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Australian Aged Care Nursing:
A Critical Review of Education, Training, Recruitment and Retention in Residential and Community Settings

3. Attrition and Recruitment of Qualified Nurses in Aged Care

3.1 - Introduction
3.2 - Protocol for the Review
3.3 - Key Findings of the Review

Attrition and Recruitment of Qualified Nurses in Aged Care

3.1 Introduction

Developing a clearer understanding of the factors that contribute to nursing attrition and identification of the changes that would encourage qualified staff to return to, or enter into the aged care workforce is vital to meet future health care demands. Several studies have been identified that examine the key reasons for aged care nursing shortages. In addition, a number of health professionals have published articles addressing what they believe are key issues and strategies to address the current shortage of aged care nurses. This review examines the best available evidence relating to the attrition and recruitment of qualified nursing staff from nursing in aged care and factors that would facilitate their return.

3.2 Protocol for the Review

3.2.1 Review Question

The purpose of this review is to present the best available information regarding the attrition of qualified nursing staff from aged care and the strategies that are considered to facilitate their return.

3.2.2 Inclusion Criteria

Types of participants

This review considered studies that included nursing staff from services where older persons are consumers of care and particularly in residential aged care. Residential aged care settings include high dependency and low dependency homes and hostels.

Types of intervention

The interventions of interest to this review were strategies and models of recruitment and retention, which have been applied in aged care settings. Any instruments used to validate and investigate these strategies/models were also of interest.

Types of outcome measures

The outcome measures included those variables that provide an indication of attrition rates and their causes, and efficacy of models of recruitment and retention. These included resident health indicators; staff satisfaction and indicators of dissatisfaction such as sick leave and staff turnover; economic indicators; staffing indicators and attitudinal data.

Types of studies

All studies of issues surrounding attrition from aged care nursing and the various models of recruitment and retention, where appropriate methods were used, were considered as part of the review.

3.2.3 Search Strategy

The search strategy was designed to access both published and unpublished materials and comprised three stages:

A limited search of CINAHL and Medline to identify relevant keywords contained in the title, abstract and subject descriptors.
Terms identified in this way, and the synonyms used by respective databases, were used in an extensive search of the literature.
Reference lists and bibliographies of the articles collected from those identified in stage two above were searched.

Articles published in the last 5 years in English and indexed in the following databases were searched:

CINAHL
Medline
Australasian Medical Index
Australian Public Affairs Information Service - Health Database,
Health & Society Database
Psychinfo
Sociological Abstracts

The initial CINAHL search terms were "gerontologic nursing", "personnel recruitment", "personnel retention", "educational status", "employment status" and "job re-entry". Equivalent terms as defined by the respective thesauruses of other databases were used.

Full copies of articles identified by the search, and considered to meet the inclusion criteria based on their title, abstract and subject descriptors, were obtained for data synthesis. Articles identified through reference list and bibliographic searches were also considered for data collection based on their title.

3.2.4 Critical Appraisal

Assessment of the appropriateness and quality of the study methods employed was undertaken. Studies were considered for inclusion in a narrative summary to enable the identification of current approaches and possible strategies.

3.2.5 Data Collection

Relevant data was extracted from each of the studies reviewed.

3.2.6 Data Synthesis

The findings were summarised by narrative. Data generated from observational and descriptive studies was summarised by narrative, listing significant factors or themes.

3.3 Key Findings of the Review

The most significant aged care workforce issue faced in Australia is the retention and recruitment of qualified nurses into the workplace. The nature of work in the aged care sector, coupled with the low status and rapid rate of structural change means that the aged care workplace is characterised by low morale and high rates of turnover and absenteeism (Stein, Heinrich, Payne & Hannen, 2000). A number of papers and studies addressing the factors associated with recruitment and retention of nurses in aged care, and the changes required to decrease current attrition rates and make the aged care sector a more attractive option for qualified nurses are presented below.

3.3.1 Retention of nurses in aged care

Emphasising a model of wellness

A key issue in the retention and recruitment of nurses is the nature of aged care; generally perceived as a field whereby there is little opportunity to 'cure' patients and see them recover from medical problems. New graduates often choose acute care because of the opportunities to provide short-term care that results in positive outcomes. This stands in contrast to long-term residential aged care homes whereby management rather than cure, and provision of palliative care is common.

In a discussion of issues surrounding the current shortage of nurses in aged care, Kuehn (1990) argued that the focus in long-term care should change from a medical focus of care to a 'wellness model'. The proposed wellness model was discussed as recognising professional nurses as the keystone to quality care. Organisational support for further training and decision making by nurses was highlighted in the model. The flaw in maintaining a medical model of illness was argued on the grounds that an inability to successfully implement a curative model devalued caring, creating an environment to optimise self-care and independence, and hence nursing input was overlooked and quality resident care suffered. The wellness model was promoted for its emphasis on dignity, maximising independence in daily living, promoting, maintaining and restoring health, and allowing the resident to maintain control of his or her life.

Kuehn (1990) also discussed other factors considered important in the long term nursing shortages, including the lack of collegiality found in acute medical-surgical settings due to the relative absence of physicians and other health care professionals, including other registered nurses on the same shifts. The lack of professional autonomy was also highlighted in the results of a survey of nursing home administrators asking, 'who should be consulted in decisions involving managerial and clinical issues?' The responses included 'administrators, owners, residents, families, physicians, ethics committees, courts and legislature'. However nurses were not listed amongst the responses.

Kuehn (1990) also claimed high proportions of unqualified staff lead to the high regulatory influence in long-term care, and created a burden of paperwork and stress not experienced in other settings. The minimal staffing limits perpetuated the understaffing dilemma as profit motives influenced levels of care available.

Preceptors for new nurses

The success of a program focussing on preceptor support for new nurses in the workforce provides encouraging support for similar programs to be undertaken around Australian aged care homes. Shemansky (1998) describes the overall effectiveness of the first long-term care preceptor program implemented in 1989. The responsibilities of the preceptor were based on the identified needs of new employees including:

orienting new staff members to their roles and responsibilities on the unit;
aiding in the socialisation of new staff members to the unit and facility;
helping new employees meet their learning needs and planning assignments with learning needs in mind;
providing ongoing feedback to new employees and the education department;
ensuring quality resident care;
acting as a clinical resource and role model; and
making educational opportunities available.

The masonic home of New Jersey's preceptor program has been very beneficial and cost effective. Over 9 years, nursing turnover has reduced from 53.4% to 17%, saving the home more than $150,000. Evaluations completed by employees verify that the program has aided socialization of the new staff to the facility and has increased job satisfaction for new employees by providing orientation continuity and a clinical resource person. By maintaining continuity, the authors claim they are ensuring quality resident care. In addition, preceptors' job satisfaction has also increased in this role.

Stress and coping

The provision of staff support and guidance for managing workplace stress are key issues in the retention of nurses in aged care. Walters, Bond and Pointer (1995) undertook an empirical evaluation of a stress management program using a single education session and ongoing relaxation exercises over a 12 week period, used with 24 aged care staff in an Adelaide nursing home. The research was undertaken in acknowledgement of the intrinsic stress associated with working in an aged care nursing home, and the need to provide coping skills to assist nursing home staff in dealing with stressors in their working environment. The findings indicated that the use of an education session and relaxation exercises twice daily over a 12 week period did not reduce perceived stress levels reported by participants, however it significantly reduced participants' blood pressure and reported symptoms of stress. These findings indicate the potential for use of stress management programs in nursing homes, as a means of reducing stress levels and associated difficulties in the workplace.

In support of these findings, Baillon, Scothern, & Vickery (1999) concluded that given current difficulties in recruitment and retention of qualified staff, routine audits of staff stress levels would be beneficial in identifying ways to minimise stress and improve coping, such as staff training and individual professional development plans.

Unqualified staff

The increasing stress and responsibilities experienced in association with working with and supervising an increasing number of unqualified nursing staff is an important issue in the retention of qualified nurses in the aged care setting. Results of the focus groups held with residential aged care nurses to examine their perception of nursing assistants indicated that nurses held positive opinions about nursing assistants and their work, whereby 'good' nursing assistants were reported to be indispensable to the provision of quality care (Garland & Schirm, 1998). However nurses indicated displeasure and stress associated with their role in supervising assistants. The authors discussed this in relation to the unpredictable performance of assistants, and nurses' subjective evaluations of assistants' performance that may make supervision difficult and sometimes ineffective. Nurses expressed difficulties with their job performance depending upon the cooperation from low status nursing home staff. As a result, this may cause uncertainty towards assistants and reluctance for nurses to supervise them.

Workplace conditions

Several studies and reports have addressed a number of workplace conditions that are contributing to the high rates of attrition in aged care. An opinion piece identified in the literature sets the scene for a myriad of problems within the residential aged care sector, and may indeed represent a large proportion of qualified nurses' view of the sector. In addressing the recruitment and retention of nurses in aged care, Courteney (2000) discusses his unwillingness to consider employment in a private nursing home, because of the working conditions encountered by both himself and his colleagues in various private nursing homes. These included continually changing verbal contracts rather than set employment contracts, promises for continuing study opportunities, pay and holiday conditions that are not met, lack of holiday pay, priorities for profit rather than quality care, lack of qualifications in proprietors, lack of staff, equipment and resources, and unfair dismissals. Courteney (2000) relates his experiences with acknowledgment that they are often extreme cases or examples, however indicates that many nurses decide not to work in private aged care because of these working conditions.

A study examining the factors associated with nurses' decisions to leave employment, Francis-Felsen et al., (1996) surveyed nurses in US nursing homes who intended to stay at the nursing home where they were employed (n = 147), and those who intended to leave (n = 45). Overall, 9 of the 20 factors that were examined were found to be significantly associated with nurses' intentions to leave. Seven of these were job-specific factors or dimensions of job satisfaction: perception of the supervisor's interest in the nurses' career aspirations, number of friends among staff, travel time to work, professional status, autonomy, interactions with other nurses, and pay levels. In contrast, personal characteristics of nurses, such as age, marital status, or previous experience were not found to be associated with decisions to leave. Limitations to the study include the small sample size of nurses intending to leave, and the differences between intention to leave and actual leaving. However the findings provide valuable exploratory information on the factors that may contribute to nursing shortages in aged care. The authors discuss the implications of these findings in terms of the control that nursing administrators may have over the factors found to significantly contribute to desire to leave, suggesting that there are opportunities for managers to make workplace changes that would improve the retention of nurses.

McDonald (2001) found from a survey of 435 Directors and Deputy Directors of Nursing, that 74% believed nursing work in aged care posed some occupational health and safety (OHS) risk to nurses. 62.5% reported increase in absenteeism due to workplace stress. 86.7% indicated that workload and stress had increased over last 12 months, and 87.1% had difficulty recruiting qualified nurses, especially registered nurses, and that nurses were resigning due to perceived lack of career prospects, heavy workloads and the poor professional image associated with aged care nursing. Around 60% of these senior nurses in management positions reported decreases in job satisfaction over last 12 months & of these 30% reported this decrease to be significant.

Issues that need attention by the Commonwealth Government:

The resident classification system (RCS)
Funding
Nursing in the Sector
Accreditation
Wage parity and working conditions
Segregation of funding for staffing and care hours
Staffing levels and skill mix
Concessional resident ratios

In an unpublished report to the Aged Care Workforce Committee (ACWC; 2000), a number of factors were identified that may improve the retention and recruitment of qualified nursing staff in aged care homes. Research by Aiken and Havens (cited in ACWC report) has identified several features of successful homes, termed 'Magnet' nursing homes, that provide high quality nursing care and have less difficulty in retaining and attracting staff. The research has indicated that magnet homes tend to prioritise the following: self scheduling; flexible workplace practices; control by nursing clinicians; mentoring programs to provider support; recruitment in local areas; and an emphasis on excellence and provision of quality care. These factors promote a professional context, whereby nurses are provided with support and greater control. This is proposed to build a sense of satisfaction and loyalty within institutions that minimises attrition and provides an attractive employment opportunity for new nurses. The Magnet Nursing Services Recognition Program was developed in America to recognise excellence and provision of quality long-term care within homes. Benefits to this form of recognition include enhanced community appreciation and support of homes and their nursing services and increased ability to recruit and retain staff into aged care.

Continuing education and training

A study by Robertson, Higgins, Rozmus and Robertson (1999) has indicated that nurses who participated in more continuing education indicated a higher level of job satisfaction. Nolan and Keady (1996) have contended that a planned program of staff development and education should be viewed as one of the hallmarks of a quality long term care environment and included in registration and inspection criteria. It is argued that effective training is beneficial for staff and older people in long term care, however there is a need for a careful balance between technical, behavioural, cognitive and affective elements, with training comprising part of a planned and coherent program.

Improving workplace satisfaction

It has been suggested that the negative image of working in long term care will not change until those working in this setting find pride in their place of work and satisfaction in the services they are providing (Nolan & Keady, 1996). Further, staff need to be able to ascribe meaning and value to their work in order to sustain their job satisfaction and morale.

A study by Fisher-Robertson and Cummings (1994) examined the factors that satisfy nurses in long-term care, and factors that contribute to retention in long term settings. The findings indicated that the most highly rated factors that satisfy nurses in long-term care included recognition from the patients, the challenge of the work, and the authority to exercise judgement for patient care. Other important factors included positive interactions with colleagues, autonomy and primary responsibility for care, and relationships with families. The most important factors contributing to retention included relationships with colleagues, available support staff, authority to exercise judgment in patient care, challenge of the work, adequate nurse to staff ratios, support for administration and adequate supplies and equipment. The authors concluded that creative strategies for the retention of nursing staff are needed to make long-term care a more attractive and satisfying practice setting.

3.3.2 Recruitment of Nurses in Aged Care

Low status of aged care

The low status and image of aged care nursing is a major contributor in the difficulties experienced in recruiting and retaining nurses. Burke (1998) discussed the difficulties associated with gerontology often being viewed as unchallenging, unrewarding, and a place where nurses lose their clinical and technical skills. The draw of more technologically oriented setting such as ICUs and coronary care and the lack of gerontological role models result in aged care remaining as one of the least preferred options for graduates. Burke (1998) has suggested that future implementations to enhance image of the field include joining forces with seniors organisations to advocate the rights of older people, educating the public, and lobbying for the inclusion of gerontological nurses on federal, provincial and municipal Government committees. Certification needs to be supported to enhance professional recognition. In addition it was argued that funding and support for gerontological nursing research must be increased to expand the knowledge base but demonstrate positive patient outcomes.

Gerontological nurses are pivotal to residential aged care: they manage facilities, assess care needs, plan and coordinate care, deliver care, supervise others who deliver care, and evaluate the effectiveness of care. However Pearson, FitzGerald and Walsh (2000) have argued that professional nursing has, to it's own detriment, probably contributed to its own increasing devaluing through:

its denial of the valuable role played by a wide range of people who carry out nursing acts;
its failure to value nursing knowledge and skills;
its failure to gain recognition for the knowledge and skills held by professional nurses; and,
its still somewhat ambivalent feelings about research and the development of nursing science.

A longitudinal study of nursing students from five NSW universities has indicated that students' intentions to work in aged care decreases as they progress through their pre-service programs (Stevens & Crouch, 1998). The students regarded areas that require a manipulation of technology (eg, surgical wards & intensive care) as the 'real' role of nursing. Discussed was the tendency for university curriculum and teaching staff to be predominantly focused on the technological nursing areas (whether due to staff background, expertise or preference), thereby establishing and maintaining a high-tech nursing culture.

In addressing strategies to improve retention and increase recruitment of nurses, Drugay (1991) discussed the importance of issues surrounding the recruitment of nursing students, the allocation of role-appropriate responsibilities for nurses, wage parity and improved staffing levels in long term care homes. Drugay indicated the importance of improving the image of nursing in general and in long term care, to attract students into professional nursing degrees. Drugay suggested that by fostering strong relationships with nursing schools and providing clinical training, long term nursing homes may impact on the number of students that later choose to enter the field.

Nay, Garratt and Koch (1999) identified a number of strategies to change the image and status of aged care:

Establishment of clinical chairs and professional units in gerontic nursing.
Appointment of senior staff who can model positive attitudes and practices.
Development of promotional videos.
A national Government funded workshop to identify contributory issues and offer suggestions for change.
A national conference conducted under the auspices of the RCNA to advance discussion and development of positive strategies.
Establishment of clinical development units in aged care environments.
A national Government strategy to promote positive ageing and similar state Government strategies.

The authors emphasised the importance of changing work practices to engage registered nurses in a positive attitude toward work in the field and develop a level of competence that meets specialist practice. Nay, Garratt and Koch (1999) indicated that young staff need a career pathway that rewards clinical skills and encourages specialization.

Roles and responsibilities

Drugay (1991) also identified the importance of adequate staffing levels and assignment of clear role-appropriate responsibilities for nursing staff, to retain current registered nurses in the US. The increasing pressures on Registered Nurses to fulfill multiple roles in the workplace, such as administrator, receptionist, housekeeper and security officer, are being encountered due to reduced funding. Registered Nurses are often the only skilled nurse on shifts at homes, and in some circumstances Licensed Practical Nurses are given the responsibilities of a Registered Nurse. Increased responsibilities and expectations are often resulting in burnout and increased attrition, due to a lack of recognition that staffing levels that were sufficient in the past are not adequate in enabling nurses to meet the current increasing needs of residents in long-term care homes.

Ageism

Gething (1999) argued that ageism (generalisations about age groups, including negative stereotypes of older individuals) is endemic in the health care sector, and that aged care is viewed as a low status option for those entering health professions such as nursing. Education is argued as a major source of negativity towards aged care, resulting in students regarding aged care as an unrewarding, unpleasant and undesirable field of work. Gething (1999) provides a framework for education that promotes aged care, without denying factors such as funding cutbacks and workplace conditions that impinge of the perceived desirability of the sector. Her recommendations for courses include:

Undergraduate:

Provide information that dispels the negative stereotypes of older people, and positive role modeling by academic staff.
Provide information on healthy ageing, to enable professionals to differentiate between healthy ageing and pathological conditions.
Inclusion of ageing issues in course curriculum, and offer specialised courses on ageing.
Provision of clinical experience, with contact with a range of older people (healthy and ill).

Continuing and post-graduate:

Provision of ongoing education for practicing professionals entering or currently working in aged care.

In contrast, a study investigating attitudes and stereotypes held by nurses who work with older people indicated that the lack of desire for nurses to work with older individuals was not due solely to negative attitudes towards ageing (Pursey & Luker, 1995). The high dependency levels of older people and the structure of aged care nursing work were found to result in fewer nurses viewing aged care as a positive career option. Contrasts and tensions between nurses' positive views of older people, and negative views of the structural context of aged care work were concluded to contribute to nurses' decision not to enter into the aged care sector.

In support of this study, a survey of nurses, physicians and social workers pre and post training was undertaken to explore attitudes towards caring for the elderly (Saarela & Viukari, 1995). The most positive attitudes were found in the reference group formed by nurses specialising in psychiatry. The groups regarded physicians as having the least interest in geriatric care while social workers felt to have the greatest willingness to care for the elderly.

Undergraduate education

A longitudinal study by Fagerberg, Winbald and Elkman (2000) followed students through the duration of their nursing course, interviewing the students at the end of each year about their experiences in residential aged care. The factors likely to encourage students to choose to work in residential aged care after graduating include: a positive clinical experience; a positive experience with a preceptor; and meeting residents with many different conditions, thereby presenting opportunities to learn a lot and provide individualised care. In contrast, the factors likely to discourage students from selecting residential aged care settings as their workplace include: caring for residents with the same care needs over a long period of time; the pace being too slow; working alone without support; and working in a workplace with poor resources and staffing levels.

The importance of undergraduate learning and practical exposure to aged care is highlighted in a study investigating nursing students' choices for work following graduation (Fagerberg, Winbald & Ekman, 2000). They found that students receive contradictory messages during the education in elder care. They found that nurses working in this field were often isolated with no support system, which in turn reinforced their own ambivalence and reluctance towards future work in aged care.

Barron (2000) discusses the implications of the integration of gerontological nursing in undergraduate curriculum, indicating that "It suffers the risks all integration does: When everybody is expected to do it, then nobody may do it well. But if it is not done well at the undergraduate level, then graduates are not likely to work with elderly individuals in life after graduation, nor are they likely to pursue advanced degrees in that area". Barron identified several suggestions for the education setting to improve recruitment in aged care:

Increasing the minimum standards for the number of Registered Nurses in nursing homes.
Providing more opportunities for formal gerontological nursing education.
Development of further teaching nursing homes.
Highlighting gerontological nursing as a positive field and career choice.
Increasing support for gerontological advanced practice nursing.
Promotion of collaborative gerontologic research.

Lack of professional recognition: pay disparities and image of aged care

Macri (2000) discusses the shortage of registered nurses across the whole spectrum of health care, with perhaps the most contentious sector being aged care, due to salary disparities between aged care and acute sectors. She addresses the need to promote the image of aged care, value nurses in the field, and present aged care amongst professional colleagues as a challenging and rewarding field of work.

Structured career paths

Tishman (1993) argued for articulation between levels of nursing qualifications to provide clear pathways for career development and a reward system that recognises education, experience and productivity. This author stressed the 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. Other recommendations included incentives such as flexibility in shifts, assignments and responsibilities, provision of childcare, transportation, tuition benefits, promotion of long-term care to secondary students and the development of scholarships.

Collaborative efforts to address nursing shortages

Stein et al's (2000) paper described a collaborative effort in NSW to address recruitment difficulties in aged care, involving 20 aged care homes and organisations. Collectively they promoted aged care to schools and a range of nursing gatherings. Stein also described a collaborative process in the development of educational workshops and new graduate education programs with tertiary recognition. Also introduced was a NSW New Graduate Consortium interview process to recruit for all member agencies, and prepare the workplace and workplace preceptors for the arrival of new graduates. Emphasis was placed on the need to support and encourage new graduates. An alumni was introduced to provide mutual support, to enable networking and sharing of educational experiences.

Multi-factor approach to recruitment

Recent studies have identified numerous factors that contribute to recruitment difficulties, and changes that are required to improve the attractiveness of aged care. In one such study, Robertson and Cummings (1996) undertook an examination of factors contributing to recruitment difficulties, by asking a sample of 604 registered nurses from around the country: "If you had complete control and unlimited resources, what would you do to make practice on your unit more attractive to other nurses?" Several important factors were identified: having enough qualified, dedicated staff; supportive and competent administration; competitive salaries and benefits; functional, attractive facilities; improved professional and public image; a caring, supportive environment; realistic regulations; decreased paperwork; progressive nurse practice models; and opportunities for educational advancement and career growth.

Nay and Closs (1997) undertook a thematic analysis of data obtained from focus group discussions and interviews with registered and enrolled nurses from Victorian nursing homes, to identify key issues related to recruitment and retention in aged care. The analyses identified several key themes: the negative image of aged care, lack of opportunity for education and professional development, poor relationships, communication and support amongst staff and management, and negative work practice issues, including staff shortages and poor skills mix, lack of funding, difficult work, and poor remuneration. Key issues and recommendations emerging from the research included:

Need to develop/evaluate practice models to appropriately match staff skills with client needs.
Increase collaborative efforts between educational institutions and aged care facilities.
Promotional work towards presentation of aged care as a positive career opportunity.
More structured support for nursing staff.
Providing aged care educational experiences early on for undergraduate students.

Problems in recruiting and retaining sufficient qualified nurses in aged care reported by Nay & Closs (1999) are clustered into 4 major themes: image of aged care; personal issues of staff; education/skills issues; work practices and conditions. Recommendations for tackling these issues include:

Public campaigns to combat ageism within the general and professional health care community.
Drive to recruit more men in aged care nursing, reducing the extent to which aged care is viewed as supplementary work for mothers.
Collaborative educational programs that provide positive practice experiences.
Positive recognition of aged care nursing in undergraduate programs.
Scholarships and financial recognition of educational qualifications.
Role differentiation and clear practice models for qualified and unqualified staff.
New roles for gerontic nurse practitioners and gerontic nurse specialists.
Research and development of new documentation models.
Provision of evidence and support to employers that registered nurses and valuable/necessary to their organisation.
Attractive remuneration packages, balanced with benchmarking best practice.
Modern management practices, providing opportunities for excellence, research, education, autonomy and job satisfaction.

3.3.3 Recent Australian Nursing Workforce Studies

The number of recent studies reflects current concerns about recruiting and retaining nurses. This section presents reviews on current Australian Nursing Workforce Studies.

Commonwealth Department of Health and Aged Care, Recruitment and Retention of Qualified Nurses in Residential Aged Care, 2001.

A recent study undertaken by Pearson, Nay, and Koch (2001) examined the factors that contribute to the rising attrition rate of qualified nurses in aged care, and strategies to increase retention and recruitment in the sector. A number of key issues were identified, and a series of recommendations developed to address the changes required to improve staffing in the residential aged care sector, including:

Strategies to promote the creation of a supportive work environment in aged care.
Collaboration between aged care homes and education providers to develop management training programs.
Encouragement for nurses to undertake advanced studies, and recognition of these achievements.
Strategies to move towards wage parity across sectors.
Establishment of guidelines for optimal skills mix.
Collaboration between the Government and media to improve the image of aged care.
The development of an agreed structure for career progression.
Funding for a national research program.
Establishment of a national re-entry program for nurses wishing to return to nursing.

Ministerial Taskforce, Queensland Health Nursing Recruitment and Retention Study, 1999

This broad-based consultative study considered all nursing specialties, including aged care and draws similar conclusion to those studies carried out in other States. Some recommendations (recommendations 54, 55 and 56) are aged care specific:

that Queensland Health set a strategic direction for aged care service delivery which includes the role and functions of Registered Nurses, Enrolled Nurses and assistants in nursing;
that aged care nursing specialists be available within each Queensland Health Zone, to provide consultancy and mentorship of aged care service delivery; and
that Queensland Health investigates the establishment of a Queensland Chair of Gerontological Nursing.

The need to support, promote and develop Queensland nursing leadership is seen as crucial. Recruitment and retention in rural and remote areas is of particular relevance with more than 50% of the population residing outside Brisbane.

An Aged Care Issues Paper included in the Report outlines key aged care nursing issues in relation to workforce planning, education, organisation (lack of support structures, career pathways, increased workloads etc) and recruitment.

New South Wales Nurses Association Nursing Home and Hostel Workforce Study, 2000

This study examined staffing levels and skills mix in aged care homes in NSW surveying 443 homes 3 times. Of these 269 homes, approximately 60% responded. This represented 15,207 residents, of whom 98% were in the high level of care categories.

A reduction in personal care hours following Commonwealth Deregulation in 1997 was reported by 42% of respondents to the first survey (1998), and this figure fell to 30% for the second survey and 28.7% for the third. In surveying hostels (282 of them) the report noted that there has been a doubling, over an 18-month period, of the residents requiring 'high care'. Hostel managers or supervisors who were Registered or Enrolled Nurses constituted 56.3% in the second survey, and 62% in the third. It is a poorly conducted study, with little or no analysis/interpretation of its findings. The report concludes that: "New funding arrangements may have impacted on nursing/personal care hours which directly affect standards of care".

New South Wales Health Department Workforce Planning Branch Estimation Of Requirements For And Supply Of Registered Nurses In The NSW Nursing Specialty Workforce Groups Of: Rehabilitation, Paediatric And Aged Care Studies, 2000

This study described estimates for the requirements and supply of rehabilitation, paediatric and aged care nurses in the NSW health system. Demographic trends impacting on aged care include admissions to NSW public hospitals, whereby the number of aged persons (65 years and over) will increase from 782,260 in 1996 to an estimated 905,770 by 2006, a growth rate of 1.6% p.a., higher than the total estimated population growth for that period of 0.9% p.a. There will be a differential growth for different age groups over the period, with those over 85 years increasing by 6.1% per annum.

The study showed wide variation between the supply and requirements for each of the four specialties, and in aged care nursing, the projections showed an increasing divergence between supply and requirements, with both qualified and unqualified nurses becoming increasingly in under-supply over the projected period. The dynamics of the aged care nursing workforce that contributed to this result included the following:

Only 2.1% of supply was from migration from interstate and overseas and new graduates, compared to double this proportion for rehabilitation and acute paediatrics.
There is a very low rate of nurses recently qualified in geriatrics/gerontology who enter aged care (0.6%).
There is a much lower rate of lateral entry from other nursing areas (15.4% compared to 23.9% to 39.5% for the other groups).

The reason that this has not resulted in a greater supply problem to date is due to the relatively low wastage rate from aged care compared to the other specialties. The comments made by the reference group suggest that aged care has become a point of re-entry to the nursing workforce for nurses seeking to enter nursing. It is not seen as an attractive area to work in and therefore the level of lateral entry from other nursing areas is low.

It may be the case that the workforce is characterised by one group who have stayed in aged care and often become Directors of Nursing in residential aged care homes; and by another group who are using aged care as a gateway to re-enter other areas of nursing. This is supported by the average age of Registered Nurse in aged care, at 45.6 years compared to 41.2 years for the total workforce. Four key issues were identified:

Whether entry/ re-entry to the unqualified aged care nursing workforce from the general Registered Nurse pool will be able to increase to feed the shortfall identified.
Work practices: as other areas of nursing increase flexibility of work arrangements, competition for Registered Nurses re-entering the workforce will increase, and it may be more difficult to attract these Registered Nurses to a specialty area which is often viewed as a less attractive area of nursing.
How will the skills mix in the aged care nursing workforce change over time? A move to greater numbers of Enrolled Nurses, assistants in nursing, and other carers may offset the need for the projected numbers of unqualified nurses.
There is a need to identify the desired skills mix for the aged care nursing workforce.

There is some discussion (and differing views) in the report in relation to the adequacy of supply of Enrolled Nurses in the aged care sector, and Enrolled Nurses were thought of as poorly utilised with their roles becoming increasingly usurped by assistants in nursing.

Office Of Chief Nurse, Department of Human Services, South Australia Aged Care Nursing Requirements Study, 1999

This report is based on an analysis of workforce data carried out by Department of Human Services staff. Key recommendations of the report include:
The importance of the provision of education for aged care nurses at a variety of levels remain a priority within South Australia.
Universities to continue working with the aged care industry and the community in the development of aged care programs and curricula.
A forum be established for key stakeholders (e.g., aged care employers, professional associations, education providers) to further explore the issue of aged care competencies.
Prior learning and experience within aged care nursing be recognised and appropriate status given within approved programs.
The experience and expertise of aged care nursing staff be recognised and utilised particularly in enhancing preceptorship opportunities for students.
The promotion and development of the Nurse Practitioner role within aged care is recommended based on its expected positive impact on the perceptions and resident outcomes of aged care.
Greater recognition is encouraged throughout the industry that graduate nurses are competent to be employed within the aged care sector.
Directors of Nursing and managers of aged care homes develop strategies to support and encourage the increased participation of all aged care nursing staff in continuing education and professional development.

Department of Human Services Victoria Recruitment and Retention of Qualified Nursing Staff in Long Term Care of Older People Study, 1999

This study used thematic analysis of information gained in focus groups to identify strategies that would facilitate the recruitment and retention of qualified nurses for aged care. Issues identified included image, relationships, educational preparation, industrial and workplace influences including skills mix and other professional issues. A total of 36 recommendations covered a range of professional development issues, all represented to some degree in previously reviewed reports.

Commonwealth Department of Health and Aged Care, Good Practice in Rural, Regional and Remote Aged Care, 2001

A project is currently being undertaken to investigate the quality of aged care practices in rural and remote areas. The project involves producing case studies of 24 residential and community aged care services. The focus of the project is to identify services that are considered to be performing well, and establish strategies to improve other aged care services. Findings have indicated that recruitment and retention of qualified nurses is a common challenge faced by rural and remote aged care services. Emphasis on staff education and provision of scholarships and other incentives including above award pay rates were strategies identified as successful in retaining and recruiting qualified staff.

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