Young Australians [FYA], 2018; Joynes et al., 2019). Twenty-first-century skills are purportedly not likely to be affected by future automation but instead lead to increased motivation, self-development, professional practice, creativity, and innovation (Foundation for Young Australians [FYA], 2017). It is anticipated that the jobs of the future will require highly skilled individuals who are flexible and critical thinkers. This seems to be echoed in the field of nursing and healthcare (Dalton et al., 2015).

The current VET system does not promote the acquisition of these skills as it only supports people to be effective in highly structured environments that are unlikely to exist in future workplaces (Hajkowicz et al., 2016). Indeed, the inability of our VET system to support these twenty-first-century skills is supported by data collected by the National Centre of Vocational Education Research (NCVER, 2021). It found more than one-quarter of employers (26%) reported that vocational training was not teaching the students the relevant skills needed by the workplace (NCVER, 2021), with dissatisfaction increasing by approximately 10% since 2011 (Joyce, 2019).

The neglect of twenty-first-century skills in VET has led some educators to suggest that current training packages evolve to include vocational streams or clusters, a more holistic approach that incorporates a strong emphasis on the types of skills that employers want, and graduates need to work in the future workplaces (Committee for Economic Development of Australia [CEDA], 2016; Foundation of Young Australians [FYA], 2018). It is generally assumed and expected that both HE and VET create job-ready graduates, yet the current VET system only delivers narrowly defined skills qualifications often devoid of twenty-first-century skills, and this consequently fails to meet current industry needs (CEDA, 2016; Mulder & SpringerLink, 2017).

Not only are twenty-first-century skills not adequately addressed in most VET courses, but they are also often taught as specific skill sets such as planning and communication. These skills are too narrowly defined to be transferrable to the workplace requirements that VET graduates encounter (Mulder & SpringerLink, 2017). VET qualifications are also taught in a unit-by-unit manner rather than as an integrated whole. There is an expectation that the student can piece units together into a holistic practice. Previous research suggests that the integration of individual pieces into the whole concept and the transfer of complex skills to the workplace are hindered by this siloed approach (Mulder & SpringerLink, 2017).

Attempts should be made to develop a curriculum that supports the learning of these essential skills. To successfully achieve this in EN mental health training, all facets of consumer complexity need to be integrated holistically into the curriculum. According to Dalton et al. (2015), students who can reflect on their learning processes are more likely to develop critical thinking and clinical reasoning skills. This, in turn, can lead to proficient graduate practitioners who can accurately identify and respond to consumer deterioration and a resultant decrease in sentinel events. This can be enhanced using metacognition and the awareness of one’s ability to learn.

The need for metacognition and reflective thinking in VET

Metacognition is often described as thinking about thinking or the cognition of cognition (Flavell, 1979). It refers to the mental processes that are involved in monitoring or controlling one’s thoughts and actions (Dewey, 1933; Rhodes, 2019), and where reason is replaced or adjusted by ethical and moral considerations (Bennett, 2016). It is argued here that reflection or reflective thinking in combination with critical thinking leads to the development of clinical reasoning and better outcomes for consumer care. In health, metacognition leads to clinical reasoning and better consumer outcomes (Sommers, 2018). This is an essential skill for all graduate nurses. Metacognitive skills are rarely used in VET courses and these skills are often not encouraged by teachers (Parker & Roumell, 2020). However, when reflective thinking skills, a component of critical thinking and metacognition, have been explicitly taught in VET, these skills have exclusively focused on the learning materials and not on how students think or make sense of the content in which they are learning (Parker & Roumell, 2020).

Students’ ability to reflect in the classroom differs from students’ ability to reflect in the workplace. According to Schaap et al. (2012), the complexity and dynamics that students face in the workplace are often overwhelming and leave them unable to integrate classroom theoretical notions and abstract models. Hager and Holland (2006) state that what is learned in the classroom does not always transfer to the workplace due to the context and complexity of the work itself. This transfer from theory to work is extremely rare and may be better addressed through the development of lifelong learning skills by being exposed to new and different environments (Parker & Roumell, 2020). This provides some challenges for the current CBT approach that relies heavily on transfer through replication, not the ability to move forward under different conditions. This suggests that transfer from the classroom to the work environment is dependent on cognitive flexibility and metacognition and is increased by an understanding of the context. Whilst there is a clear connection between critical thinking and metacognition, it is not clear that current vocational education institutions address the learning and teaching of metacognition (Cummings, 2015), which in turn hinders the development of critical thinking.

Failure to develop critical thinking in the learner

The skill of critical thinking strongly stems from traditional education and is very much attributed to and a part of HE, but it appears to be limited in the curricula of VET which predominantly concentrates on skills. This has led to complaints from employers that employees cannot solve complex problems (Carver & Harrison, 2015). Critical thinking seems to have its foundations in the work of Dewey (1933) where it refers to ‘active, persistent, and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusions to which it tends’ (p. 9). Critical thinking is a process that allows the student to analyse, synthesise and evaluate knowledge to make appropriate decisions (Audétat et al., 2017). Critical thinking is seen as the comparison of information, which leads to problem-solving, judgment, decision-making, and creativity capabilities (List, 2022). It is the ability to explore all parts of the problem, raise and formulate questions, gather, and formulate solutions, and communicate this to others (List, 2022). It is not only seen as necessary in the educational context to create lifelong learners but also to create workers who can adjust to complex situations they will experience in the workplace as technology advances (Serrat, 2017). The process itself requires several skills, interpretation, analysis, evaluation, inference, explanation, and self-regulation, as well as dispositions including inquisitiveness, open-mindedness, and understanding (List, 2022).

The development of critical thinking requires a pedagogy that is innovative, flexible, and learner-centered (List, 2022). It needs to create in the learner a sense of control over one’s understanding and responsibility for their learning. This can best be accomplished with educators using effective techniques that are flexible and responsive to enhancing critical thinking, problem-solving, and creativity (List, 2022). If the aim is to create adaptive workers that can not only survive but thrive in an uncertain future work environment, then the current VET system, particularly the Diploma of Nursing for ENs, needs to address this deficit. Furthermore, critical thinking remains a requirement of Enrolled nurse’s practice standards (Nursing and Midwifery Board of Australia [NMBA], 2017).

Assessment deficiencies in VET

In relation to assessment, CBT is often criticized for only recognising the presence or absence of competence and failing to assess the quality of the performance (Townsley & Schmid, 2020). Nursing graduates are required to respond to life-threatening deteriorations in their consumers. To do this effectively, being competent may not be enough and proficiency would be a more appropriate measure. For employers, recruiting the best candidate for a job is usually the optimum outcome and whilst there are many considerations including, but not limited to personality, company culture, experience, and skills, many employers will recruit those employees with higher academic achievements (Beltram et al., 2018). The ability to measure proficiency is severely limited by CBT assessment as the CBT results of ‘competent’ or ‘incompetent’ do not differentiate between graduates who excel and merely pass. Even competence itself must be defined as a point on a performance continuum, which is difficult to identify and often subjectively determined by the assessor (Townsley & Schmid, 2020). Too often the assessment of competency is evaluated on students’ placement in industry, but assessments in these situations are based on random encounters with no standardisation. Drawing conclusions about a student’s performance under these circumstances may not be valid (González-Gil et al., 2020). Past efforts to use performance grading on competency criteria have also been heavily criticised. Studies suggest that generic criteria cannot be applied effectively to competency-based assessments (Townsley & Schmid, 2020). Many argue that CBT itself was only ever designed to assess observable performance, and theoretical knowledge is either neglected or poorly assessed using subjective criteria (Wheelahan et al., 2022). Furthermore, the acquisition of some areas of competency occurs through formal VE or on-the-job training, but the acquisition of professional competence is far more complicated and multifactorial than just being able to perform a skill. Competence is required to be assessed across all domains of learning, knowledge, cognitive skills (problem-solving, critical thinking, and communication), and practical skills (technical skills of the job) (Mulder & SpringerLink, 2017). Therefore, CBT in VET may not provide a valid measure of the performance standard required in the workplace.

Failure to address academic skills

Despite providing pathways to further education or employment for 4.2 million students in 2017 (Joyce, 2019), VET continues to be viewed as the ‘poor cousin’ of HE, the less favourable and lower status option, and even the last resort for those who fail to achieve the necessary grades to enter HE (Joyce, 2019; Mulder & SpringerLink, 2017). The dichotomy between HE and VET seems to have originated in Plato’s Liberal education where theoretical learning and knowledge (‘genuine knowledge’) and applied practical learning (‘mere opinion’) were inextricably linked to social class stratification (Hyland, 2014). In contemporary times, this continues to remain a constant in both developed and developing countries (Buli & Yesuf, 2015). Academics in HE often criticises CBT for focusing too heavily on learning outcomes whilst neglecting the learning processes and underpinning theoretical knowledge. VET also fails to properly support autonomous and lifelong learning and often ignores the theoretical frameworks (Catterall et al., 2014). For example, a study on facilitating the transfer of VET learners to HE found that there were gaps in preparedness, expectations, knowledge, learning styles, and management of workloads for students articulating from VET (Knight et al., 2022) The authors suggested that change in learning orientation from CBT to critical reasoning, critical reflection and autonomy, coupled with the absence of direct and explicit instruction was difficult for students to adjust to (Knight et al., 2022). Although this does not determine whether the focus on applied skill-based instruction in VET or the focus on critical thinking, reflective, and deep learning constructs in HE offers superior learning, it does make it clear that there is a significant difference between the two sectors. Critical thinking is seen as an essential skill for nurses and is required for clinical reasoning and consumer safety (Levett-Jones & Lapkin, 2014). Failure to address this skill in VET means EN graduates will enter the workplace underprepared and without the necessary skills.

Systemic issues: lack of teacher autonomy

The negative attitudes associated with VET have also been attributed to those who teach in VET as they are often seen as less educated than other teachers (Nakar & Olssen, 2022). The low status of VET is further reinforced by the limited curriculum discretion available to educators and limited professional support and research funding by the institutions (Billett et al., 2020). In Australia, this status is compounded by the heavily prescriptive, uniform, and nationally regulated top-down curriculum that is often described as poorly aligned to local industry needs and restricts educators’ ability to be responsive to those needs. This is due to the excessive regulation and compliance monitoring by a national regulator of training providers and courses delivered in the VET sector, namely the Australian Skills Quality Authority (ASQA) (Billett et al., 2020). There is also the misconception that VET is exclusively about apprenticeships even though apprenticeships comprise only 10% of its core business (CEDA, 2016). Australian national regulations have become more stringent constraining the knowledge being taught and the assessment requirements. This has diminished the discretion of the educators to use their professional judgment and expertise and often fails to consider the diversity of the learners, their capabilities, and the specific needs of local industry (Billett et al., 2020). Indeed, industry consultation, government, and unions determine what is taught with minimal consultation with educational experts, teachers, or recipient students (Billett et al., 2020). What is needed is a reform of the current CBT model in VET to become a more responsive, engaging, and innovative system that empowers teachers to guide curriculum and ensure VET is comprised of well-educated and well-trained teachers.

The quality of VET providers

VET failures are further compounded by poor quality ‘private for-profit’ providers that have grown in numbers in recent years and have made significant profits from providing courses that have subsequently eroded Australia’s VET system (Wheelahan, 2016). Since CBT does not require a minimum duration of time to complete a course, it lends itself to courses being offered over a reduced timeframe where assessment results are not reliable or valid. Private providers that have capitalized on the absence of a minimum time requirement have resulted in qualifications being stripped from their recipients following senate reviews, which in turn has led to further regulation of VET courses and further restrictions on teacher autonomy (Joyce, 2019) Enrolled nursing is protected from this by accreditation being regulated by ANMAC establishing a minimum duration.

Current and future workforce requirements in the twenty-first century

As mentioned previously, the main purpose of VET is to prepare students with the knowledge and skills for the workplace. The demand for healthcare will increase as Australia’s population of over 65 years doubles by 2035 (Hajkowicz et al., 2016; McPake & Mahal, 2017). Moreover, it is expected that health services are less likely to be affected by automation due to their need for personal and social contact. It is also the case that students in these courses require more than just technical skills, and need cognitive, social, and communication skills to allow interaction in complex situations (Hajkowicz et al., 2016). The current employment climate is also seeing a flattening of organizational structures resulting in fewer management levels leading to greater responsibility for the worker to be able to solve problems. It is now less likely that a worker can escalate issues up the organisational structure, and as such, there is a need for the employee to be autonomous and make decisions (Hajkowicz et al., 2016). This is true for ENs in both general and mental health contexts.

Foundation for Young Australians (Foundation of Young Australians [FYA], 2018) analysed the big data on 4.2 million online job postings in Australia between the years 2012 to 2015 to determine what skills the employers were seeking for early career entrants of between 0–5 years of work experience. According to the data analysis, critical thinking, creativity, and problem-solving were significantly in greater demand compared with previous years. The demand for twenty-first-century skills increased by 70% overall and employers were 20% more likely to request twenty-first-century skills than technical skills (FYA, 2016; Joyce, 2019). It is anticipated future advances in technology will allow for a decrease in manual tasks and lead to an increase in communication, creative thinking, and collaboration (FYA, 2017). By 2030, it is estimated that critical thinking will consume 15–17 hours/week in most jobs and interpersonal skills and interpersonal skills 7–11 hours/week (FYA, 2017). Whilst testing the development of twenty-first-century skills in students is often difficult, research conducted through the Programme for International Student Assessment (PISA) found that around 35% of Australian 15-year-olds showed low proficiency in problem-solving and this was much lower for students of low socioeconomic background and Aboriginal or Torres Strait Islanders. Twenty-seven percent showed low proficiency in digital literacy and 29% in financial literacy (PISA, 2009, as cited in De Bortoli & Macaskill, 2014). In this regard, these students entering tertiary education already have a significant deficit in employability skills. These skills will need to be taught in the VET curriculum. While most countries have seen the expansion of their education and skills training systems over time, there remains a considerable gap in what skills are needed for the workplace and what the system provides, and this is reflected in the unemployment and underemployment of young people (FYA, 2017).

Skills required for ENs in the mental health context

ENs in the mental health context require the same twenty-first-century skills as all VET graduates to ensure the best outcomes for their consumers. Specifically, they need the ability to critically think and clinically reason to meet changing healthcare needs (Schwartz, 2019).

This suggests ENs need greater preparation for their future careers in nursing, beyond the development of technical skills using contemporary teaching methods. The goal is to produce work-ready graduates who are lifelong learners prepared for the challenges of the workforce (Schwartz, 2019).

Communication skills

Mental health interactions require nursing students to be capable communicators (ANMAC, 2017; Jacobs & Van Jaarsveldt, 2016). Therapeutic communication includes collaboration, consumer-centered care, crisis intervention, and safety assessments (Cusack et al., 2017). Communication is a central component of all human interactions in nursing and is a critical skill for nursing consumers with mental health issues (Williams et al., 2017). Fundamental to working with those who have mental health challenges is the therapeutic use of self. Well-developed interpersonal communication skills provide the basis for establishing a therapeutic relationship that can best create a landscape for change and recovery (Isobel & Delgado, 2018). When used effectively, communication skills can create psychological safety for the consumer and lead to the development of a trusting, collaborative, empowering relationship during which recovery can be achieved. It is important here to clarify that recovery does not necessarily mean the amelioration of symptoms but rather living a fulfilling life despite symptoms (Cusack et al., 2017).

In a quantitative study of 336 consumers, 40% of people with schizophrenia reported receiving insufficient information about their diagnosis and stated that they would rather receive a “bad diagnosis“than not know anything at all (Ferreri et al., 2000). Consumers want to know and talk about their mental health issues. Effective communication between health professionals and consumers is associated with better consumer outcomes, greater consumer satisfaction, and increased consumer adherence to treatment. It also enhances accuracy in identifying consumer problems, improves confidence, and decreases emotional distress for both the consumer and nurse (Ditton-Phare et al., 2016). The Joint Commission on Accreditation of Health Care Organizations [JCAHO] (2022) reported that communication breakdowns in health care contribute to 65% of medical sentinel events or medical errors in hospitals and this significantly increased in 2021. The reason for this was not stated. In contrast, poor communication between practitioners and consumers can result in dissatisfaction, complaints, poor treatment adherence, negative health outcomes, and litigation. Furthermore, good communication and collaboration among health workers were also found to be critical to consumer safety in the mental health setting (JCAHO, 2022)

Critical thinking and clinical reasoning

ENs must develop their critical thinking skills as well as make judgments based on evidence to ensure consumer safety (ANMAC, 2017). Whilst critical thinking has been central in Bachelor of Nursing programs, it is now necessary to integrate this into the Diploma of Nursing program more comprehensively and holistically across core units and skill sets. Research suggests that higher educational levels correlate with higher levels of critical thinking (Siburian et al., 2019). This assumes that those studying the Bachelor of Nursing would have a greater ability in this area compared to those studying Enrolled Nursing. Evidence suggests that critical thinking can be learned regardless of learner level, which provides an imperative for curriculum revision and inclusion in the Diploma of Nursing (Siburian et al., 2019)

Clinical reasoning is critical for accurate diagnostics, treatment, and management plans and for ensuring desirable consumer outcomes (Dalton et al., 2015; Huang et al., 2016). It is considered a necessary skill for proficient nurses across all areas of specialty, yet a significant disparity has been identified in the education of nurses and their ability to clinically reason in practice (Benner, 2015, Dalton et al., 2015; Stec, 2016). Whilst it is more often present in experienced nurses, the novice nurse struggles with the development of clinical reasoning. This is because it involves the skilled application of problem-solving in clinical situations and the ability to reason across time and transitions in a consumer’s health status (Benner, 2015). The components of judgment and decision-making include the ‘ability to discern between typical and atypical consumer situations, and the ability to frame relevant facts of a consumer situation’ (Stec, 2016, p. 54). To add to the complexity, each situation or problem has multiple responses and can affect multiple participants (i.e. the consumer, family, health professional, and peers) (Runco & Jaeger, 2012). Clinical reasoning incorporates both cognition (critical thinking) metacognition (reflection) and discipline-specific knowledge. This is sometimes referred to as nursing judgment (Runco & Jaeger, 2012). The judgment needs to be contextualized to both the consumer and the situation incorporating cultural background, environment, illness experience, and stakeholders. It is being able to adapt in ‘real-time’ as the consumer’s condition changes (Runco & Jaeger, 2012). It is complex as it integrates both clinical and classroom teaching, is domain-specific, and needs to be learned in context. It also involves accountability and responsibility for consumer outcomes (Runco & Jaeger, 2012).

Addressing the current shortfalls of VET – simulation

One way to be responsive to the training needs of ENs is to move away from the current teaching approach that focuses on narrowly defined competencies to a more holistic integrated curriculum that prioritises the teaching of communication, critical thinking, and clinical reasoning skills. Teaching methods must focus on experiential, constructive pedagogy that is grounded in reflection and based on deliberate practice, synthesis, and evaluation to enhance competence. Nursing students require realistic experiences to consolidate and contextualize their skills and develop critical thinking, problem-solving, and clinical reasoning. Traditionally this has been achieved through practical clinical placements, however, with the current competition for quality clinical placements, it is becoming increasingly difficult to secure this type of experience. It is often compounded by shorter consumer stays (Spence et al., 2019), and the impact of the COVID-19 coronavirus pandemic where placements have been cancelled or delayed (Joffe, 2021; Wynter et al., 2022). There is an urgent need for an alternative approach. Simulation-based education is one technique that can address this shortfall as it offers a way to deliberately practice critical thinking, communication, and mental health assessment skills (Harvey, 2023).

Simulation has been adopted in the Australian undergraduate nursing curriculum at an unprecedented pace (Edgecombe et al., 2013; Hall, 2017; Hall & Tori, 2017). However, mental health nursing has been slow to integrate this teaching methodology into the curriculum (McGough & Heslop, 2021). Research to support its use in the context of EN mental health training is almost non-existent. Simulation has been shown to develop through deliberate practice the 21st-century skills of critical thinking, clinical reasoning, and communication skills that are required to work with those with mental health issues now and in the future (Williams et al., 2017). Different types of simulation are available but simulation that incorporates simulated participants (SPs) actors who play the role of a consumer is deemed the most appropriate for developing mental health nursing skills. The SP can show emotional responses that make them invaluable in the teaching of communication and interpersonal skills. Moreover, SPs can offer valuable feedback to the learner about their interactions (Williams et al., 2017). In a simulation, SPs can address the absence of the human element experienced by using Human Patient simulators or mannikins. They can articulate both verbal and nonverbal individual responses to a disorder and respond to the interactions of the student (Alexander et al., 2018). When simulation is followed with a structured debrief it is shown to increase critical thinking and clinical reasoning (Dreifuerst, 2009; Hall & Tori, 2017). Also, simulation in VET has the added benefit of addressing the current placement issues associated with nursing (HWA, 2010; McGough & Heslop, 2021).

Conclusion

Australia’s healthcare needs are changing and as our population ages, it will experience an increased incidence of age-related disorders and chronic illness. Mental health issues are also increasing, and nurses will need to have the appropriate knowledge, skills, and attitudes to become proficient practitioners capable of improving the health outcomes for consumers. Australia is already struggling with a shortage of healthcare workers and there will be insufficient RNs to deal with the increasing number and complexity of consumers with mental health problems in the future. It is critical that more ENs enter the nursing workforce to compensate for the shortage of RNs, and that these ENs be trained in 21^st-century skills such as communication skills, critical thinking, and clinical reasoning to enable them to be proficient in a mental health context. The criticisms of the current VET system and current CBT model demonstrates a clear need for reform to the training of Australia’s ENs and the creation of an alternative and innovative curriculum to prepare ENs for future healthcare delivery is required.

Disclosure statement

No potential conflict of interest was reported by the author(s).