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National Review of Nursing Education 

Discussion Paper

Chapter 6
The nursing workforce in Australia

• Job growth and turnover in nursing and related occupations
  • Nursing Workforce
  • Nursing professionals
  • Enrolled Nurses
• Shortages
• Specific shortages and difficulties
  • Rural and remote nursing
  • Aged Care
  • Mental Health
  • Nurses the solution?
• The problem of retention: why nurses leave nursing
• Supply
  • Higher Education Statistics on Nursing Education
  • Relationship between supply and demand
  • Particular Supply challengers
• Exhibits

Recently the Federal, State and Territory governments have expressed an interest in examining from the national perspective the issues surrounding health workforce planning. While the States and Territories have been examining workforce issues, as attested by the many Reports listed in Johnson and Preston (2001), a more national approach is now being explored. The Health Department Chief Executive Officers established the Australian Health Workforce Advisory Committee (AHWAC). This Committee is examining midwifery and critical care nursing and will report in the first half of 2002. Recently the Health Ministers established the National Health Workforce Council to provide long-term advice on health workforce strategies.

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Job growth and turnover in nursing and related occupations

Caution should be used when interpreting the numbers found in this Chapter. Models of changing employment are based on sets of assumptions that can be found in the paper from which the numbers are drawn, but are not included here. Changes in classification categories can impact on trend data. Data is collected for various sources by asking somewhat different questions and much of the data relies on self reporting which requires individual interpretation of categories and labels. However, it is possible to gain a picture of the trends from the information supplied.

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Nursing Workforce

The Review commissioned a research study to investigate job growth and turnover in nursing occupations in the period 1987–2001 (Shah and Burke, 2001). The researchers examined changes in overall employment, the age profile of workers and reported hours worked per week. Even allowing for the uncertainty of data and the reclassification of some categories of nursing occupations, they found evidence of similarities in employment trends across Australian States and Territories, but also significant differences between them.

The nursing workforce is a group including Personal Care Assistants, Assistants in Nursing, Directors of Nursing, Nursing Professionals and Enrolled Nurses. A separate group who work in areas associated with nursing but not included in the nursing workforce classification are the Aged and Disabled Person Carers.

More detail than that provided in the following material is available in the exhibits at the end of this Chapter. Much of the detail below is taken directly from the report of Shah and Burke.

The researchers reported that

The employment of Nursing Workers grew at an average annual rate of 0.8 per cent, which is half the rate for all occupations, to 249 000 in 2001. Not all States recorded a growth. In South Australia and Tasmania employment contracted while in Queensland the growth rate was 2.7 per cent per year. (Shah and Burke, 2001, Executive Summary). (See Exhibit 6.1 for comparison with all occupations.)

Table 6.1 shows that the two groups that underwent a decline were the Enrolled Nurses and the Personal Care Assistants (PCAs) and Assistants in Nursing (AINs).

Table 6.1 Change in employment in nursing and aged and disability person carer occupations, Australia, 1987–2001 (adapted Shah & Burke, Table 1)

Note: The average annual rate was estimated by fitting a log linear model to the annual employment data. Except for Personal Care and Nursing Assistants, all other estimates are significant at less than 10 per cent level.

In the following description the researchers do not include Aged and Disabled Person Carers. The researchers noted that:

An alternative way to view the changes in the employment levels is to consider the number of Nursing Workers employed per 100 000 population. After initially increasing to about 1 400 in the second half of 1980s, the ratio has been steadily declining and currently stands at about 1300, which is just below the level in 1987. The ratios varied widely across jurisdictions in the mid-1980s but have been converging ever since to the ratios for New South Wales, Queensland and Western Australia which have remained relatively stable.

Changes in the relative proportions of the three main groups—Nursing Professionals, Enrolled Nurses, and Personal Care and Nursing Assistants—suggest the growth in the first group has been at the expense of the other two groups. However this pattern of substitution is not uniform across States and Territories and does not take into account the Aged and Disabled Person Carers (see Exhibit 6.2). The employment of this latter group grew in all States and Territories, but Victoria is by far the largest employer of unregulated carers when aged and disability person carers are combined with AINs and PCAs.

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Nursing professionals

Nursing professionals, include Registered Nurses, Registered Midwives, and Nurse Managers. While all of these groups underwent an average annual growth rate, the group that experienced the lowest growth rate was the Registered Nurses with an average annual growth rate of 2.5. The pattern of growth is of particular interest in the light of current claims of shortages. Figure 6.2 shows a considerable drop in employment in 1994–95. Since that time there have been periods of growth and stability, but between 2000–01 the pattern of growth was considerable. By 2001 the employment level was 183 900. (See Exhibit 6.3).

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Enrolled Nurses

The employment of Enrolled Nurses underwent a decline in 1994–95 much like the trend for Registered Nurses, but though increases in Registered Nurses occurred since 1998 the change in employment of Enrolled Nurses has been sharply negative. Between 1987 and 2001 the decline was 20.6 per cent to an employment level of 22 500 in 2001. The States responsible for the decrease were NSW, Victoria and Tasmania. In the ACT, Queensland and the Northern Territory the pattern was one of growth. In the Northern Territory while the numbers were small, only about 200, the growth was over 200 per cent (see Exhibit 6.4).

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Personal Carers and Nursing Assistants

The recent pattern is one of decline for this group. Figure 6.4 shows that after a steady growth from 1992 to 1997, the decline has been fairly rapid and at a constant rate, steadying in 2000–01. The States having most impact on this latter decline were Victoria and South Australia (see Exhibit 6.5). The level of employment by 2001 was 39 300, a decline of 1.7 per cent between 1987 and 2001.

Of particular note is that there has been a steady decline in both Enrolled Nurses and personal carers and nursing assistants since 1998 nationally. While this period has been one of growth for Registered Nurses, the number of other nursing workers per 100 000 population was declining. For 2000 there is evidence of a return to about the level in 1999, but still less than that of 1987. At the same time there was rapid growth of Aged and Disabled Person Carers.

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Aged and Disabled Person Carers

As Figure 6.5 shows the number of aged and disabled person carers has undergone a steady increase since 1987, which accelerated after about 1992 to reach an employment level of 71 000 by 2001.

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Job openings

Growth forecasts of employment in nursing occupations are 0.4 per cent per year, on average, over the next five years compared to 1.5 per cent for all employment. Large growth in employment is expected in the managerial occupations and among Registered Midwives, but a contraction in employment is expected among Enrolled Nurses and Personal Care and Nursing Assistants (see Exhibit 6.6).

Net labour turnover is estimated at 1.8 per cent per annum for nursing occupations. The rate for Enrolled Nurses and Personal Care and Nursing Assistants is expected to be slightly lower than for Nursing Professionals (see Exhibit 6.7).

Job openings for new entrants are the sum of growth in numbers employed and net turnover. The total job openings for new entrants into nursing occupations is expected to be about 27 000 over the next five years, about 80 per cent of them due to replacement and only 20 per cent to growth. The job openings translate to an annual rate of 2.2 per cent, compared with an average of 3.7 per cent for all occupations in the economy. The rates vary across occupations with some of the highest rates for managerial occupations and Registered Midwives. The rate for Enrolled Nurses is less than half that for all nursing occupations while that for Personal Care and Nursing Assistants is almost zero (see Exhibit 6.8).

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Factors impacting on demand

While it is difficult to identify why particular patterns of growth and decline occur, two factors that are likely to impact on future demand are the ageing of nursing workers and the proportion of part-time to full-time nurses in the workforce. Figure 6.6 shows the changes in age distribution of nursing workers and Table 6.2 the hours worked by nursing professionals.

Overall Nursing Workers are older now than they were in 1987. The proportion of workers aged 45 years and over increased by 17 percentage points between 1987 and 2001. In general, the age profiles across occupations are similar, apart for Nurse Managers and Directors of Nursing who have a much higher proportion in the 45 and older age group, while Registered Midwives have a much lower proportion in the same age group.

The norm for retirement of nurses is around 55 years, so the large increase in the 45–54 age group and the enormous decrease from 54 per cent to 30 per cent in the under 34 age group suggests that the ageing of this workforce will continue for some years, resulting in a significant impact due to high numbers of retirements. There has also been a shift in the age distribution of aged and disabled carers since 1987. Over 45 per cent are of these carers are older than 45 years of age and only 9 per cent less than 25 years old in 2001.

The increase in part-time nursing workers means a greater number are needed in 2001 than were required in 1987.

As Table 6.2 shows the increase in part-time is largely due to changes in work patterns by Registered Nurses and Registered Midwives.

There has been a shift towards working shorter hours among Nursing Workers. Unlike for the labour force in general, in which the shift in hours has been from the normal full-time hours towards very short or long hours, in the case of Nursing Workers the shift has been more from the normal full-time hours towards working 16–34 hours per week.

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Shortages

Presently, there appear to be shortages or predictions of shortages in many countries including Australia, England, Canada and the United States. Cycles of Registered Nurse shortages have been part of the history of nursing in Australia as is evident in the Kelly Report of 1943 in NSW which was prepared in response to nursing shortages. The persistency of the shortage, the fall in enrolments in nursing courses and the international shortage suggests that the present situation is unlikely to be easily turned around.

The shortages of nurses were identified in a number of submissions and during meetings. In the Northern Territory the description of the shortage of remote area nurses was ‘humanitarian crisis’. Uniting Care Australia indicated that rural and remote Australia had already reached a crisis point. The Australian Private Hospitals Association suggests that the present shortage is being masked by increasing shifts, the use of agency nurses, the closure of services and beds, and the lack of national statistics. The reduced length of stay further increases pressure on staff.

Skill shortage research undertaken by the Department of Employment Workplace Relations and Small Business (DEWRSB) produces its information on shortages by examining recently advertised positions and contacting employers to see if these positions had been filled. The survey covers government and non-government hospitals and nursing homes.

Unpublished data based on June and July 2001 updating confirmed that there were widespread shortages of Registered and Enrolled Nurses throughout Australia. As can be seen from the following summary, shortages of Registered Nurses in most specialisations occur in most States and Territories, and of Enrolled Nurses in all States apart from the two Territories which appears to be in balance at present. Most States and Territories were experiencing shortages of Registered Midwives and Registered Mental Health Nurses.

Shortages of Registered Nurses in most specialisations and regions of Sydney and NSW are expected to persist over 2002. Shortages of Enrolled Nurses are also likely to persist, but at a lower intensity, and in midwifery over the short term at least.

Registered Nurses and Enrolled Nurses, including a broad range of specialisations were in shortage in Victoria.

Nursing is in shortage across Queensland. Regional and rural Queensland have acute shortages across all nursing areas. Some specialty positions are particularly difficult to fill. The most acute of these is aged care.

Demand of Registered Nurses is expected to exceed aggregate supply for the foreseeable future. Demand for Enrolled Nurses has stripped supply in the aged care sector, and recruitment difficulties are expected to persist throughout 2001 and 2002. Recruitment difficulties have re-emerged in the metropolitan area in Midwives, and shortages persist in rural and remote areas.

Shortages of Registered Nurses continue in most specialisations. Recruitment of Enrolled Nurses is particularly difficult in aged residential care and regional locations. Additionally, increasing numbers of Enrolled Nurses have moved from permanent full and part-time employment to take up casual and part-time agency work. In WA the labour market for Registered Midwives has been in continuous shortage for the past five years.

Shortages of Registered Nurses continue in a number of specialisations and across all sectors. Difficulties in recruiting Registered Midwives, with the situation likely to become more difficult in the short to medium term.

Shortages of Registered Nurses continue in most specialisation, and across all sectors, and these are expected to persist over 2001 to 2002. Demand for Enrolled Nurses is not as strong and supply seems adequate to meed demand.

Shortages of Registered Nurses continue in most specialisations and across all sectors. Demand for Enrolled Nurses is not as strong and supply seems adequate to meet demand.

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Specific shortages and difficulties

DEWRSB data provide a grim picture of particular shortages across Australia by State and Territory (see Table 6.3).

Table 6. 3 Shortages of Registered Nurses by specialisation/Enrolled Nurses – March 2001

N = National shortage
S = State or Territory wide shortage
D = Recruitment difficulties
R = Regional shortage (outside capital city only)

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Rural and remote nursing

The Review had drawn to its attention the difference between rural and remote nursing. The literature review commissioned for this Review covers both rural and isolated/remote nursing. Francis, Bowman and Redgrave (2001) point out that:

(P)eople who live in rural and remote Australia experience many health disadvantages. These include higher mortality and morbidity rates for some diseases, higher exposure to injury in the workplace, socioeconomical disadvantage, and inequitable access to health services as compared to urban counterparts. …[A]s the population size decreases access to professional healthcare is reduced and poorer health results (pp.11–12).

The researchers make the claim of connections between low population density, reduced availability of health services, and the need for health clinicians in rural and remote Australia to have a wide range of skills to meet community needs:

… [A]pproximately one-third of Australia’s population live outside capital cities and metropolitan centres which are concentrated on the coastal fringes of the continent. Approximately 84 per cent of the Australian population live on 1 per cent of the land mass. …[W]ith increasing distance inland there is an inverse decrease in population. Therefore the provision of health services which are largely determined on a population based formula means that service provision is also reduced with distance from areas of high population density. Health services which are provided in rural/remote areas rely on clinicans having multiple skills to meet community needs (p.14).

People in rural and remote areas have less access to health services than other Australians. In addition to lack of health facilities there is also reduced access to health professionals. There is a well-known shortage of medical doctors in rural and remote Australia—a situation which various current medical education and other incentive programmes aim to address. There is also a shortage of nurses available to practise in rural and remote settings, and in many of these settings nurses become the principal—and in some remote settings the only—providers of many kinds of healthcare.

The researchers provided workforce data suggesting that:

• the proportion of nurses who are Registered Nurses falls with increasing rurality (p.25);
• there has been a decline in the number of Enrolled Nurses in rural and remote Australia, as elsewhere (p.25);
• the rural nursing workforce is ageing, so a greater proportion of rural and remote nurses may be seeking part-time work or retirement in the coming decade (pp.25–6);
• only a small proportion of nursing graduates take positions in rural areas (p.26); and
• rural nurses are being deskilled and have inadequate opportunities to maintain and develop knowledge and skills commensurate with their responsibilities (p.26).

The researchers argue that the shortage of nurses is already being disproportionately felt in rural and remote areas, with many vacant positions remaining unfilled for longer periods (pp.27–8, 34–5). In rural and remote Australia, there is a demand not only for generalist and specialist nurses; there is also a demand for nurses able to practice at a high level of expertise across a range of clinical areas which, in metropolitan Australia, are served by nurses with highly focused specialised clinical expertise.

Studies analysed by the researchers reveal a complex interaction between government policies supporting primary healthcare, the kinds of facilities and services provided, and rural and remote people’s perceptions of healthcare. Policy favours the provision of primary healthcare, but many healthcare workers and community members interpret improved health services in terms of access to medical services—in particular the provision of medical doctors and hospitals. Given the shortage of medical doctors in rural and remote Australia, there is a corresponding valuing of rural medicine over rural health services. This is not limited to community perceptions: some studies suggest that many rural nurses favour hospital nursing practice over community nursing based on and promoting a primary healthcare model of service delivery (p.19).

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Aged Care

A literature review on aged care nursing was commissioned for this Review which provided information on nursing within that sector. Pearson, Nay, Koch, Ward, Andrews and Tucker (2001) suggest that in 2000 about 20 per cent of Australia’s population over the age of 70 use aged care services—about half of them supported by home and community care services, and the remainder in nursing homes (5 per cent), hostels (3.7 per cent) or through community aged care packages (0.2 per cent). At 30 June 2000 there were 3005 occupied aged care homes in Australia providing a total of 141 162 places. In addition, 18 149 community aged care packages were also provided. Of these permanent residents, 62 per cent were high care residents (RCS1–4) and 38 per cent were low care residents (RCS5–8).

Between 1993 and 1999, however, the employment of nurses in geriatrics and gerontological nursing declined, from 41 691 to 38 272. This rate of decline—8.2 per cent—is substantially greater than the 5.5 per cent noted for the rate of decline in the overall nursing workforce in that period.

Of the 38 272 nurses employed in geriatrics and gerontological nursing in 1999, 34.0 per cent were in government nursing homes, 39.8 per cent in non-government nursing homes, 13.4 per cent in hospitals, and 3.2 per cent in hostels. The rate of decline of nurses employed in two of these kinds of services—government and non-government nursing homes—is higher than the overall rate of decline in geriatric and gerontological nursing. In non-government nursing homes, the number of these nurses fell from 18 260 in 1993 to 13 426 in 1996—a decline of 26.5 per cent. In private nursing homes, the number fell from 17 019 to 15 521—a decline of 10.4 per cent. The researchers also report some NSW projections indicating that there was also an increasing under-supply of PCAs and AINs.

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Mental Health

In the report of research commissioned for this Review, Clinton, du Boulay, Hazelton and Horner (2001) argue that, in 1997, consumers of mental health nursing care reported

problems with access to services, poor service quality and stigmatising attitudes among some mental health workers. At the same time, primary healthcare providers have complained that there is little help available when managing mental health problems in the community that do not require specialised psychiatric care. Similarly, many consumers have reported that they have become disenfranchised by the focus on ‘serious mental illness’ in the National Mental Health Strategy, a concern that was addressed, to some extent, in the Second National Mental Health Plan. (p. 7).

The authors argue that

Current problems in the Australian mental health nursing workforce stem from:

• the much needed transition from psychiatric to integrated mental health services;
• the downsizing of psychiatric hospitals without sufficient re-education of the mental health nursing workforce;
• the replacement of psychiatric nurse education by generic tertiary education programmes;
• the demise of separate registers for psychiatric nurses; and
• problems arising from the organisation and delivery of mental health services (p.7).

The report also indicates that Mental Health Nurses have a crucial role in the delivery of mental health services in Australia; nurses comprise approximately 75 per cent of all mental health professionals.

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Nurses the solution?

When seeking to alleviate the conditions brought about by the shortage of doctors two types of proposals involving nurses are usually put forward. One type suggests an increase in the number of nurses who assist doctors by taking over from them some of the work nurses are qualified to perform, that is, the ‘practice nurse’. The other suggests additional training and widening the scope of practice for nurses to enable nurses to perform in areas they normally leave to other health professionals. In some States this has been the focus of the development of the Nurse Practitioner or advanced skills nurse, who with the backup of the medical and other health professions as well as additional education and training covers a more extensive range of health work than the usual nurse. Both of these proposals are premised on an adequate supply of nurses with the appropriate interests and skills who are willing to work in areas of need. Different groups contest both proposals.

While this debate continues, the expectations of employers and the communities in rural and remote settings often go beyond the practice allowed under legislation (Rural and Remote Nursing Summit Report, 1998, p.24). Nurses in these settings are often the first line of contact for community health services and in some places the nurse is the sole primary healthcare provider.

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The problem of retention: why nurses leave nursing

The question of retention of nurses, and why nurses leave nursing is not new. Since the transfer of Registered Nurse education into the higher education sector in 1993, a number of studies have looked at various aspects of nurse education, and at those aspects of nursing which have made it difficult to retain nurses. A number of these studies, which were considered in the context of this Review, include the Queensland Ministerial Taskforce – Nursing Recruitment and Retention (Queensland Health); NSW Nursing Recruitment and Retention Taskforce Report (NSW Health); Attracting Nurses back in to the Nursing Workforce (Health Department of Western Australia); Factors Influencing the Recruitment and Retention of Nurses in Rural and Remote Areas of Queensland (University of Southern Queensland); and the Victorian Nurse Recruitment and Retention Committee; Final Report (Victorian Department of Human Services).

During the Review, we spoke with nurses and received submissions from nurses and nursing organisations which confirm many of the well-documented reasons that are causing nurses to leave nursing—most of which relate to the different aspects of working conditions such as lack of autonomy, safety in the workplace, their capacity to function professionally as a nurse with current staffing shortages, recognition of their skills and knowledge, childcare, shiftwork, and conditions of pay.

Information about retention rates is not readily available. It is clear however, that retention is a key issue in ensuring an adequate nursing workforce in the future. The small proportion of the workforce in the less than 30 years of age category means that those who might be interested in a long term career in nursing will be sourced from fewer nurses than in the past. Each highly skilled nurse lost to the system will take at the very least four years' investment in education to replace. The cost of high turnover is enormous. Replacement costs for one year of Registered Nurse Level I (RNLI) turnover for Alice Springs hospital were estimated to be $300 000. (Territory Health Service, 2001)

Comparative international research suggests that countries like the US, Canada, England and Scotland which are experiencing similar shortages to our own have had 30–40 per cent of nurses dissatisfied with their job and in a high burnout range, much of this associated with inadequate numbers of nursing staff to provide quality nursing care. The researchers found the under 30-year-old group more likely to be planning to leave within a year (Aiken et. al., 2001, pp.43–53).

In a small survey of 38 Directors of Nursing and Chief Executive Officers, conducted by Aged and Community Services, Tasmania (2001) the most cited reasons for nurses leaving aged care were:

• Workload/burnout 15
• Documentation overload 11
• Injury from heavy work 6
• Age of workforce 6
• Lack of wage parity 4
• Lack of career path 4

Six exit interviews confirm this general list with the first two dominating in aged care. Community representatives also mentioned documentation overload in discussions about difficulties in aged care during the consultations.

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Supply

Higher Education Statistics on Nursing Education

Data on supply are not easy to interpret. The trends suggest there are State differences in patterns of commencements and completions in Bachelor of Nursing courses for both pre-registration and post-registration between 1994 and 1999. Although these courses contain both post-registration and pre-registration nurses, the former group has decreased across the period. Some States appear to have at least retained a stable or even a small increase in numbers, while in others the number of commencements and completions of undergraduate courses have steadily decreased across the period.

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Commencements

The following section provides an overview of the changes in commencements, completions and total enrolments in nursing courses at universities since 1994, the first year in which the Commonwealth assumed full responsibility for the funding of general nursing education. It also summarises the distribution of students by the type of course undertaken, and the distribution of Higher Education Contribution Scheme (HECS) liable and HECS-exempt units. The four figures below are produced from DETYA data supplied by the universities.

Figure 6.7 shows the trends in student enrolments in nursing courses. It includes non-overseas (domestic) undergraduate, postgraduate and research students across the period 1994 to 2000.

Domestic student bachelor commencements decreased across the period from a peak of 11 653 in 1994. There was only a slight increase in one year, 1998. By 2000 the number had dropped to 8423. Of interest in relation to these figures is the discussion about the overproduction of new nurses in the 1994 review on the transition of nursing education into higher education. This is summarised in the statement from the report: ‘Evidence gathered during the course of the Review suggested that, in 1993 and 1994, the overall supply of (Registered Nurses) RNs exceeded the requirement for RNs, although there were variations by State, Territory and region, and shortages in some specialist areas, and in rural and remote locations’ (Reid, 1994, p. 116). Across the same period there has been a steady increase from a very low number of overseas students to a total figure of 1980 in all courses by the year 2000.

Across the same period commencements in Higher Degree Research, Doctorates and Masters rose from 68 in 1994 and have varied around the 100 since 1996. The numbers of commencements in Higher Degree coursework rose from 410 in 1994 to 839 in 1999 and dropped to 813 in 2000. The group ‘postgraduate other’, which includes postgraduate diplomas and certificates, rose across the period to 1996 when there were 2599 commencements and have been declining until in 2000 there were 2159 commencements. The numbers in Masters by coursework combined with Postgraduate Certificates and Diplomas have been a decline since 1996.

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Total enrolments

The total enrolment is the number of students enrolled in a particular course such as a Bachelor of Nursing in any one year. The decline in domestic nursing student total enrolments between 1994 and 2000 was 5893. The slight reduction since 1997 is likely to be due, at least in part, to the decrease in numbers of hospital-trained nurses upgrading their qualifications. This view is supported by a drop in the number of enrolments in the category ‘undergraduate other’ which included these types of courses. The growth in enrolments for overseas students across the period was 2420.

Figure 6.8 compares domestic student numbers for different course types. Higher degree research includes masters and doctorates by research. Higher degree by coursework includes masters and doctorates by coursework. The category ‘other postgraduate’ captures the remaining courses classified as postgraduate, usually postgraduate certificates and postgraduate diplomas. This latter group contains most of the courses that prepare nurses for specialities in practice.

The number of students enrolled in Bachelor Degree courses has declined across the period, but the decline has been less marked since 1997. The number of students doing courses in the other postgraduate category rose until 1996. Since then numbers have been declining despite the gradual drift of nursing specialisation preparation to the universities across the period. Last year, the number of students enrolled in this category of course was 2865. Enrolments in the higher degree courses had been slowly rising, but these also experienced a slight downturn last year. The number of domestic students undertaking a higher degree by coursework in 2000 was 1451 and by research, 298.

The trend for domestic undergraduate students shows a steady decrease in completions of nursing courses from a high of 9525 in 1994 to 5844 by 1999. In 1999, 1381 overseas students completed bachelor degrees. Domestic higher degree research completions have been about 30 each year between 1996 and 1999 and coursework degree completions have risen from 119 in 1994 to 353 in 1999.

The other postgraduate category has had a rising completion rate from 1144 in 1994 to a peak of 1975 in 1998. In 2000 there were 1949 completions.

Some 2000 and 2001 completions data is available from the study of Ogle, Bethune, Nugent and Walker (2001). Undergraduate completion data over the past three years indicate some differences between States and Territories. Data for 2000 and projections for 2001 in Victoria and New South Wales indicate similar completion rates which are above those of 1999. In South Australia graduate numbers for 2000 were lower than those of 1999 but the projected completion rates for 2001 indicates a 25 per cent increase from 2000. Queensland completion rates for 1999 and 2000 were relatively stable but indicate an increase of 14 per cent for 2001. Western Australia shows a steady increase over the past three years including a projected 17 per cent increase from 2000 to 2001. Northern Territory completions rates for 1999 and 2000 were stable, and indicate an increase of 27 per cent from 2000 to 2001. Tasmanian data indicate a decline from 1999 to 2001 of 6 per cent while ACT data indicate a decline of 25 per cent from 1999 to 2001.

Wastage from courses is a question for workforce planners. Due to the flexible modes of courses and the time some students take to complete it is difficult to provide data. However a DETYA study (Urban, Jones, Smith, Evans, Maclachlan and Karmel, 1999) of the 1992 nursing university cohort showed that 73 per cent had completed a course by 1997. This figure is considerably higher than the 60 per cent average across all fields of study. The study found that a number of factors increased the likelihood of completion, including being a full-time rather than an external or part-time student. Female students were also more likely to complete than male students. Younger students are more likely to complete than older students. While these data do not provide information on the rate of completion of nursing courses as distinct from completion of any university course. The results do suggest that the drop-out rate from nursing is well within an expected range when compared with other university courses and a great deal better than for many fields of study.

While it is more natural to think in terms of numbers of students, the funding of places (whether by the Commonwealth or individuals) is determined at the unit level. These units are converted to a common ‘currency’, effective full-time student units (EFTSU).

The following figure compares the total domestic EFTSU in nursing on the basis of whether they attract HECS, fees or are HECS exempt, that is, the units belong to the ‘other’ category²⁰ . It also provides information on the total EFTSU allocated by the universities to nursing for domestic students. This allocation has dropped by about 2000 across the period. Clearly most domestic EFTSUs attract HECS, but this category has declined across the period from 23 121 in 1994 to 19 494 in 2000. There has been an increase in the number of domestic EFTSU which attract fees from a low base in 1994 to 1074 last year. The student load attracting fees is largely in the category covering postgraduate certificates and diplomas with about 20 per cent in the higher degree-course work category. Overall the total EFTSU for domestic students since 1997 has been relatively stable at around 21 000.

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Enrolled Nurses

The following section provides an overview of the changes in commencements and total enrolments in Enrolled Nurse courses in the VET sector during the recent past. Further information on the Enrolled Nurse data used for this section is contained in the report Enrolled Nurse Education (McKenna et al. 2001) commissioned for this Review.

This report notes that the data on Enrolled nursing commencement and enrolments should be treated as indicative at best due to a number of factors that can skew the data. For instance, enrolments in Victoria and Queensland are only included from 1997. More recently, coverage of VET enrolments was expanded to include private training providers. This expansion should have resulted in the inclusion of enrolments in private providers of Enrolled Nurse education in Victoria and Tasmania and a further apparent increase in enrolments, but this was not reflected in the data. Notwithstanding, it does appear that in the last few years there has been an increase in enrolments in Enrolled Nurse courses in New South Wales, Queensland and Western Australia.

Figure 6.11 shows enrolments in Enrolled Nurse courses in the VET sector from 1994 to 2000. During the 1990s the education of Enrolled Nurses gradually transferred from the hospital sector to the VET sector, and this accounts for most of the increase in enrolments reflected in the data for this period. No enrolments in Tasmania and the Northern Territory were recorded, although it was noted that several courses for Enrolled Nurses were in fact being offered in those areas. These courses appear not to have been allocated to the appropriate occupation code when VET data were being collected.

The report also points out that enrolments over time can be misleading since students may be counted more than once if their course extends over more than one year or if they are enrolled part-time. Therefore any comparison between the different States and Territories should be made with the awareness that there may be changes over time between the duration of courses, the mix of students (full or part-time) and in the commencement dates of courses between the different jurisdictions. All these factors will impact on the reliability of the data.

Figure 6.12 shows commencements in Enrolled Nurse courses for 1997 to 2000 by State and Territory. Data prior to 1997 were not available. As with enrolments, the data indicate an increase in commencements in recent years. The absence of any commencements recorded in Tasmania and the Northern Territory appears again to be a problem with the data.

Completion rates are not examined due to discrepancies with the data. No institutes interviewed reported that completion rates were declining, and in fact many reported that almost 100 per cent of students reached graduation. However the report notes that the responses of course coordinators about completion rates were in marked contrast to official data, and suggests that completions in the VET system may be poorly recorded. There appears to be number of discrepancies with completion rates where full and part-time courses, and traineeships programmes co-exist, with part-time students having a far lower completion rate (50–60 per cent) and traineeships even lower. It is difficult to correlate commencement to completions, as some students complete their course in one year, while others may take several years.

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Overseas nurses

In its August 2001 submission to the Senate Inquiry, the Department of Immigration and Multicultural Affairs (DIMA) provided information on the numbers of qualified overseas nurses entering Australia permanently or temporarily to join the Australian nursing workforce. It also outlined the schemes by which overseas nurses may come to Australia to work (see Exhibit 6.9)

It is estimated that, in 2000–01, 580 nurses permanently entered Australia and 4 830 nurses entered on a temporary basis. This increase must be set against decreases in the number of nurses in Australia caused by nurses leaving the workforce or going overseas. The net gain in nursing professionals in Australia over the period 1997–98 to 1999–00 was 1200 nurses.

During the consultations comments were made about the three-month limit on work with a single employer for those on holiday work visa. This time limit was seen as restrictive in a time of shortage. There were also some concerns raised about changes to the requirements for students to gain visas that have just been introduced.

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Relationship between supply and demand

While supply is important, the attractiveness of a career in nursing may well be related to the availability of work. Across the 1990s there have been periods of over supply, reduction in workforce and now under supply.

The change in proportion of graduates in full-time work within four months of graduating increased from a base of approximately 70 per cent in 1992 and has been rising. According to Graduate Destination Survey figures in April 2000 it was 95 per cent. It should be noted that 1992 was the year when the biggest shift in commencement into the university sector occurred. In 1991 the number of non-overseas commencements in bachelor degrees was only around 4000 but the following year it had risen to about 12 000 and has been falling²¹  ever since until in 2000 it was approximately 8400.

Some early work on nursing workforce projections by Karmel and Li, not yet finalised, demonstrates a number of features of the nursing workforce not included in earlier parts of this Chapter:

• A projection of net exit rates based on 1995 and 1996 data shows the highest exit rates are for 19–21-year-old Registered Nurses. The exit rates range downwards from 40 per cent to 10 per cent, rates that do not reappear across the age spectrum until the group who are 56 years and older.
• A projection of numbers of Registered Nurses shows that an increase in the exit rate of nurses has a big impact on the number of Registered Nurses. Compared with the model developed from 1995–96 data an increase in exist rate of 2 per cent causes a decline of over 35 per cent between 2000 and 2010. This finding is supported by some figures projected from NSW numbers by O'Brien-Pallas presented at a meeting with the Review Panel on 21 November, 2001.

Together these models provide support for the position that the biggest issue for the maintenance of a sustainable nursing workforce is retention. Supply while important will not overcome current shortages now or in the near future.

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The role of nursing agencies

The current nursing shortages are providing an important test of the impact of nursing agencies in a system under pressure. Evidence that the shortages are driving up the cost of using agency nurses was provided to the Review. This evidence suggests that across a period of twelve months from September 2000 the average cost per effective full-time nurse obtained from an agency could have increased by a factor of 50 per cent or more. The Australian Private Hospitals Association in its submission indicates that the shortages have left hospitals ‘with little choice but to pay the substantially higher costs to ensure patients receive adequate care’.

The submission also goes on to explore the implications of lack of comprehensive planning combined with the increasing costs:

There are no bodies coordinating the combined requirements for government and non-government acute hospitals. This has lead to ‘cannibalism’ and provided opportunities for agencies to act as brokers for nurses seeking more flexible and possibly more highly paid work.

While the use of agency nurses is having an impact on costs, the system has in the past been reliant on the use of staff from agencies to accommodate the fluctuation in demand for services. Some agencies are now offering nurses a level of flexibility and support that is not available in hospital employment, and in the current climate, better remuneration. Should this become a well established pattern of employment for large numbers of nurses who want more control over their work arrangements, the heath and aged care sectors will need to examine their work organisation. The difficulties the Australian Private Hospitals Association sees due to the spiralling costs of using large numbers of agency nurses are that:

Health funds are unwilling to recognise the increased cost of a skilled workforce and are increasing the requirements of private hospitals to justify staffing levels through increasing levels of documentation to demonstrate quality services and risk management strategies.

Higher acuity or patients need higher staff:patient ratios. If skilled nurses are not available alternatives (albeit at a higher cost) solutions will be sought by private hospitals.

In a submission to the Review, Aitken, Manias, Peerson, Parker and Wong (2001) provide an overview of research on nursing agencies. The literature suggests that there is an increasing use of casual labour in nursing. Interviews conducted by this team in South Australia identified the desire to reduce costs by having a core of permanent staff, ‘topped up’ with agency staff as the reason for the doubling of advertised casual and short-term positions between 1993 and 1997.

The predominant reasons nurses give for leaving employment for casual roles is for the flexibility afforded by casual work. ‘In addition, nurses are attracted to casual work in order to combine work with their personal life, meet family and study commitments and for opportunities to work in a variety of clinical settings’.

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Particular Supply challengers

Rural and isolated undergraduates

During the consultations and in the submissions the needs of rural and isolated Australia have been strongly represented to the Review. This is an area which has attracted provision of a range of scholarships both State and Federal. Many of these areas are suffering the shortages that are impacting on nursing across Australia. As is demonstrated by the small number of agency nurses and the high turn over in places like Alice Springs combined with seasonal fluctuations, shortages combined with other factors bring unique problems to rural and isolated healthcare.

Arguments that students coming from the ‘bush’ are more likely to return to that environment to nurse are promoted as a way of gaining support for this group of students. There is some support for this in the Saltmarsh study:

On one rural university campus students were generally residents of the town, or had travelled from nearby rural areas. Not surprisingly, a large proportion of these students planned to work locally once they had completed their qualifications. This is not to suggest, however, that a preference to study and work locally is solely a characteristic of rural students. Students in the study who attended a university campus on the western fringe of a capital city had also applied for places at their ‘local’ campus and aspired to work in that area (p.2).

In some places that the Review visited, support for rural and isolated clinical placements for nursing students is a higher priority than scholarships for rural and isolated students. The ‘locals’ are more likely to want to leave at least for a time, and attracting students from outside the area who have had a positive experience is necessary to sustain a workforce in these parts. This is a particular issue for the Northern Territory which relies heavily on importing nurses from other States.

While not to suggest that rural and isolated communities are well served by nurses, the number of rural and isolated students in undergraduate courses has not dropped as dramatically across the period as students living outside these areas. Indeed in 2000 students from isolated and rural areas made up 30 per cent of the undergraduate students (see Exhibit 6.10). This figure compares well with the 29 per cent of the population living in rural and isolated areas. Further students studying at rural campuses in pre-registration courses in 2001 make up approximately 30 per cent of the students in Victoria, NSW and Queensland and NSW and Queensland have more than 50 per cent completing post-registration courses in rural campuses (Ogle, Bethune, Nugent and Walker, 2001, p. 99)

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Preparation for Specialisation

The numbers of students commencing postgraduate certificates and diplomas are captured in the group displayed in Exhibit 6.11. The large majority of courses preparing nurses to work in clinical specialisations fall into this group, and is generally captured in commencement data, though not necessarily in completions data. Many of these courses articulate directly to Masters degree programmes. Students choosing to continue would not appear in the completions data for this group. The number of students in postgraduate certificates and diplomas rose to a peak in 1996 with 2552 commencements and since then has steadily decreased until in 2000 there were 2114 students beginning these courses.

The need for new graduates to move into areas of speciality due to shortages is essential to meeting labour market needs. There has been a significant decrease in the under 30 domestic age group doing Postgraduate Certificates and Diplomas. After a peak in 1996 to 3741, by 2000 this age group had decreased by 33 per cent. Something has caused a decline in enrolment in courses for specialisation after the earlier growth (see Exhibit 6.11). The information from the universities only represents part of the picture since across the period there was a range of other organisations involved in delivering Postgraduate and Graduate Certificates in areas of specialty preparation. One key player is the NSW College of Nursing, which has a contract with NSW Health to provide this type of education. In 2001 the College is likely to have 795 completions of postgraduate specialist courses (Ogle, et al., 2001, p. 162). This was also the period of consolidation of much of postgraduate nursing education in the universities.

The factors impacting to produce the decrease are difficult to disentangle. The arguments that both HECS and fees, particularly the latter, have acted as a disincentive, has been put to the Review. The contention holds particularly for those nurses carrying HECS debts from undergraduate study. Most nurses under 30 years of age would fall into this category. Various State governments have been paying HECS for students and offering limited numbers of targeted scholarships to try to encourage nurses into speciality shortage areas. Further, although universities are involved directly in the credentialling of postgraduate certificates and diplomas, an increasing number of partnerships are developing in this area which have a range of funding agreements and resource arrangements associated with them.

Other issues likely to impact on the decline in numbers particularly in the latter years are:

• the decrease in completions of undergraduate nursing courses since 1994 which have a flow on effect (see Figure 6.8);
• conditions in the workplace that make additional study very difficult due to staff shortages and work demands, and;
• the lack of additional pay for completion of courses which has recently been acknowledged in some States and has been addressed under new Enterprise Bargaining Agreements.

Exhibits

• Exhibit 6.1 Employment growth
• Exhibit 6.2 Proportional comparison of nursing workers
• Exhibit 6.3: Nursing professionals employment growth
• Exhibit 6.4 Change in Enrolled Nurse employment
• Exhibit 6.5 Changes in PCA and AIN employment
• Exhibit 6.6 Labour market growth
• Exhibit 6.7 Net replacement needs
• Exhibit 6.8 Projected net job openings
• Exhibit 6.9 Nurse migration
• Exhibit 6.10 Rural and isolated students
• Exhibit 6.11 Postgraduate certificate and diplomas

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