Australian Aged Care Nursing:
A Critical Review of Education, Training, Recruitment and Retention in
Residential and Community Settings
4. Synthesis of Key Findings from the Critical Review
4.1 - Education and Training
4.2 - Retention
4.3 - Recruitment
4.4 - Conclusion
4. Synthesis of key findings from the critical review
4.1 Education and Training
The following section provides an overview of the key findings from the critical review and a number of suggestions for future directions in the education and training, and the improvement of retention and recruitment of nurses in aged care.
4.1.1 Pre-service and undergraduate education
Key issues identified in the literature relating to the presentation of aged care in undergraduate and pre-service education included: increased exposure to aged care topics and experience; more positive exposure to aged care environments and issues surrounding healthy ageing; and the use of appropriately qualified teachers (i.e., those with aged care experience).
Exposure to aged care in undergraduate courses needs to be a quality and positive experience. To assist this aim, the preparation of nursing homes to be appropriate educational environments is a key factor in successfully providing a positive experience of aged care. All such experience in clinical placements in any program should be preceded by appropriate education about older people, the problems they face and learning how nurses may manage difficult situations. The literature also suggests that a greater focus on recruiting males into pre-service and undergraduate courses is required and that a clearer articulation between enrolled nurse programs and undergraduate degree programs should be developed.
4.1.2 Improving continuing education and training opportunities
The literature has indicated numerous positive outcomes from continuing education and training. Access to education and training for nurses increases their skills and knowledge which, in turn, improves the quality of care and thus improves work satisfaction. The provision of advanced education and training for nurses has the potential to improve their status in the community, supports career advancement; and the effective training of other direct care staff reduces the stress of supervision by nurses.
4.1.3 Collaborative education
A key issue identified in the literature was the importance of collaboration between educational institutions and industry. Teaching nursing homes; one of the more recent innovations in the aged care sector are promoting closer collaborations between clinicians, managers, teachers, students and researchers. It is envisaged that this close collaboration will ultimately reduce the current costs being faced by universities for clinical educators.
4.1.4 Interdisciplinary approach to aged care
A number of educational institutions have addressed the need to adopt an interdisciplinary approach to the provision of aged care, including nursing, medicine, and social work approaches. This holds the benefits of providing holistic care to older individuals, taking into consideration knowledge, research, and best practice from a range of disciplines. The literature indicates that a key focus of quality aged care provision involves the input from a range of health professionals. Education and training programs that address this need allow new nursing students to adopt a more cooperative and holistic approach to providing care.
4.1.5 Re-entry and refresher training
Re-entry and refresher training was addressed in the literature as a positive influence in increasing recruitment of nurses back into the aged care workforce. Recent research has provided a number of recommendations for the further development of re-entry training courses in aged care, as a direct strategy to increase the number of nurses returning to the workforce. Recommendations included the establishment of a national, aged care specific nurse re-entry model.
4.2 Retention
4.2.1 The work environment
The lack of a supportive work environment is highlighted in the literature as a major influence on staff morale. The creation of a supportive environment involves adequate supervision, access to professional and emotional support, provision of opportunities for stress management, establishment of systems that provide feedback to staff (such as regular staff appraisal), and the presence of strong professional leadership.
4.2.2 Career progression in the aged care sector
Recent research has indicated the importance of recognition of qualifications, provision of opportunities for professional development, and structured career progression within the aged care sector is essential in retaining qualified staff and recruiting new nurses to the field.
There has been a lack of literature addressing these issues, however recent Australian workforce studies have been increasingly identifying the need for a recognised career structure within the aged care sector. Research suggests that a career pathway in aged care for Registered Nurses will increase levels of recruitment and retention.
4.2.3 Improving staffing levels and achieving an appropriate skills mix
Studies investigating and reviewing appropriate skills mix of staff in aged care have been reported in recent research, and there have been broad guidelines published as a result of this work. An appropriate skills mix is particularly important in a sector where there are a number of different levels of nurses and care staff with varying skill levels. Similar to inadequate staffing levels, an inappropriate skills mix will impact on work satisfaction, recruitment and retention of nurses.
The literature reports that low levels of staff numbers have an impact on not only the level of care provided to older people, but staff job satisfaction and morale. Appropriate staffing levels in the aged care sector need to be examined further and the results of this examination be presented to industry stakeholders for consideration and implementation.
4.3 Recruitment
4.3.1 Emphasising a model of wellness
The wellness model is promoted in aged care 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. This is promoted in response to the commonly held perception that aged care is as a field whereby there is little opportunity to 'cure' patients and see them recover from medical problems. Whilst this model exists, greater promotion amongst the wider community to increase recruitment of nurses into the aged care sector.
4.3.2 Low status
The broader context to the promotion of the wellness model is the low status of aged care nursing. Although both aged care and acute care sectors have significant difficulties in recruiting nurses, aged care experiences greater staffing difficulties, as it is often perceived to be the poor cousin of acute care nursing. Aged care is typically viewed as a field that lacks glamour and excitement, and often receives very poor media presentation. There is minimal research addressing these issues, however studies investigating perceptions of ageing and working with the aged indicate that the low status of aged care nursing may be more attributable to workplace issues than caring for the aged themselves.
4.3.3 Generating professional recognition
A common theme in the literature is the lack of acknowledgment within the aged care sector, general nursing community, and by the general community of the complexity of knowledge and skills needed for the effective and appropriate nursing of older people. This is supported by the low enrolment rates of students in specialist postgraduate courses, and the expectation that to work in aged care does not require specialist postgraduate education or training unlike the expectations placed on intensive or emergency care nurses. This leads to the recognition that to work as a nurse in the aged care sector is a low-status role.
This is further supported by the disparity between rates of pay for aged care nurses and acute care nurses which clearly acts as a major obstacle to recruitment and retention of nurses in the aged care sector.
4.3.4 Establishing a national research program in aged care nursing
Establishing aged care as an area of practice that utilises evidence derived from well-designed research and promotes innovation and its rigorous evaluation is likely to improve the status of aged care and to improve recruitment and retention. A nationally competitive research funding scheme would promote research activity in the sector, increase evidence to improve care and increase the status of aged care nursing.
4.4 Conclusion
The results of this critical review suggest that a number of issues surrounding the education, training, recruitment and retention of nurses require attention if the ongoing needs of proving a nursing service in aged care are to be addressed.
All sectors of the health care system continue to experience difficulties in recruiting suitable staff to deliver effective and appropriate personal care and nursing care and this is very apparent in the aged care sector. The current structure of the nursing team (registered nurses, enrolled nurses and nursing assistants in continuing and community care3) appears to be an inappropriate structure in terms of providing employers with staff to provide adequate levels of personal and nursing care. In all Western countries, the recruitment of registered nurses is problematic and is likely to remain so for the foreseeable future. Changes in gender roles and the resulting expansion of career opportunities for women that have lead to a decline in the number and quality of entrants to undergraduate nursing programs; the rise in technology in health care that has increased the demand for flexible, skilled direct-care staff; and the professional resistance to changing the composition of the nursing team that has prevented the introduction of new approaches to nursing service delivery have combined to create a situation where the need for nursing and personal care has become increasingly difficult to meet.
Historically, most Western health systems have faced similar difficulties and have responded by creating various levels of care providers. In the United Kingdom, the State Enrolled Assistant Nurse SEAN) was introduced in 1948 and was subsequently renamed the State Enrolled Nurse, before abandoning the role in the 1980s. The plan then was to create a small cadre of highly qualified nurses - State Registered Nurses - to lead nursing teams made up largely of SENs and untrained Nursing Auxiliaries. Because trainee SENs - known as pupil nurses- were less easy to recruit than student nurses, the UK strategy failed to meet the objective of providing a viable workforce. Currently, the UK now recruits and trains large numbers of Health Care Assistants (HCAs) who work alongside Registered Nurses. In North America, numerous attempts have been made to meet the need to provide nurses. In most US states and Canadian Provinces, a plethora of nursing roles have been developed. Registered nurses (who may have completed a two-year associate degree, a three-year diploma or a four-year degree) are assisted by Licensed Practical Nurses, Licensed Vocational Nurses, Nurses Aides and Personal Care Assistants.
In Australia, the Registered Nurse is generally assisted by Enrolled nurses, who have completed a one-year VET course and by nursing assistants. The role of the enrolled nurse is now seen to be too restricted and, even though their education and training is at the most basic level, there is increasing pressure from Governments to extend the role of the enrolled nurse to include the administration of medications and the assessment of nursing needs and prescribing nursing care.
Employers in aged care, facing as they do, continuing difficulties in recruiting staff capable of delivering safe and effective nursing and personal care, are eager to engage in innovative approaches to staffing nursing services but there is insufficient industrial, professional and educational leadership to generate innovative approaches to deal with the recurring problems of providing enough nursing staff to meet the health needs of the population.
The profoundly low job satisfaction felt by nurses as a factor in retaining and recruiting nurses to the aged care sector is emphasised in the literature and the lack of a supportive work environment is cited in many studies as a major causative factor in the area of morale and this is supported by the findings of this study. Staff shortages are reported to have compounded the low morale experienced and overworked nurses express their inability to provide quality resident care, thereby reducing their own estimation of personal professional effectiveness, and self-esteem. These factors result in endemic low morale and poor image which appears most profound in the aged care sector. Recruitment therefore becomes problematic as women in general, and nurses in particular, seek employment opportunities that are more rewarding emotionally and financially.
Another common theme in the literature is the lack of acknowledgement within the sector and the general community of the complexity of knowledge and skills needed for the effective and appropriate nursing of older people. This is reflected in the low participation rates of aged care nurses in specialist award courses in gerontological nursing and the generally accepted view that, whilst acute care nurses such as those in intensive care or emergency require specialist postgraduate education and training, no specialist, advanced knowledge or skills are required to nurse older people. This lack of recognition of expertise serves to devalue the role and, thus, render aged care nursing a low-status pursuit.
The disparity between rates of pay for aged care nurses and acute care nurses clearly acts as a major obstacle to recruitment. Generally in the recruitment and retention literature, the evidence suggests that salary in itself plays a less important role in recruitment and retention than is often assumed. However, the literature suggests that a 20% difference in salaries between acute and aged care sectors in some states acts as a major disincentive for nurses.
All of the studies reviewed suggest that the image of aged care and of older people is a major obstacle to recruitment and retention. It is difficult to ascertain how this can be overcome and few studies identify successful strategies to improve the image of aged care.
Education and training play a number of roles in increasing the recruitment and retention of nurses. Access to education and training for nurses increases their skills and knowledge which, in turn, improves the quality of care and thus improves work satisfaction; the provision of advanced education and training for nurses improves their status in the community and supports career advancement; and the effective training of other direct care staff reduces the stress of supervision by nurses. Currently, there is no clear, articulated approach to education and training in the sector and inconsistency exists in the recognition of advanced education and training. This inconsistency means that there are few incentives for nurses to pursue advanced education and training. A structured and well understood education and training profile in aged care will increase work satisfaction and could be an important marketing tool in recruitment.
Establishing aged care as an area of practice that utilises evidence derived from well-designed research and promotes innovation and its rigorous evaluation is likely to improve its status and to improve recruitment and retention. Some provider agencies in Australia have already forged links with higher education institutions and established joint honours projects and modest scholarships; others have established clinical schools focusing on research. Research funding bodies such as the NHMRC have consistently failed to fund such endeavours, as their practical, applied focus does not coincide with the focus of existing research funding bodies. A nationally competitive research funding scheme would promote research activity in the sector, increase evidence to improve care and increase the status of aged care nursing.
Drawing on the literature, the Consultants conclude that the following strategies require consideration:
Strategy 1 : A review of the structure of nursing and personal care teams in aged care (including roles and gender composition).
Strategy 2 : Expansion of the role of the registered nurse in aged care.
Strategy 3 : Consideration of an increase in the period of education and training for registered nurses to at least four academic years (i.e., 112 weeks).
Strategy 4 : Expansion of the role of the enrolled nurse in aged care.
Strategy 5 : Consideration of an increase in the period of education and training for enrolled nurses to at least two years and eligibility for high performing graduates to enter the third year of a four year degree program in nursing.
Strategy 6 : Identification and implementation of strategies by the aged care sector to promote the development and maintenance of supportive work environments in aged care homes.
Strategy 7 : Collaboration between The Royal College of Nursing, Australia, the Australian Nursing Federation, and other parts of the aged care sector and key stakeholders to develop a strategy to credential advanced practice aged care nurses.
Strategy 8 : Higher education and training providers, in collaboration with aged care homes, further develop and market clinically relevant postgraduate programs in aged care.
Strategy 9 : The aged care sector develop strategies to encourage nurses to undertake advanced studies in gerontological nursing; explicitly reward nurses who complete advanced studies; and develop roles to accommodate the specialised knowledge and skills of advanced gerontological nursing clinicians.
Strategy 10 : Development of strategies to improve the image of aged care, involving collaborative efforts between the Commonwealth Department of Health and Aged Care, aged care sector and the media.
Strategy 11 : Development of an agreed national education and training plan for aged care nurses by Industrial Nursing Organisations and other relevant parts of the aged care sector.
Strategy 12 : Establishment and funding by the Commonwealth Department of Health and Aged Care and aged care sector for a national aged care nursing research program.
3In Victoria, Registered Nurses are referred to as "Registered Nurse Division 1" and Enrolled Nurses as "Registered Nurses, Division 2"; Nursing assistants are sometimes referred to as Personal Care Assistants of Health Care Assistants. In this discussion , Registered Nurse refers to a professional nurse who has completed a degree in nursing or a recognised certificate froma three year program conducted in a hospital school of nursing; Enrolled Nurse refers to a second level nurse who has completed a TAFE of hospital certificate course of 1 full time years duration. Nursing assistants currently receive no systematic education or training.
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