An Overview of Issues in Nursing Education

Dick Johnson
Barbara Preston
The Australian Council of Deans of Nursing

01/12
October 2001

Higher Education Division

© Commonwealth of Australia 2001
ISBN: 0 642 77222 3 (Internet copy)
DETYA No. 6761HERC01A

This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of the source and no commercial usage or sale. Reproduction for purposes other than those indicated above, require the written permission from the Commonwealth available through ausinfo. Requests and inquiries concerning reproduction and rights should be addressed to the Manager, Legislative Services, ausinfo, GPO Box 1920, Canberra ACT 2601.

This research was commissioned by the National Review of Nursing Education funded by the Department of Education, Science and Training and the Department of Health and Ageing.

The views expressed in this report do not necessarily reflect the views of the Department of Education, Science and Training or the Department of Health and Ageing

Contents

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Abbreviations and acronyms

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Acknowledgments

This project was funded by the Evaluations and Investigations Programme of the Department of Education, Training and Youth Affairs. It was under the auspice of the Australian Council of Deans of Nursing and was based in the School of Nursing at Deakin University which provided administrative support and assistance.

The advisory team for the project comprised:

• Associate Professor Pauline Nugent, Head of School of Nursing, Deakin University and Chair of the Australian Council of Deans of Nursing;

• Professor Jill White, Dean Faculty of Nursing and Midwifery, University of Technology Sydney and Executive member of the Australian Council of Deans of Nursing;

• Ms Elizabeth McDonald, Department of Education, Training and Youth Affairs, Higher Education; and

• Ms Christianna Cobbold, Assistant Secretary, Health Capacity Development Branch, Department of Health and Aged Care.

The advisory team was appointed by the Department of Education, Training and Youth Affairs as a consultative body to work in an advisory capacity on matters such as scope of the project and methodology. Advisory team meetings were held 3 monthly.

Appreciation is expressed to members Australian Council of Deans of Nursing who contributed to the project through assistance with identification of appropriate reports and participation in discussion groups.

Appreciation is expressed to Ms Kate Duyvestyn, Ms Carmen Mills, Ms Helen Hamilton for the production of this report.

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Executive summary

Soon after the complete transfer of registered nurse education into the higher education sector in 1993, Professor Janice Reid led a review of nurse education (1994)¹. Seven years later, two national reviews have been initiated, one into nursing generally, by a Senate committee, and one into nurse education by the Federal Government. Between these two dates a large number of smaller studies were carried out, partly into aspects of nurse education and partly into questions of supply and demand.

This project commissioned by the Department of Education, Training and Youth Affairs, (DETYA) provides an overview of the more recent of these reports and aims to synthesise the outcome to provide a national picture of the issues. The project was overseen by a Steering Committee comprising representatives from DETYA, Commonwealth Department Health and Aged Care and Australian Council of Deans of Nursing, (ACDN). A number of issues come up frequently in the reports, either as the specific focus of a report or as an aspect of a wider ranging study. These are:

• The changing context of nursing—increasing complexity, pressure; changes of clientele—the aged, the community;

• Dissatisfaction with conditions of work—shift work, frequent changes, overloads, lack of appreciation by superiors and colleagues, lack of child care. Pay is an issue, but not as big as several others;

• Transition from university to employment—the first year, especially the first few months of employment;

• The practicum—finding clinical placements, and funding them. Clinical supervision. Different expectations of academics and clinical supervisors; lack of communication;

• Specialisation—training for it, credentialling of it, specialist and advanced practice; and

• The supply of nurses; issues of recruitment and retention. Why do people enter nursing, and (more urgently) why do qualified nurses leave the profession?

The numerous reports which have focussed on workforce emphasise the need for a national approach to nursing workforce strategies. State and Territory reports have been insular in their recommendations for:

1. Consistency and accuracy of data collection in relation to workforce numbers;

2. Family friendly and flexible work environment;

3. Partnerships between universities and health services in relation particularly to clinical practice and successful graduate transition programs; and

4. Recruitment strategies.

Reports from speciality areas have highlighted the need for career enhancement strategies including postgraduate courses. The sheer volume of work in this area and its segmental and insular nature further emphasise the importance of a national approach.

Some issues are not addressed in the reports:

• Leadership development, management, interpersonal relations - what sort of person is the good supervisor or the good director of nursing? How are they to be developed?

• Evaluation of on-line education for nurses;

• Indigenous issues evaluation of education of indigenous nurses, and education of nurses to care for indigenous clients;

• Education of nurses for multicultural society; dealing with minority groups;

• Issues in education for rural and remote area nursing: limited opportunities for continuing education, staff development, acquiring further qualifications; range of expectations put on the rural/remote area nurse;

• The trend towards specialisation and specialist credentialling;

• Quality of graduates; this is usually seen as a matter for registration boards, but some boards simply accredit universities on the basis of documents and do not assess the quality of the graduates;

• Teaching quality in schools/faculties of Nursing. That does not mean this issue is not addressed; such reviews are carried out within the school or faculty and would not be published by it or the university. There are also many reports of quality teaching within the Australian Universities Teaching Committee (AUTC) and its antecedents;

• Expectations/attitudes of incoming students; comparison with new graduates;

• Links between nursing and non-traditional medicine; and

• Evaluation of double degree programmes.

The workforce studies are usually carried out by government agencies rather than by universities, and focus on estimating and achieving an adequate supply of nurses to meet predicted needs, both for general nurses and in special fields of nursing. These studies are hampered by some inconsistencies of approach and inadequacies in the data.

1. Nursing Education in Australian Universities Report of the National Review of Nurse Education in the Higher Education Sector - 1994 and beyond. AGPS 1994

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1. Overview of recent and current reviews of aspects of nursing and nurse education in Australia

1.1 Introduction

The Deans of Nursing in Australian universities are aware of a large number of reports and reviews of various aspects of nursing education in recent years. They have participated in and/or requested their undertaking and believe that it would be an advantage to have a conspectus to identify common elements in them, divergences or inconsistencies between them, and gaps in their coverage. The Deans identified over forty such studies, carried out usually by nursing academics, sometimes with a focus on a single university, sometimes on issues within a State and occasionally nationally. Each of these has been read and summarised. In this overview they are grouped into the categories of reviews of educational programmes, and workforce studies. This overview sets out the common elements and issues addressed in the reports and mentions some areas which are not addressed. Appendix B lists the reports studied and Appendix C provides the summaries of the educational programmes.

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1.2 The context of nursing today

Health care has become far more complicated and difficult in the last 15 to 20 years than it used to be. As one senior nurse has put it: ‘The people now in general wards were in intensive care fifteen years ago’ and many people cared for in hospital 15 years age are now cared for in the community. The people who are now in intensive care would have died fifteen years ago’. Nursing in hospitals is more intense, more stressful, and far more scientifically based than it used to be. Much more technology is used in hospitals, and the nurses have to know how to use it.

Because of the cost of hospital care, hospital staff from managers to nurses in the wards are under pressure to discharge patients as early as practicable. That meant people in hospital beds are in general sicker and are there for shorter stays than they used to be; for instance, in a base hospital in a rural city the average length of stay is three days, and 70 per cent of patients stay one day. There is thus extra stress on the nurse, and less chance to balance this with the human satisfaction of getting to know a patient and watching a recovery. Another contribution to stress is the decline in the numbers of support staff; between 1991 and 1996 the number of enrolled nurses (EN) went from 39 485 to 24 559. Between 1993 and 1998 the numbers declined by 21 per cent. There has also been a compounding effect of a reduction in non nursing staff eg support from ward clerks. The nursing workforce is expected to be very specialised and very efficient.

At the same time, the places of work for nurses are changing. General hospitals remain the main institutions of employment, but between 1991 and 1996 there was a 47 per cent decrease in the number of psychiatric hospitals as people with psychiatric problems were absorbed into the general community; and an 80 per cent increase in the number of community health centres. Community health and home care are now major fields of activity for nurses. The numbers of midwives increased by 39 per cent and mental health nurses by 11.3 per cent while those in the area of developmental disability increased by 55 per cent. Nursing homes and aged care are another large and growing area of employment for registered nurses (RN), enrolled nurses (EN) and assistants in nursing (AIN). In rural and remote areas nurses continue to function, but without as much support from doctors as previously; doctors are notoriously hard to recruit to such practices. The nurse in these areas is required to be multiskilled, but is given little leave or other opportunity to become so qualified.

The educational standard of entrants to university nursing courses has risen and is now, at the minimum, equivalent to the general entry level for university health science courses; while at the top, students in the top 10 per cent of school leavers are entering nursing. Nurses of this calibre, with university degrees and the habits of mind which degree courses inculcate, are less likely to tolerate aspects of health care management which nurses of previous generations had to accept. This can lead to tensions between practitioners and may contribute to the rate of separation of nurses from the profession - an issue dealt with more fully below.

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1.3 Conditions of work

Several of the reports covered by this project deal with the question of retention of qualified nurses in the nursing workforce and touch more or less heavily on the conditions of work. In so far as the dissatisfaction of nurses reaches the newspapers it is presented as a dispute over pay; but pay is not a major reason for leaving the profession. Nurses, like teachers, ministers of religion, social workers and many other occupational groups, know in advance that they are never going to make big money, and they do not enter the profession with that expectation. They leave the profession because they are no longer prepared to put up with the conditions of shift work, with frequent changes of schedule and inability to plan their own days and weeks satisfactorily. They are tired of being overloaded with work and with emotional stress. Low pay is an extra irritant, not a primary motive.

Nurses complain that in a heavily female profession their workplaces do not provide adequate childcare. They complain, often and bitterly, in one questionnaire and interview after another about poor management practice and a general lack of appreciation. One nurse who left the profession and has no intention of returning said, of her current workplace: ‘When I leave at the end of the day, the boss says "Goodnight, and thank you"; that never happened to me in twelve years in nursing’. Clearly, whatever happens in the education of nurses and nurse managers, there is room for programmes to deal with these issues.

Particularly disturbing is the number of nurses who leave nursing in their first year of employment. They have spent three years in university education, with a total of 40–55 per cent of their courses in practical work in hospitals and other health care settings. Their first employers, typically major hospitals, often expect them (in a phrase so over used as to become a wry joke) to ‘hit the ground running’, to be instantly adept at all the requirements expected of an experienced ward or theatre nurse. No other profession expects the neophyte to be adept; the new recruit to an architectural firm is not called upon to plan a skyscraper, the new engineer to design a major bridge or steelworks. Nurses used to be trained by apprenticeship in hospitals, so it was to be expected that by the end of their training they were adept at the skills needed in that hospital. University based courses are to provide nurses with greater depth of understanding of health care, and the on-the-job skills should be developed on the job. The studies covered in this report suggest that after about six months of employment with an intelligent employer the graduate nurse has learned the requisite job skills; those who have unintelligent employers with unreasonable expectations may well leave the profession.

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1.4 The practicum

Every university nursing course in Australia has a component of practical work in health–care settings for its students across the years of the course. This is an attempt to prepare graduate nurses better for employment, and in educational terms an attempt to marry theoretical knowledge with its practical applications. Although it is obviously a commonsense measure, it is one of the commonest sources of inquiries and reports. Ten out of the twenty reports listed under ‘Educational programmes’ in Appendix B are concerned with the clinical component in some way.

Busy nurses in the hospitals tend to see the students as extra hands to help, not as learners who need help and to the extent that they need help they are a distraction from the nurses’ main tasks. The university staff have expectations of the hospital, the hospital staff have expectations of the university, that each party sometimes fails to fulfil. The university wants its practicum at a particular time of year, which might not always suit the hospitals where the practicum is to be accommodated. The issue of competition is a concern particularly when there are two or more schools/faculties of nursing in the city, as there is in every mainland State capital, and all are seeking hospital placements at once which may or may not be met.

There are also costs involved in the hospital providing clinical supervisors for the students, and hospital and university do not always agree on costs and payment. However there are many new models of clinical education that are being adopted throughout Australia.

The ten reports mentioned above and summarised for this paper address these questions and solve them, for one university or another. Universities generally could well learn from these small-scale solutions.

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1.5 Specialisation

As the nursing profession develops in understanding and practice it naturally develops areas of special knowledge and expertise. In keeping with modern trends in professional education, courses to prepare people for such specialisations are developed and people want awards or credentials attached to such courses. Just as we have diplomas and masters degrees in commercial law and international law and several other fields of law, so are we seeing awards for named specialities in nursing and midwifery. This trend seems certain to continue. There is some danger that anomalies and inconsistencies of standards will develop unless some body such as the Council of Deans or the Australian Nursing Council is able to take action to ensure that an award with a particular title means the same no matter from which university it comes. It also becomes imperative to provide nurses with opportunities to access such courses and credentials.

A related development, just emerging in Australia, is the establishment of the categories of Advanced Nurse and Nurse Practitioner. These are nurses whose scope of practice is beyond that of senior clinicians and with legal authority for practices beyond the usual boundaries for nurses. Some of the reports included in this overview relate to this innovation. As this class of nurse expands, there will be increasing need to devise suitable programmes to prepare nurses for this role.

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1.6 Labour force issues

This review is concerned with nurse labour force studies in as far as they have implications for enrolments in initial and post-initial nurse education, and the nature (content, structure, location) of nurse education programs in universities.

A number of States have put substantial resources into labour force studies – general and specialist workforce projections, and surveys to investigate the issues involved in the successful recruitment and retention of nurses. Many of these studies are reviewed in this report. However, the usefulness of much of the work has been limed by problems of data quality and methodology. The recent Victorian Nurse recruitment and Retention Committee: Final Report (Bennett, 2001) noted that:

The Committee has been hampered by the lack of available nursing workforce data. A review of local and international literature has shown that many state and federal governments have identified lack of workforce data and lack of integrated nurse labourforce planning as major impediments to addressing nursing workforce shortfalls (p. 1).

and:

The first, and probably most important [concern in the literature on the nursing workforce], is the lack of a coherent workforce planning model which enables prospective adjustment of nursing supply to fit demand (p. 30-31).

Workforce projections (and related studies) are inherently difficult and controversial. However, some methods are more suitable than others in particular circumstances, and often the quality of the necessary or useful data can be improved.

The conclusions of workforce projections and related studies often have little influence on policy and practice. The reports and studies reviewed touch on several possible reasons for this. First, there may not be a strong strategic policy connection between those responsible for commissioning and receiving the report (usually a State department of health), and those who are actually responsible for implementing explicit or implicit recommendations (usually university administrations at the central or faculty level, operating within a framework of policy and negotiation with the Commonwealth Department of Education, Training and Youth Affairs). Second, the study may have several widely differing scenarios or options with no clear indication of which is to be preferred as a basis for practical policy, and why. Third, the conclusions or recommendations may be very different from the current practice or the common sense judgement of stakeholders (for example, if graduate numbers are suggested to be several times more, or significantly less, than current levels), and the document may not include convincing supporting evidence and argument for its conclusions or recommendations. Fourth, the methodologies of workforce projections are at best difficult to follow, and in most of the studies considered in this report key aspects of the methodology or derivation of the values of inputs are not transparent or are questionable. A lack of transparency of methodology, let alone apparent data or methodology problems, can weaken the credibility of a study’s conclusions with those responsible for policy implementation.

Some major methodological and data problems with some workforce studies include:

• a range of problems related to estimating or projecting future values for attrition (or separation) rates, including: not taking account of age profiles; and not consistently determining values for both separations and re-entry;

• problems of not adequately accounting for graduates’ availability or suitability; and not accounting adequately in subsequent periods for graduates unable to gain desired positions in an initial period; and

• projected future workforce size is very difficult to estimate, and judgements must be made regarding appropriate (or likely) mixes of staff with different qualifications and work roles, work intensity, industry structure and work organisation, and other matters.

Data problems include: timeliness of data (especially the time lapse between data collection and publication of the major Australian Institute of Health and Welfare (AIHW), nurse workforce surveys); inadequate response rates for surveys (including the AIHW survey); lack of distinction in some data collections between ENs and RNs; problems with definitions of specialties; a lack of information about those with nursing qualifications who are not registered; and problems of data management, especially in individual States. The Northern Territory Taskforce for the Recruitment and Retention of Nursing Staff reported on the lack of consistency in data collection, the lack of data systems, and the lack of data in usable form (Bowden 2001, p.6). The Taskforce made eight recommendations to improve data systems in the Northern Territory, and to provide in the future the types of data it considers essential for workforce planning (pp.10–11).

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1.7 Gaps: issues not addressed in reports

There are a number of issues relating to nurse education which are not addressed in the range of reports we have studied. One of these (which is treated in one of the discussion papers for the New Zealand review) relates to the development of the skills of management and interpersonal relations. What sort of person is the good nurse, the good supervisor or the good director of nursing? How are they to be developed? Given that a significant source of stress in hospital-based nursing is such relationships with superiors and peers, as reported in some of the reviews, it is a serious omission. Human relations and the skills of management figure in the curriculum of other departments in a university as they do in schools of nursing, but there are no reports of studies in this area.

Another area which seems to have received no attention is the on–line education of nurses, whether at the undergraduate or postgraduate level, or in continuing education. This is an area currently receiving attention in the universities and amongst policy makers and politicians. On–line provision is resulting in much activity in nursing course development and is especially suited at least to the continuing education needs of nurses: they should value its flexibility of time and place of access; they are likely to have access to computers in many workplaces; their workplaces may well be far from metropolitan areas. At the same time, on–line education poses particular problems in course development and delivery and system maintenance. Yet there do not seem to have been reports or evaluations of initiatives to provide on-line learning for nurses at any level.

There are no reports on teaching quality in schools/faculties of Nursing. That does not mean this issue is not addressed; such reviews are usually carried out within the school or faculty and would not be published by it or the university. There are also many such reports submitted to AUTC, or its antecedent bodies, from schools and faculties of Nursing. However, there is concern amongst some senior nurses about the quality of graduates. This is usually seen as a matter for registration boards, but some boards simply accredit universities on the basis of documents and do not directly assess the quality of the graduates. There would seem to be scope for an assessment and report on their quality, since the quality of nurses is a matter of safety of patients.

Some areas of most mainland States have significant indigenous populations who need nurses. There are cultural differences between these clients and the mainstream population, and nurses need to be educated to recognise, respect and work within these differences, but none of the reports studied addresses this matter. Australia also needs to encourage the education of indigenous nurses, which might well require special measures, but there are no reports of such initiatives, let alone evaluations of them. However the ACDN is aware of many such initiatives.

Similarly, nurses need to be educated to relate to the many minority groups in our pluralistic society, but there are no reports of such initiatives, nor studies of what might be done or needed.

Australia has huge rural and remote areas which require the presence and practice of nurses. This is recognised in the educational programmes of some schools of nursing, but there are few reports on the particular needs of nurses in these areas. There are no reports on their limited opportunities for continuing education or staff development, or the possibility of their acquiring further qualifications. There are no reports on the range of expectations put on Remote & Rural Area (R&RA), nurses and how those expectations are being fulfilled or might be better achieved and there is no reference in the reviews to the Commonwealth funded university departments of Rural Health and the role they may play.

As in all professions, nursing is experiencing a trend towards specialisation and specialist credentialling. There are no reports on the educational implications of this for better or worse. The rural and remote area nurse faces special difficulties in trying to get such credentials, but this problem is not documented or covered by a report, the extent of the need is not assessed and the possible ways of meeting it are not canvassed in any reports we have seen.

Student nurses and recent graduates not infrequently withdraw from nursing altogether, saying that nursing is not what they expected when they enrolled. It would be informative to have some studies of the expectations and attitudes of incoming students, and a comparison with new graduates. This could provide the basis for future recruitment campaigns either by individual institutions or the profession as a whole.

One development of relatively recent years has been the growth in fields of health care beyond the traditions of Western science, such as acupuncture, naturopathy, homoeopathy and various therapies which often have an Asian origin. The medical profession is devoting cautious but increasing efforts to understand and evaluate these. Do they (including the many varieties of massage) have any implications for the practice of nursing? There appear to be no investigations on these lines.

A feature of university education generally in Australia over the last decade or more has been the growth in the number of combined or double degree programmes, sometimes in combinations which seem surprising at first sight. Has this trend affected nurse education? If so, what is its extent and what are the combinations, and where are the evaluations? Here again there are no reports.

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1.8 The New Zealand review of undergraduate nurse education

It is interesting to compare the Australian experience and views with the issues arising from consultations in the NZ review. The main value of the NZ material for Australian use appears to lie in its wide and perceptive treatment of the changing context of nursing and the attributes required of the nurse of the future. The nursing curricula issues are similar to those noted in Australian reports: the handling of the practicum, the first entry to practice after graduation, multicultural sensitivities are also similar.

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1.9 Conclusion

Section 1 has provided a broad introduction to the issues prevalent in nursing education in contemporary Australia. In the following sections the data on which the broad issues raised in this section are based are presented in detail by way of summaries and commentaries of a range of reports and studies.

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2. Labour force issues in reports

2.1 Introduction

This part of the project is primarily concerned with nurse labour force studies in so far as they have implications for enrolments in undergraduate and post registration nurse education, and the nature (content, structure, location) of nurse education programmes in universities. The major studies only were selected for review and those identified by ACDN; however other reports have been acknowledged.

Much of the literature and discussion on the nursing labour force rests on the assumption that education and training for nursing lead inevitably into a nursing career. In fact, nursing has become a stepping stone to careers, usually with some human relations aspect, for instance, in the travel and hospitality industries or in retailing and management. The nursing qualification offers both a sound preparation and a fall back employment qualification in case of need. Workforce planning, to be realistic, needs to allow a fair amount of ‘wastage’ between the numbers graduating and the numbers practising. The idea expressed in some studies that an ‘excess’ of graduates that initially failed to enter the work force immediately after graduation would enter the profession a few years later, is not soundly based.

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2.2 Methodological problems

Broad or macro level nurse supply and demand projections studies are explicitly concerned with the numbers of graduates in nurse education programmes and, therefore, with intakes and net attrition during courses. However, there are some methodological and data related difficulties with many of these reports. These difficulties are discussed below.

In policy and strategic reports, such as Rethinking Nursing, the report of the National Nursing Workforce Forum (held in Canberra in September 1999), in its executive summary and recommendations, there is a tendency not to draw out implications for numbers of students, especially for undergraduate nurse education.

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2.2.1 General supply and demand projections

Problems encountered with data are presented.

• Lack of transparency due to commercial-in-confidence claims;

• Problems with attrition rates:

  • not taking account of age profiles (assuming equilibrium);
  • inappropriate data/assumptions re those qualified not working as nurses (see AIHW commentary);
  • not being clear about attrition (turn over) from a particular employer, compared with the industry as a whole, and non use of ‘net separations’ (problem is indicated by uncritical/unqualified reporting of annual separation rates of 20 per cent or more. This includes not taking account of the sort of information collected and analysed in the ‘recruitment & retention’ studies); and

• Other data problems.

  • Provision of alternative scenarios (eg. Projections of 'high', 'constant', 'low' supply), with no evidence-based discussion of probabilities of the different scenarios, thus the implications for policy on matters, such as nurse education intakes, are uncertain.
  • Sometimes a reluctance to countenance the need for increased intakes into nurse education programmes (and thus increase overall supply). This might be presented as a concern with ‘quality’ rather than ‘quantity’; a concern with ‘distribution’ or ‘service delivery’ rather than overall supply. These are set up as ‘either/or’, rather than being seen to be inter-related.

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2.2.2 Recruitment and retention studies

In general, studies and projects concerned with ‘recruitment and retention’ are remarkably unconcerned with the numbers of graduates from nurse education courses. The main ‘recruitment’ focus tends to be on attracting back nurses that have previously worked in the specialty or jurisdiction concerned. Reference to nurse education tends to be focussed on the qualitative nature of courses, so that nurses are better prepared, and less likely to leave (this is part of the ‘retention’ agenda, rather than ‘recruitment’).

Problems encountered with data are presented.

• Weaknesses in samples (drawn from Registration Boards so those not currently working as nurses would at least be those wanting to maintain some connection with the profession as they maintain their registration);

• Frequently the focus is narrow - on recruitment only from those qualified but not working as nurses. There is little consideration of graduates at source or the number of graduates as a key factor in recruitment, (but, when graduate numbers are a concern, the strategy favoured is increasing student demand for places via media campaigns, rather than actually increasing provision); and

• Lack of critical analysis of attrition/retention – including, low attrition not necessarily a good thing (for patient care and professional job satisfaction), and high attrition not necessarily a bad thing, or it may be simply unavoidable if, say, the workforce is mostly close to retirement age.

There is a general problem with both types of studies being carried out without reference to each other. Reference is made to concerns with, and developments regarding, consultation, coordination and collaboration between the Commonwealth and the States/Territories, and among the States/Territories.

Sections 3 and 4 following, provide a review and summary of the selected reports, labour force studies, reports and reviews. In section 3 the reports are grouped according to the type of report either national and State/Territory strategic reports; according to the subject, that is, nursing specialist reports or according to the method used, that is, survey based reports

In the subsequent section reports are grouped according to the State/Territory where they were carried out.

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3. Work force studies reviewed

3.1 National strategic reports

One of the major national Nursing strategic reports in recent years is Rethinking Nursing: a report of a national workshop held in Canberra in 1999. A review and commentary follows.

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3.1.1 Rethinking nursing: national nursing workforce forum

Report of a forum held on 21-22 September 1999, Commonwealth Department of Health and Aged Care, Canberra.

The Commonwealth convened this forum ‘with the aim of identifying the challenges facing nursing into the future, and helping to facilitate some appropriate responses’ (p. 5). Those attending included representatives of the nursing workforce, employers, educators and regulators.

Recommendations of the forum arose from consideration of how the ‘vision for the future’ for nursing, developed by the forum, could be realised. Major recommendations of relevance to nurse education included:

• the establishment of an Australian Nursing Workforce Advisory Committee, to report to and be resourced by the Australian Health Ministers Advisory Council (AHMAC), and with a brief to develop a ‘national nursing workforce strategy that would provide a focus for national data gathering and evaluation, and would focus on key nursing issues, including . . . education and preparation of the nursing workforce’; and

• liaison between the Commonwealth and States and Territories to ‘ensure there are extra university places where there are shortages (some of these could be funded)’ (p. 3).

Key challenges identified at the forum included:

• a worldwide shortage of nurses (in Australia especially in rural and remote areas and certain specialties);

• difficulties in recruitment and retention of nurses;

• the nursing workforce not being representative of the broader community; and

• concern that nursing education is not sufficiently responsive to workplace needs.

The report of the forum includes background information about the Australian health system, the nursing workforce, attraction to and retention in nursing, and nurse education. Transcripts of major speeches are also included.

Some of the significant issues of relevance to nurse education raised in the background information and addresses to the forum include:

• The Commonwealth has a broad leadership role in health, little direct responsibility for the nursing workforce, though it funds registered nurse education though universities (p. 15).

• The Commonwealth provides universities with one-line funding, and universities are free to allocate that money as they determine. However, the Commonwealth does take a particular interest in nurse education (Tom Karmel address, pp. 53, 55), and

• There is an international shortage (or impending shortage) of nurses, which is being attributed to the: increasing need for nurses.

The age of today’s nursing workforce; increasing age of nursing students when they graduate; perception of nursing as a female occupation and thus not attractive to men (Kirsten Stallknecht address, p. 43).

The report does not make explicit in its executive summary or its recommendations important implications for nurse education in universities that are considered elsewhere in the report. For example, in the executive summary, two of the four key challenges identified are ‘a worldwide shortage of nurses’, and ‘difficulties in the recruitment and retention of nurses’. It is commented that ‘this raises issues about the status and working conditions of nurses, as well as broader societal issues, such as the increased range of career options for young people, especially women’ (p. v). There is no reference here to the numbers of graduates of initial nurse education programmes, and the financial and other issues involved. Yet the supply of graduates (not just from Australian universities) could be considered a key factor in responding to a worldwide shortage, and in responding to recruitment difficulties in Australia. Similarly, in the recommendations, student places are only mentioned in reference to specialties. However, these quantitative matters are central to the agenda of the recommended Australian Nursing Workforce Advisory Committee. Implications for the nature of courses are also not drawn out. The ‘vision for nursing in the future’ includes an:

increasing emphasis on integrated care, chronic disease management, and disease prevention and on encouraging and supporting health lifestyles’; ‘professional boundaries being redefined’; ‘new technologies . . . will change the way health care is delivered’; ‘nurses will need to be more flexible’; ‘nurses will work collaboratively with other professions and with the community in a consumer-focussed and culturally sensitive way … (pp. 1-2).

While it is noted that ‘nurses’ education and training and skill mixes will change’ (p. 1), there is no reference to the nature of nurse initial and post-initial education under the heading ‘realising the vision’ (p. 3).

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3.2 State and territory strategic reports

The following are reviews and commentaries on the major State and Territory strategic reports.

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3.2.1 Victorian nurse recruitment and retention committee: final report

Prepared for the Victorian Minister of Health by the Nurse Recruitment and Retention Committee (Margaret Bennett, Chair). Victorian Government Department of Human Services, Melbourne, May 2001 (210 pp.) http://nursing.health.vic.gov.au/recruit.pdf

The Nurse Recruitment and Retention Committee was established by the Victorian Government in February 2000 ‘to address the current shortage of nurses in Victoria’ (p. 1). The terms of reference, in summary were:

• To review local, national and international experience and measures to address nurse recruitment and retention; and

• To consider a range of strategies for improving recruitment and retention of nurses, including the areas of undergraduate recruitment, undergraduate educational programmes and clinical practice opportunities, access to continuing education, access to refresher courses, particular needs of rural and regional Victoria, workplace reform, and work role reform opportunities (p. 113).

The main report is in two sections:

• The scope of the problem – covering nurse shortages (international, national and in Victoria, data sets and indicators), problems in nursing (workload, unsafe working environment, equipment availability, career structure, support for nurses, education costs and access, family issues, specific issues for rural nurses, specialty issues, management); and

• Strategies – covering attracting nurses into the workforce (image of nursing, undergraduate recruitment, attracting nurses back in to nursing, injured nurses), education of nurses (undergraduate education, postgraduate education, graduate nurse programmes, continuing education, study leave, the ‘training and development grant’), retaining nurses in the workforce (the workplace, working conditions, specialty issues).

In addition to the main report, there are appendices that include substantial reports on quantitative and qualitative findings from a survey of registered, non-working nurses, and reports of open consultation forums and focus group consultations.

The Committee considered many substantive issues concerning the effectiveness and professional satisfaction of nurses which have implications for the quality of patient care as well as the recruitment and retention of nurses.

The Victorian Government’s response to the report was released in June 2001, and is at http://nursing.health.vic.gov.au/govresp.pdf.

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3.2.2 Northern Territory taskforce for the recruitment and retention of nursing staff: final report

M. J. Bowden (Chair), Territory Health Service, Northern. Territory Government, February 2001 (71 pp.)

The Territory Health Services Taskforce for the Recruitment and Retention of Nurses was commissioned in October 2000. It was to: ‘develop urgently Territory-wide strategies for the support, recruitment, retention and deployment of nursing staff that would ensure the continued safe and effective delivery of the range of services provide by or through Territory Health Services’ (p. 6). Noteworthy features of the Northern Territory nursing workforce reported include:

• 1 340 full time equivalent nurses are required to match current (2001) workload and work practice arrangements;

• a high rate of 57 per cent in annual turnover of nurses, with a 127 per cent turnover in Central Australia (predominantly Alice Springs Hospital) (p. 20); and

• 49 per cent of nurses were over 40, and only 17 per cent under 30.

Data problems made the work of the Taskforce more difficult, especially the lack of consistency in data collection, the lack of data systems, and the lack of data in usable form (p. 6). The first eight recommendations of the Taskforce deal with improvements in data systems (pp. 10–11).

Recommendations are made for strengthening partnerships with universities to allow Central Australian students to undertake most of their pre-registration nursing education near their home location (through Alice Springs Hospital), as well as supporting clinical placements locally.

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3.2.3 Queensland ministerial taskforce: nursing recruitment and retention. final report

Queensland Health, September 1999 (121 pp.) www.health.qld.gov.au/publications/hau/qh_nrr.pdf (Accessed 11 July 2001).

The Ministerial Taskforce, Nursing Recruitment and Retention was commissioned in August 1998. Its terms of reference were to:

• Undertake a comprehensive review of the pre and post registration education, training and staff development needs of nurses to better match workforce planning needs;.

• Develop guidelines for the management of nursing resources and workloads; and

• Promote the introduction of family friendly rostering and management practices.

Expert working groups were formed to consider five topic areas:

• Corporate Approach to Nursing —including nursing resource management, professional training and development provision, performance management state wide, and the differences for implementing initiatives for nursing in metropolitan, provincial, rural and remote areas;

• Best Practice Model for Recruitment — marketing, advertising and selection processes;

• Undergraduate/Graduate Transition Support— undergraduate nursing education and support for the graduate year (transition support);

• Supply Strategies —current and future number of nurses and qualifications needed to meet workforce needs; and

• Flexible Work Environment — models of nursing service delivery, skill mix, patient dependency, workloads, rostering practices, family friendly and flexible work practices, rewards and opportunities, and career structure.

Data were collected through a range of methods, and validated through triangulation methodologies. Rigour was sought to best ensure credibility, fittingness and auditability (p.17), though limitations of data and method were recognised (p.18).

The Taskforce report includes 59 recommendations (pp.7–11), more than a third of which have some bearing on nurse education in universities. Major issues covered by those recommendations include:

• Promotion of and support for student participation in pre-registration nurse education, including work experience in nursing and marketing to secondary school students (R. 1); scholarship system to support employment of nurses in rural and remote areas (R. 2); implement a Nursing Career Advisory Service to, among other things, promote nursing as a career and advise undergraduates, new graduates and postgraduate nurses (R. 3);

• Nursing student intake numbers, with recommendations to maintain the current level of 1 200 pre-registration intakes for the next five years to ensure 800-900 nursing graduates are available each year (R. 4), and to develop a standing committee representing Queensland Health and the tertiary sector to match post-graduate courses to industry needs (R. 8); to systematically evaluate nursing workforce requirements for cardiac, aged care, rural and community nursing as a priority, using Queensland Health’s ‘Nursing workforce - a framework for evaluating the balance between supply and demand’ (R 26); and for the Health Advisory Unit (Nursing) adopt a role in assessing the analysis of workforce planning data on an annual basis for the formulation of strategic advice and direction (R. 27);

• Clinical educational experience, with a recommendation that Queensland Health reiterate its commitment as a provider and allocate resources appropriately (R. 5);

• Partnerships between the health and higher education sector, with a recommendation that a representative standing committee to address on-going issues be established and resourced by Queensland Health (R. 6);

• Pathways for pre-registration and postgraduate programmes, including Enrolled Nurse (and Assistants in Nursing) to Registered Nurse transition (R. 11-14);

• Establishment of Clinical Professor of Nursing positions (R. 16); and

• Induction of graduates into the nursing profession, with recommendations that recruitment processes meet graduates’ needs (R. 17), and that transition support funding be reviewed (R. 19) and be adequate (R. 20).

This recruitment and retention study gave considerable attention to quantitative issues of nurse supply and demand, making explicit the implications for enrolments in pre-registration and post-graduate nurse education programmes. Queensland Health’s Nursing workforce - a framework for evaluating the balance between supply and demand is supported as having been ‘successfully applied to the midwifery workforce’ (that study is reviewed separately in this report), and it is noted that ‘other workforce analyses methodologies had been unsuccessfully applied to nursing in Queensland Health’ (p. 38).

The document includes some rich qualitative data from workshops, focus groups, submissions and the expert working groups, covering matters such as: clinical placement of undergraduate nursing students; graduate transition processes (including the role of preceptors); nurses’ working conditions and practices; and career structures.

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3.2.4 NSW nursing recruitment and retention taskforce report

[recommendations on the web at: www.health.nsw.gov.au/nursing/rrrecs.]

Two of the eighteen recommendations of this report directly concern nurse education. They are:

• Recommendation 9. That local health services and universities be encouraged to strengthen partnerships with each other in relation to undergraduate and post-graduate course development, clinical practicum and research infrastructure to ensure workforce needs at local level are accommodated within university planning frameworks (page 7: section 3.4); and

• Recommendation 18. That the NSW Health Department develop a range of strategies/incentives to increase nursing recruitment (including increased access to undergraduate education programmes) and retention in the rural sector (page 10: section 4.4).

Other issues covered by the recommendations included: workloads, flexible work practices, work environments, management and support practices, professional and management networking and sharing of best practice, and promotion and public relations.

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3.3 National projects on nursing specialisations

Reports reviewed in this section look at issues in nursing specialities including aged care, intensive care and mental health.

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3.3.1 Aged care nursing workforce issues project

A Commonwealth Department of Health and Aged Care funded project being undertaken by the School of Nursing at La Trobe University (principal consultant: Professor Alan Pearson). www.health.latrobe.edu.au/Health/Schools/NUR/projects/work/index (accessed 3 May 2001).

The project is investigating issues surrounding the recruitment and retention of nurses in the aged care sector (both residential and community settings) – specifically nurses who have left the workforce, nurses returning to aged care, and nurse refresher courses in the aged care sector. The project is in response to difficulties that the industry reports in recruiting and retaining suitably qualified staff for residential aged care facilities, and indications that a significant proportion of qualified nurses are not currently working in nursing.

The project involves literature reviews (see below); the examination of similar studies; submissions, especially from qualified nurses who are currently not working as nurses; a survey of a national, random sample of nurses who have not renewed their registration/enrolment; and meetings and forums with stakeholders. Findings and recommendations will be reported to the Commonwealth Department of Health and Aged Care.

The project will identify the current level of qualified nurses who have left the profession (across the disciplines), and reasons why they left; identify the factors that would encourage qualified nurses to return to aged care sector, and consider the implications of this. Strategies will be designed to facilitate the return of nurses.

Two literature reviews have been completed, and are available on the project website.

Nurse returners project. Critical literature review: models of refresher training for nurses re-entering the aged care centre (15 pp.)

The literature reviewed includes fields of nursing outside aged care, from countries other than Australia, and going back at least a decade — because of the scarcity of recent literature that specifically addresses refresher training for re–entering aged care nurses in Australia. Eighteen studies were reviewed. Only two were related to the aged care sector, and only three were based in Australia.

Types of participants, types of interventions, and outcome measures were reported on. Some general findings and conclusions were that:

• Programmes unanimously reported providing beneficial outcomes for both the participants and health institutions in providing a cost effective strategy to increase the pool of available competent nurses in a relatively short period of time (p. 12);

• Course flexibility, and staff encouragement and support are very important (p. 13); and

• Profound nursing shortages appeared a major driver of agencies’ (especially hospitals’) eagerness for refresher programmes (p.11), though the actual numbers of graduating nurses are modest (p.13).

The central finding is the lack of relevant, useful evaluations of nurse refresher programmes specifically designed to address the nursing shortfall in the Australian aged care sector (p.13). From this literature review there is little that is directly relevant to university-based nurse education, but there are implications for research.

Nurse Returners Project. Critical Literature Review: Attrition and Recruitment of Qualified Nurses in Aged Care (24 pp.)

The review examined the ‘best available information regarding the attrition of qualified nursing staff from aged care’ and ‘strategies which should be considered to facilitate their return’ (p. 3). It was thus not concerned with the initial recruitment of nurses into aged care (after graduation from initial or specialist nurse education programmes, or from other areas of nursing).

Again, there was little literature that was Australian or directly concerned with nurses in the aged care sector. Eleven recent Australian studies and projects relevant to nurse recruitment and retention are summarised, with particular emphasis on findings about, and implications for, aged care (pp. 16 – 21). These are reviewed separately in this report. With the exception of AIHW’s Nursing Workforce reports, State authorities have conducted these other studies and projects.

There is detailed consideration of theoretical and methodological literature, as well as empirical findings, on employee turnover from disciplines of management, psychology, sociology as well as nursing.

Some matters relevant to nurse education in universities include:

• One study argued that nurses who would be most suited to working in long-term care need to be sought out, and there should be collaboration with schools of nursing in identifying them (p. 6);

• One study ‘argued for levels of articulation between levels of nursing qualifications to provide clear pathways for career development and a reward system that recognises education, experience and productivity’; need for consensus in nursing competencies in long-term care, and using these competencies as the basis of models that recognise past experience for credit waivers, to encourage and facilitate career development’ (p. 9);

• Stress was the central factor in attrition, and ‘chronic and profound nursing shortages compounded the stress experienced by overworked nurses’ (p. 12); and

• A range of matters concerning the nature of professional work, professional relationships, models of aged care (‘wellness’ rather than ‘curative’, and being ‘person-centred) are discussed, and may have implications for curriculum and pedagogy in nurse education in universities, but such implications were not made explicit.

The literature concerned with recruitment was primarily focussed on refresher courses, and was dealt with in the companion literature review (see above). It was noted that there is ‘little high quality research reported in the literature currently retrieved on alternative effective recruitment strategies or on recruitment in general in the field of aged care’ (p. 14). Five papers specific to aged care are reviewed, and other matters are incorporated in the summaries of general Australian nurse workforce studies and projects referred to above.

Two of the papers directly looked at initial nurse education and the recruitment of recent graduates. Findings include:

• A successful process involving twenty aged care facilities and organisations in NSW to promote aged care in schools, and develop new graduate education programmes with tertiary recognition; the organisations also formed a consortium to coordinate recruitment and prepare the workplaces and workplace preceptors for the arrival of new graduates, with an emphasis on the support and encouragement of new graduates (p. 14);

• Students who were followed through their nursing course comment that theoretical education in gerontological nursing was inadequate, inappropriately placed in the course, and of low status (p. 15); and

• Factors likely to encourage students to work in residential aged care after graduation include: ‘a positive clinical experience; a positive experience with a preceptor; and meeting patients with many different conditions, thereby presenting opportunities to learn a lot and provide individualised care’ (p. 15).

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3.3.2 A consensus driven method to measure the required number of intensive care nurses in Australia

By G. F. Williams and T. Clarke (2001), Australian Critical Care, vol. 14 (3), pp. 106–115.

In this paper a methodology is developed and applied to determine the current annual requirement for newly qualified critical care nurses for intensive care units (ICUs). The methodology is comprehensive and transparent, and could be applied to other nursing specialisations.

The paper begins with noting the increase in the number of intensive care unit (ICU) beds, and the apparent shortage of nurses to staff them. The lack of fit between supply and demand of nurses to Australia’s ICUs could be due not only to issues regarding individual nurses and units, but a general lack of policy direction.

The method draws from published data (such as Australian Institute of Health and Welfare’s Nursing Labour Force and published research papers); accepted standards (such as Australian and New Zealand College of Anaesthetists – Faculty of Intensive Care, Minimum Standards for Intensive Care Units), and consensus views of a panel of sixteen critical care nursing expert leaders from around Australia (to consider issues such as nursing ratio standards, mixes of nurse roles and specialisations, usual number of years nurses work in intensive care, effects of leave). Using this base data and standards, the answers to seven key questions are explicitly calculated. The questions are:

1. What is the average number of full time equivalent (FTE) nurses required to staff an ICU bed?

2. How many FTE nurses are required to staff ICU beds across Australia?

3. How many qualified and unqualified ICU nurses (FTE )are required to staff Australia’s available and physical ICU. beds?

4. What is the required replacement factor of ICU nurses per year (ICU qualified and unqualified) to manage the attrition rate?

5. What are the costs of maintaining a steady flow of qualified critical care nurses to ensure a propensity for qualified critical care nurses remain at the bedside?

6. What are the minimum nursing costs of keeping one ICU bed operational for one year in Australia?

7. What is the estimated total nursing cost (indirect and direct) of maintaining available ICU services in Australia?

Each element in each of the seven calculations is set out.

Regarding nurse numbers (question 3), they conclude that:

• Australia does not have an Intensive Care bed shortage but an Intensive Care nurse shortage and that there is a strong correlation between the number of ICU nurses available and the number of ICU beds available at any given time (p. 118).

Regarding newly qualified critical care nurses, they conclude that:

• It is important to note that Australia requires 1 000 newly qualified critical care nurses for ICUs each year. Australia’s universities produce approximately 500 per year, therefore suggesting further difficulty maintaining and supporting any growth in ICU bed demand and service in the foreseeable future.

Comment and suggestions are made about data quality (such as the need for a uniform definition of a ‘qualified’ critical care nurse, and the time-lag in availability of AIHW data).

As the methodology is comprehensively and transparently set out in the paper, it is now available for application for other professions, and for recalculation for intensive care nurses as new data (or standards) become available.

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3.3.3 Articles arising from a scoping study of the Australian mental health nursing workforce 1999

By M. Clinton and M. Hazelton (2000)

‘Scoping mental health nursing education’, Australian and New Zealand Journal of Mental Health Nursing, Vol. 9, No. 1, pp. 2–10.

‘Scoping the Australian mental health workforce’, Australian and New Zealand Journal of Mental Health Nursing, Vol. 9, No. 2,, pp. 56–64.

‘Scoping practice issues in the A mental health workforce’, Australian and New Zealand Journal of Mental Health Nursing, Vol. 9, No. 3, pp. 100–109.

‘Scoping the prospects of Australian mental health nursing’, Australian and New Zealand Journal of Mental Health Nursing, Vol. 9, No. 4, pp. 159–165.

This comprehensive and detailed set of articles draws on extensive consultations around Australia, submissions from stakeholders, and surveys of international literature and experience. The work is oriented to consumer outcomes, and evidence-based policy and decision-making. It draws from the first national scoping study of the mental health workforce in Australia, prepared for the Commonwealth Department of Health and Aged Care, and focuses on the problems of recruiting and retaining mental health nurses and the current challenges facing mental health nursing education.

Findings of direct relevance to nurse education in universities include:

• There is clear evidence that due to funding cuts, rationalisation of educational profiles and the inability to attract teachers of mental health nursing to academic positions, Australian universities, despite their achievements in developing nurse education and related research, are less than completely successful in preparing undergraduate students for their role as beginning practitioners of mental health nursing;

• The take up rate of postgraduate places in mental health nursing courses is inadequate to meet the future needs of specialist mental health services;

• Postgraduate education in mental health nursing is in need of rationalisation and reform; and

• Attempts to involve universities and health authorities in delivering courses in mental health nursing have not been entirely successful.

Other findings include: the increasingly stressful and difficult nature of mental health nursing practice, especially as a consequence of changes in mental health practice; the need for mental health services to move away from paternalistic models of delivery; the need to develop, recognise and support advanced nursing practitioners; and the inadequacy of planning and development of the mental health nursing workforce.

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3.4 Survey based projects

Reports reviewed in this section utilise survey methods as part of the data collection strategies.

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3.4.1 New South Wales workforce research project report

Nursing and Health Services Consortium 2000, New South Wales Health Department, Sydney.

This 73 page report was prepared for the NSW Health Department by the Nursing and Health Services Research Consortium (incorporating the Sydney Metropolitan Teaching Hospitals Nursing Consortium and the NSW College of Nursing), and published in September 2000.

The project method involved a survey in May 2000 of the more than 30 000 NSW registered and enrolled nurses who had indicated they were not working as nurses in an earlier (1998) survey or whose employment details were unknown, and for whom complete address details were available. One third responded. Telephone interviews were conducted with 98 respondents.

The report includes a thoughtful discussion of broader theoretical issues that should be taken into account. It is noted that, ‘the construction of nursing as a traditionally ‘feminine’ occupation implies that any shifts in the prevailing attitudes to women and work will have significant consequences on nursing as a profession’ (p. 11). It is concluded that ‘the development of strategies to redress the declining interest in nursing as a profession requires an approach that not only addresses specific workplace conditions (salary, hours) but also places these conditions in the context of current attitudes of Australians to careers and lifestyle’ (p. 12).

Results are provided in detail in the body of the report and appendices. ‘In line with the demographic profile of the respondents, nurses identified family responsibilities and lifestyle issues around shiftwork as the main reasons for leaving nursing’, and flexibility and choice around working hours were important incentives to return to the nursing workforce in NSW (p. 9).

There are some implications for nurse education in universities.

Respondents were asked about the incentives to return to work as nurses. After items related to ‘suitable working hours’ (67 per cent of responses to the item) and ‘better pay’ (30 per cent), ‘support in education’ was the most commonly cited (26 per cent). Specific examples cited in the report are: ‘paid to attend refresher course; flexibility in refresher course such as part-time and more offered in rural areas; staggered shifts to ease return to work or mentor system; time for ward in-service’ (p. 32). Many respondents expressed uncertainty and apprehension about how to return to nursing, and were unaware of services and support available (p. 37).

It appears that no respondents cited generally poor initial nurse education as a reason for leaving nursing or being dissatisfied with nursing, though there were no particular options that prompted such responses. However, there was a comment that ‘university training needs larger practical component’ (p. 37). There was concern expressed about deployment in situations in which they were not experienced (such as an intensive care nurse sent to a medical ward).

The lack of incentives for further education, and the costs to nurses of further education were commented on (p. 36).

There is an indication of the tightness of the nursing labour market in that for the ‘main reason for currently not nursing in NSW’, only 1.6 per cent cited ‘no jobs in preferred area of nursing’, and 1.3 per cent cited ‘no nursing jobs near where I live’ (p. 57). These were cited among the average of three to four ‘other reasons’ for not currently nursing in NSW by 7.0 and 1.5 per cent respectively.

There are several problems with this study in terms of its usefulness in informing nurse education policy and practice. First, it covers both enrolled nurses and registered nurses (and midwives), with enrolled nurses 17 per cent of respondents. Most of the reporting of substantive findings does not differentiate between enrolled and registered nurses/midwives.

Second, like other studies that use registration board databases as sources for study populations, the usefulness of this report is limited by this fact. It is especially limited by the failure to discuss the implications of using such a group of respondents. It does not include those with nursing qualifications who are no longer registered. There is little data on those who have qualified as registered nurses, but are not currently registered. However, a 1989 Australian Bureau of Statistics (ABS), labour force supplementary survey collected data on persons who had ever qualified as registered nurses (March to July 1989 Career Paths of Qualified Nurses Australia, ABS Cat. No. 6277.0). This survey found that 19 per cent of those who had ever qualified were not currently registered, and that the rate increased with age. AIHW data indicates that about 87 percent of currently registered nurses are employed in nursing, and that more than 90 per cent are in the nursing workforce (that is, working as nurses, on extended leave, or looking for work in nursing). (Though the original sample selection for this study appeared to indicate that around one third of registered and enrolled nurses in NSW in 1998 were not working as nurses, in response to the 2000 questionnaire 41 per cent reported that they had in fact worked as nurses during 1998, which leads to a figure very close to the AIHW figure for NSW). Thus, of those who are qualified to be registered nurses, it appears that roughly twice as many are not currently registered as are registered. More pertinent to the study being considered here (with all respondents currently registered), the question to ask those who have left nursing is why they have maintained registered status. It is not surprising that those who have taken time out for family responsibilities, and plan to return (even if for only occasional casual relief employment), maintain registration. Similarly, maintaining registration is no surprise for those who have taken up administrative, policy or academic positions associated with nursing. Others may maintain registration as protection in an unexpected event such as being called upon to assist an injured person.

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3.4.2 Attracting nurses back in to the nursing workforce

Prepared by BIZTRAC, Faculty of Business and Public Management, Edith Cowan University for the Health Department of Western Australia, (Health Workforce Reform Division) September 1997 (35 pp.).

A questionnaire designed by the Workforce Planning and Development Section of the Health Workforce Reform Division was mailed to a sample of nurses who applied for re-registration for 1997. Just under half (553) responded.

The questionnaire included items on respondents’ age; last nursing position; level, area of work; geographic location; year left that position; reasons for leaving (eighteen options, including ‘other’ provided, with space for comments); whether respondents would consider returning to nursing; when, what would attract them back and what is their preferred area of nursing practice.

The report provides tabulations of responses to individual items. However, with no cross-tabulations or other analysis, and a lack of relevant data from other sources, interpretation is difficult in important areas.

Not surprisingly, as more than half of these registered nurses not currently working as nurses are aged in their thirties, and 98 per cent of them female, more than half of them cited ‘family responsibilities’ as a reason for leaving nursing. For many of them, lack of family friendly conditions (childcare, appropriate shifts) were a reason for leaving nursing, and what would attract them back into nursing are parallel. However, as three quarters of the respondents were considering returning in one to five years, it is unclear how decisive the matters listed in response to ‘what would attract you back into nursing’ would be.

Other elements, in addition to a more family-friendly workplace, the report indicates may lessen separation and enhance re-entry include: improved pay, better career opportunities, better job design (for example, less paperwork, more support staff), and support and professional recognition.

There are some conclusions that can be drawn that are relevant to this project. After ‘family responsibilities’, the most commonly cited reason for leaving the nursing workforce, listed by almost one third of the respondents, was ‘increased demands and workload due to nursing staff shortages’. The report notes that ‘most respondents made the comment that staff shortages not only increased their workload but also affected patient care and their psychological well-being’ (p. 16). This points to a ‘vicious cycle’ of shortage, when shortage leads to poor working conditions, leading to increased separations (including, most probably, increased absenteeism of those employed), exacerbating the shortages, and so on. The report does not explicitly draw any conclusions about the need to increase the supply of nurse education graduates in response to the staff shortages, though this could be a reasonable conclusion. However, it would need to be known whether the problem was inadequate general supply, or a lack of recruitment because of agencies’ financial constraints, or some other reason.

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3.4.3 Junior registered nurses labour force survey

Prepared by BIZTRAC, Faculty of Business and Public Management, Edith Cowan University for the Health Department of Western Australia, November 1998 (39 pp.).

This project has similarities to the earlier work of the same authors reviewed above. However, the respondents were quite different, and the structure of items in the questionnaire makes comparisons difficult except at a high level of generality.

In mid 1998 Western Australian junior registered nurses in the first two years after graduation were surveyed by mail to investigate factors contributing to retention and attrition. A 43 per cent response rate was achieved (360 respondents).

The questionnaire was developed in consultation with the Western Australia Health Department and the Nurses Board. Items covered: basic demographic data; initial nursing education (which university attended); additional tertiary study (whether related to nursing); current employment (whether nursing, hours of work, workplace type and location, and area of nursing with eleven options); a very diverse range of fifty opinion and preference items covering attitudes to nursing, likes and preferences about the nature of their work and conditions, career and personal aspirations and expectations (on an eight point scale of agreement); how long respondents expect to remain in nursing; matters that would influence whether they choose to leave or stay in nursing (family commitments, pay, work environment, staff shortages, career opportunities, and so on); factors that would encourage respondents to stay in nursing (specific cases of the preceding matters); and, for those currently not working as nurses, matters that influenced their decision to leave, and factors that would attract them back (these two items paralleling the previous two).

Some of the major findings included (as ordered in the report):

• Respondents ‘appear to view nursing as a short-term career’, only 57 per cent reported that they felt it likely that they would be in nursing in five years, and only 31 per cent in ten years (pp.1 and 15). However there was no comment in the report on the likelihood that their current perception would match the reality of retention (and re-entry). The net separation rates entailed by the junior nurses’ responses are an annual average of 8.6 per cent in the first five years, and 9.1 per cent in the following five years. Both rates, especially the latter, are very high relative to the underlying rates indicated by ABS Census data discussed in the text of this report. Thus this finding could be taken as some indication of levels of lack of long term career commitment to nursing (though not necessarily any lack of commitment to current work), but treated with great caution as a possible indicator of likely future quantitative separation rates;

• Remuneration was a significant issue, with three pay-related items eliciting the strongest agreement of the fifty attitudinal items, and rating first or second on the items that would encourage nurses to stay or influence decisions to leave. However, as the survey was carried out after a period of industrial disputation over nurses’ pay the issue may not have been as prominent at another time, (pp. 1, 12, and 15-17);

• The work environment was a major concern (p. 1). Staff shortages were a significant, explicit item as a factor that would (or did) influence a decision to leave nursing (pp. 15 and 17). ‘Increased staff levels to reduce workload’ was second (after increased pay) as a factor that would encourage nurses to stay (p. 16), and third (after increased pay and reduced stress) as a factor that would attract nurses who had left back to the workforce (p. 18). The prominence of staff shortages (and probably related matters such as ‘stress’) as a factor in retention and re-entry points to vicious circle, where emerging shortages are exacerbated by the effects of existing shortages; and

• Family issues did not rate very highly though there were many relevant items in the questionnaire — probably because nearly three quarters of the respondents did not have dependents. However, there was quite strong agreement with the statements that ‘I would like to continue working after I start a family’, and ‘I would leave nursing if may work hours interfered with my family life’. The authors of the report commented that ‘it is encouraging that nurses have indicated that they would like to continue nursing after starting a family but the down side is this is dependent on suitability of hours offered to them’ (p. 2).

There were a number of items that touched on matters related to pre-registration and continuing nurse education. However, it is difficult to interpret them in ways that can inform decisions about the nature of nurse education in universities.

Regarding pre-registration nurse education, there was strong agreement with the statement, ‘The "real world" (of nursing) is nothing like I expected when I was at uni’, and strong disagreement with the statement ‘I think university prepared me well for nursing’ (pp. 12 and 13). However, there were not items that indicated whether the professional skills and understandings developed at university were adequate or appropriate, or exactly what it was that university did not prepare them for. The emphasis given by respondents to issues of pay, stress, staff shortages, effects of health system restructuring, lack of support from management, and perceived lack of promotion opportunities, may indicate that some of these are the matters for which they were not prepared (that were different from their expectations). How, and how much, universities (or induction programmes for beginning nurses) should deal with such matters are not easy issues to resolve.

Regarding continuing professional education, a quarter of the respondents had undertaken or were undertaking additional tertiary study, two thirds of those indicated that their study was in nursing. There was strong agreement with the statement ‘Additional training in some areas would be of assistance’ (p.12), and ‘more training opportunities’ rated quite high as a factor that would encourage nurses to stay (p.16) and return to nursing if they have already left (p.18) —ahead of rostering and other work organisation matters, but behind pay and reduced stress and workload. However, there is no indication whether this refers to short, on–the–job training, or more substantial or specialist study at university.

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4. Labour force projections reviews

Labour force studies are generally State based projects because most nurse employment is State based. The following represents a review and commentary of reports undertaken in States and Territories and lists other reports not reviewed.

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4.1 Victoria

4.1.1 Nurse labourforce: requirements and supply projections Victoria 1993-2003

Prepared by R. van Konkelenberg for the Victorian Department of Human Services, September 1993 (20 pp.).

This report provides an update of a similar 1991 report, and covers the period 1992–2003. Its publication date precedes the general period for studies reviewed in this report, but it is listed here because it was evaluated in 1998 (see following), and the methodology used is the basis of other reports in Victoria and Tasmania.

The report was prepared at the time of severe adverse economic conditions, sharp reductions in government funding, and restructuring of the health industry and of higher education in Victoria. This affected assumptions used in developing the projections, and actual outcomes. Some relevant matters are discussed in the following review, where this report is referred to as the 1993 Report.

The only explicit recommendation was for a reduction in intakes to at least less than 2000 (from the reported 1993 intake of 2 326 —a reduction of 14 per cent), and a suggestion that the intake ‘can be as low as 1 400 to 1 700’ (a reduction of 30 to 40 per cent p. 9). Actual intakes through the second half of the 1990s averaged around 1 880, according to DETYA Selected Higher Education Statistics.

The report discussed the balance between RNs and State Enrolled Nurses (SENs), and developed scenarios based on differing ratios.

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4.1.2 Evaluation of Nurse Labour Force Planning: Final Report

Prepared for the Victorian Department of Human Services (Public Health and Development Division) by Health Outcomes International Pty Ltd, November 1998 (50 pp.)

The Victoria Department of Human Services commissioned Health Outcomes International Pty Ltd (South Australia) to evaluate 1991 and 1993 nurse labour force studies (see above). The studies had been carried out under the auspices of the Victorian Department of Human Services, using a ‘re-engineered version’ of a package developed by Ron van Konkelenberg of South Australia. Dr Konkelenberg was undertaking a third study for the Department (see following) as this evaluation was being carried out.

The terms of reference required the evaluation to determine the extent to which the studies provided an accurate prediction of nurse labour force needs in Victoria, and to evaluate the extent to which the underlying assumptions for the studies were valid (p. 1). The evaluation process involved extensive consultations with stakeholders as well as analysis of the studies’ methodologies and conclusions in relation to international literature and subsequently available data. The impact of the ‘predictions’ on the different organisations, and the uses made of them by stakeholders, were also investigated.

Major findings and conclusions include:

• It was recommended that such studies cover only about three to five years, rather than ten (p. 3);

• Matters such as the introduction of casemix-based funding and the stringent funding cuts had a major impact on actual outcomes, but could not have been foreseen or accurately modelled (p. 4);

• Different issues affecting rural nurses compared with urban nurses should be taken into account within the model.

Whilst the trend within the metropolitan networks of Victoria is for nursing staff to specialise, the rural sector demands the opposite of its nursing staff . . . the emphasis is for nursing staff to have general skills in a range of areas including accident and emergency services, midwifery, general nursing, aged care services, theatre skills and high dependency nursing skills. (p. 4);

• There is a lack of understanding of the nature of and responsibilities for the AIHW Nurse Labourforce database, which was a major data source for the projects. It was suggested that better communication and consultation processes occur;

• The majority of those interviewed in the evaluation process indicated that they had a limited understanding of the methodology and other aspects of the models. It was suggested that ‘future studies can do much to ensure relevant skills and knowledge transfer takes place, and that the modelling process is transparent’ (p. 6);

• The evaluation team made no technical criticism of the model, finding that ‘the assumptions underpinning the 1991, 1993 and current nurse labour force planning studies are reflected in the international literature’ (p. 8);

• The model used in 1993 is outlined. However:

The detailed mathematics upon which the model has been developed was not disclosed to the evaluation team as it represents commercial in-confidence material. Nevertheless, the principles upon which the model has been formulated appear consistent with other supply and demand models used in manufacturing and other industries, as well as those documented and used by other bodies in projecting health labour force requirements identified by the evaluation team through the literature search (p. 19–20);

• As one of the terms of reference for the evaluations team’s work was, ‘Gauging acceptance of the existing tool/model . . .’, it is not surprising that:

The apparent lack of transparency in terms of the mechanics of the model was a concern in terms of the key stakeholders’ understanding of the existing tool/model (p. 20).

The evaluation team accepted the commercial in-confidence restriction, but went on to recommend a structured training course in the application and utility of the model for staff of the organisations utilising the outcomes of the model (p. 20). However, if significant elements of the model remain inaccessible to critical evaluation on technical grounds or on substantive grounds, the process will not gain from potential expert and informed input, and users must remain sceptical of conclusions if those conclusions arise out of a ‘black box’, the workings of which have not been independently examined.

Of those elements of the model that are described in the evaluation report there are several that appear open to critique (or, perhaps, further explanation or investigation).

One very significant element is net separation (‘net loss’ or ‘net attrition’) rates. Separation rates are one of the most significant aspects of any supply/demand projections. A basic assumption of the studies was that ‘the nursing profession is a predominantly female workforce which has specific workforce participation patterns such as casualisation rates, part-time employment, attrition rates, etc’ (p. 21). Yet there appears to be no recognition that these patterns vary significantly according to age. For example, for the 1993 ‘baseline scenario’, ‘the net loss of RN labour force of 5.49 per cent was revised to a net loss of 2 per cent based on expected improvements in the economy’ (p. 24). This is an accurate report of the original assumptions (see 1993 Report, p. 3), yet generally an improvement in the economy leads to an increase in net separation rates in occupations such as nursing because alternative employment opportunities become available for both those currently working as nurses and for potential re-entrants to nursing. There is no explanation or discussion of this anomaly in the evaluation report or the original 1993 Report (where the 2 per cent rate net separation rate is maintained through the period to 2002 – see p. 14). From a methodological point of view, it is not appropriate to assume that the state of the general economy is the only significant factor in changes in net separation rates for a predominantly female occupation with a very peaked (not flat) age profile, especially for projections over a ten year period. Developments in the age profile are generally the major factor over the long term, while changes in the economy (including increased or decreased funding for nursing, perhaps leading respectively to increased attractiveness of nursing work, or to redundancies) are probably more likely to account for short term fluctuations in net separation rates. At key times the age profile may be the major factor in very short term changes in net separation rates, such as when a sharp peak in the age profile just enters the common retirement age. The age profile would indicate a low net separation rate early in the period (but still above 2 per cent), increasing later in the period as the age peak moves out of the low net separations late thirties to early forties age range. The difference in demand for new recruits resulting from different assumptions about net separation rates can be seen from applying the rates to the headcount of just over 33 000 RNs used in the projections. A net separation rate of 2 per cent is 660, 3 per cent is 990, and 5.49 per cent (the rate estimated to be prevailing in 1993) is 1 811.

A second element in the 1993 Report model that needs critical consideration is the prop