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8. Organising and planning nursing workThis chapter sets out our views on principles and directions to underpin a national strategic approach to planning for a sustainable nursing workforce. Securing an adequate nursing workforce is crucial to the health and welfare of Australians. Provision of quality and safe care to the sick, aged and disabled relies on an adequate supply of a well prepared workforce backed up by appropriate standards and resources. Australia has a skilled and dedicated nursing workforce. It represents a significant national investment in human capital—therefore, its effective and efficient management is essential, both as a matter of good stewardship of public resources and because the global market for nurses is highly competitive. 8.1 Moving forwardPast models and approaches to securing an adequate nursing workforce are unsustainable. New models of care, the demands and pressures on Australia’s health, community and aged care sectors, and career choices available to the Australia workforce make change inevitable. The organisation and planning of nursing work must cater for these changing needs and circumstances. Traditionally in Australia, the focus has been on health workforce planning designed to resolve current workforce problems, in particular addressing shortages and improving distribution. Increasingly, governments are concerned to ensure that there is an adequate supply of skilled labour in all areas of the economy and usually workforce planning has been implemented through education and training policies (Duckett 2000). Today, human resource planning for health care is receiving growing recognition and interest, reflecting greater understanding of the complex dynamics involved in ensuring an adequate, flexible and highly competent workforce. Some countries such as the United Kingdom have a long experience in human resource planning for health care while for others, like Australia, it is relatively new. In this report, we have used the term ‘workforce’ due to its common use in relation to nursing. However, we note that when a human resource planning approach to considering these matters is used, it is more usual to use ‘labour force’. Reliance on single solutions, such as increasing the supply of nursing places in the education and training sector or recruitment and re-entry programs for nurses who have left nursing employment, is not the answer to addressing Australia’s nursing shortages and building a sustainable nursing workforce for the future. A national strategic approach is required that focuses on human resource planning, with action occurring on the following related fronts:
Conceptual frameworks for nursing education must be aligned with the ongoing development of the nursing workforce. The scope of practice for nurses underpins the education and training of nurses who, if they are to be regarded as professionals, must work within a professional decision making framework. While this is a key element of the way nursing services are provided, it is not developed in this chapter because it has already been examined in Chapter 5 due to its relationship with the legislative/regulatory framework. 8.2 Work organisationHealthcare delivery involves a complex and dynamic set of systems and processes. As discussed in Chapter 4, the variety of places and settings where services are delivered is increasing, as are the range and types of services provided. Since these trends are likely to continue, they pose challenges for nursing work organisation. Nursing work organisation is context-dependent because it occurs in a range of different settings that provide nursing care to different client groups. Within these different contexts, work organisation must recognise the spectrum of care comprising nursing work, from trained care assistants through the various levels, and must recognise the appropriate mix of competencies required across the spectrum to provide the community with quality and safe services. 8.2.1 Maximising value—resources and professional capacityWork organisation must ensure the best use of available nursing resources and must ensure that nurses are able to practise to their full professional capacity within particular care contexts. Often ‘best use’ is considered in financial terms only, not in terms of cost effectiveness. For example, concerns are expressed about the relative high costs of registered nurses, with attention often placed on the wages and salaries bill nurses represent to hospitals and other health and care services and on ways to employ other types of care workers as substitutes. Overseas research in the acute care setting, however, indicates that a ‘rich skills mix’ in the delivery of care, comprising a high proportion of registered nurses, may not be more expensive than a mix with a large number of unregulated workers. O’Brien-Pallas, Thomson, Alksnis and Bruce in The economic impact of nurse staffing decisions: Time to turn down another road? (2001) present evidence showing that the right number of nurses and right skill mix has cost benefits. They report that understaffed hospitals had higher costs than hospitals employing more care givers, that reduction below a certain proportion of registered nurses increased costs, and that adequate nursing levels can contribute to cost reductions. Fagin (2001) also reports a study by Sovie in 1999 that found that the cost drivers were fewer registered nurses and equivalent staff and hours worked per patient day, not the proportion of registered nurses.Recommendation 28—Work organisation Because the nursing workforce (including trained care assistants) contains a range of experience and skills, and because it needs to adapt to an evolving care environment, work organisation throughout the health, aged and community care sectors should: a) constantly seek to achieve the most effective and efficient use of the total nursing workforce (including learning from best practice elsewhere) b) ensure that skills and expertise are matched to the work required in the particular workplace c) take account of the interrelationships with other health professionals d) ensure that nurses are encouraged to practise to their full professional capacity. Proposed responsibility: The NNCA and employers 8.2.2 Responsive to changeThe organisation of nursing work must be dynamic with capacity to respond in timely and effective ways to changing community needs. Models of nursing care will change as health, community and aged care systems change, often in response to shifts in attitudes or new technologies. Models of nursing care and practice should be continually monitored, reviewed and evaluated to ensure their appropriateness, cost effectiveness and relevance. New models of best practice should be developed and tested to address changing needs and circumstances. 8.2.3 Guiding principlesOrganising nursing work requires:
8.3 National approach and leadershipModels of work organisation have developed on a State and Territory basis or by particular groups within the nursing profession, reflecting service delivery arrangements and particular professional interests. A national strategic approach across the nursing workforce is vital. The proposed National Nursing Council of Australia (NNCA) is best placed to provide national leadership on nursing work organisation. It should undertake regular reviews of nursing work organisation in Australia, monitor developments and practices, and report on examples of best practice in the organisation of models of nursing care. 8.3.1 Workplace cultureA supportive workplace culture that takes account of professional and personal needs and aspirations is essential to securing an adequate nursing workforce. Nurses’ professional needs and their expectations of the workplace were a recurring theme in Review submissions and consultations. Nurses want:
Nursing students anticipate completing their studies to enter a workforce that recognises their qualifications and experience and in which there will be mutual respect and teamwork. Instead, as one group of nurses and nurse educators noted ‘they often find they belong to a profession often controlled in a paternalistic manner and one that is not held in high regard by other "health team" members’. Additionally, ‘upon entering the profession the reality they encounter is one of endless shift work, low pay, horizontal violence, social isolation, risk of injury and disease’. (Senate Community Affairs References Committee 2002, Submission No.51). 8.3.2 Positive work environment and professional recognitionThe importance of a supportive work environment is a recurring theme in the research literature and the Review submissions and consultations. Many nurses feel that their work is not valued, that they do not have the power to influence the system in which they work, and that their high levels of clinical judgment and decision making are not recognised in the workplace. Many nurses consider that nursing shortages compromise their capacity to function as a nurse and provide care. Long and inflexible hours and supervision of casual workers and those with little or no education and training were identified as contributing factors. Current shortages have created a climate that often results in aggression between staff, and hostility from families and patients. A number of submissions raised the issues of cost cutting or rationalisation of healthcare funding impacting adversely on nursing. Support services to nurses (supply, clerical, human resources, cleaning and food services) have been reduced with experienced nurses spending more time undertaking tasks that take them away from delivering nursing care. Pearson and colleagues (2002), in a recent review of recruitment and retention of nurses in residential aged care for the Commonwealth Department of Health and Ageing, identified the importance of a supportive work environment in improving the retention of nurses by minimising stress, burnout, low morale and low organisational commitment. The most powerful emerging theme was profoundly low job satisfaction felt by nurses. They conclude that simplistic cosmetic tinkering will be ineffective. Substantial structural changes are required to begin to rectify the poor working conditions and low morale of the existing workforce. Further, they noted the impact of documentation load in aged care— a theme we often heard during the Review consultations. Consequently, we make the following recommendation in the interests of encouraging nurses to remain in aged care. Recommendation 29—Aged care nursing To ensure that residents of aged care facilities have access to quality nursing care and that nursing in the aged care sector is an attractive option for nurses, Commonwealth aged care responsibilities and funding arrangements should enable professional nursing time to be focused on residents in aged care facilities by separating professional nursing documentation from the funding tool. Proposed responsibility: Commonwealth Department of Health and Ageing 8.3.3 Multi-professional team workA positive work environment involves the promotion and fostering of multi-professional team approaches to care provision. As noted in Chapter 4, increasing features of emerging models of care in the health, community and aged care sectors are integration and care coordination. This requires both new approaches to education and training of nurses and other health professionals and changes in the work environment to foster multiprofessional teamwork. 8.3.4 Occupational health and safetyOccupational health and safety was a key concern identified by Review respondents. Safety was seen as directly related to the increasing pressure and stress nurses are facing and the inherent risks and dangers involved in working long hours and large amounts of overtime. Hospitals and nursing homes are areas within the health and aged care sectors that most commonly experience injuries and subsequent workers’ compensation claims (Submission from Queensland Nursing Council). Many submissions called for employers to ensure the safety of nurses in the workplace and when leaving work. In research undertaken for the Review on what nurses are doing every day in various practice and work settings and the challenges they are facing, Jones and Cheek (2001) concluded: Of grave concern throughout the study has been the degree to which nurses have shared experiences of aggression and/or violence in their practice area. Aggression can be verbal abuse from other staff, doctors and patients and/or their family members or it can be threat to harm, and at times physical assault. Many nurses expressed concerns for their personal safety and those in their care. Some workplaces within the study do not have readily available on site security or adequate systems of security. A significant challenge expressed by many nurses was the lack of support provided by management for safety and a sense of feeling ill-prepared to anticipate and manage escalating events. 8.3.5 Need for actionIt is clear that nurses will not continue to work in environments that take little account of their professional and personal needs and aspirations. Research on why nurses are leaving full-time employment suggests that unless the working environment is such that it meets nurses’ needs, they will choose either to move to casual employment or leave nursing. Nurses today have a range of skills in high demand in the labour market and, combined with higher levels of education, they are in an excellent position to choose from a range of other career options. A culture change is required. Organisational and other barriers must be overcome and an environment created where professional nursing practice is valued and supported over time. We acknowledge that this is not an easy task and that simplistic solutions will not bring about sustainable change. New approaches are required including ways to encourage health, community and aged care organisations to adopt practices that involve nurses in decision making, promote collaboration among health professionals, give nurses the opportunity to pursue continuing education and organise care to improve patient outcomes. Investment in the nursing workforce in these ways is crucial to the health and welfare of all Australians and will enhance the nation’s ability to respond to public health needs and crises. It is essential that all players work together on these matters, that innovations to bring about structural changes are encouraged, and that approaches and results are shared. Recommendation 30—Workplace culture To develop a constructive workplace culture, management in all health, aged and community care sectors, in consultation with staff, should establish and implement a suite of policies that encourage: a) support for professional development b) a positive work environment in which staff feel valued and are able to make their full contribution c) multi-professional team work d) workplace safety and cultural sensitivity e) a work/life balance. Proposed responsibility: Commonwealth, State and Territory health ministers and other employers 8.4 Planning the nursing workforceAchieving a balance of supply and demand in the health workforce is difficult for several reasons: long lead times for education and training of health professionals, low mobility of health professionals, and the impact of rapid technological change on demand projections. Low mobility of the nursing workforce is a particular feature of some rural environments. 8.4.1 Australian health workforce planningNational self-sufficiency has been the main policy goal and the mal-distribution of the workforce between urban and rural areas has been a constant challenge to policy makers. These challenges are likely to be a continuing part of policy developments since there will always be locations and communities that are less attractive employment settings. Health workforce planning has sought to minimise divergences between supply and demand. Duckett (2000) has observed that Australian health labour market planning has tended to influence supply, with demand being viewed as exogenous. As Duckett (2000) points out there are real costs associated with imbalances. Under-supply results in poor access, unmet need, potentially poorer health outcomes, overworked and stressed workers (which may make the profession or area unattractive and further reduce supply), and increased costs of alternative provision. Over-supply may lead to unnecessary costs in education and training. A primary focus of planning has been the medical workforce, with planning undertaken through the Australian Medical Workforce Advisory Committee (AMWAC). However, attention is shifting to other health professionals, with the nursing workforce now a priority concern. This work is being conducted by the Australian Health Workforce Advisory Committee (AHWAC), which was formed in 2000 to provide a national approach to human resource planning for other health professionals including nurses. This is an important national development. Previously, nursing workforce planning was undertaken largely on an individual State and Territory basis. 8.4.2 Australian nursing workforce planningInitially, AHWAC is concentrating on future workforce supply for critical care nursing and midwifery. A similar approach to that used by AMWAC to estimate the number of medical practitioners required to meet but not exceed future population requirements is being adopted. The approach covers workforce supply and workforce productivity (supply side measures), population requirements for services (demand side measures) and matching future supply and requirements. It should be noted that this methodology is currently under review. AHWAC is also conducting another project, Profile of the Nursing Workforce, to establish a national agreed baseline profile of the nursing workforce in different settings, sectors and jurisdictions. Unfortunately, the findings were not available for consideration in this Review. The project is due to report in October 2002. In the past, States have put considerable work into nurse workforce studies (general and specialist workforce projections and surveys to investigate issues around the successful recruitment and retention of nurses) (Johnson & Preston 2001). Much of this work has been limited by data quality and methodology problems. It is important, however, that lessons learnt from this work are drawn upon in current and future nursing workforce planning initiatives. For this Review we commissioned two studies: Job Growth and Replacement Needs in Nursing Occupation (Shah & Burke 2001), and The Nursing Workforce 2010 (Karmel & Li 2002). The projects are based on different methodologies. Both projects identify the difficulty of capturing a picture of all paid workers involved in nursing work. Both relied on data from the Australian Institute of Health and Welfare (AIHW) and Australian Bureau of Statistics Labour Force surveys and the Labour Mobility survey for 2000. The implications of the findings of these studies for supply are discussed later in this chapter. 8.4.3 International developmentsInternationally, the Organisation for Economic Co-operation and Development (OECD) has identified an interest in exploring human resource policies for healthcare that best contribute to efficient and effective delivery of health services across OECD health systems. The project recognises the importance of health workers in timely delivery of good quality health care, that they represent a significant share of OECD workers and population, that healthcare is an expanding area for employment and that OECD countries are facing various labour market scenarios. Some predict an over-supply of doctors or nurses or both. Others expect shortages either in general or in specific regions or specialisations. The project, Human Resources for Health Care, will focus on physicians and nurses. 8.4.4 Supporting information and researchTimely, reliable and comprehensive workforce information is an essential planning ingredient. Workforce information on nurses is collected periodically by State and Territory nursing registration boards in conjunction with renewal of registration. Data is processed electronically by State health authorities. In addition, every two years the AIHW conducts a survey of the nursing workforce in Australia at the time of registration renewal. The AIHW draws together information from these and other sources in a national nursing workforce publications series. There are long lead-times associated with collection, processing and release of nursing workforce information. Similar problems are experienced for other areas of health workforce. They relate to the use of administrative sources across eight jurisdictions. As well, differences in definitions and nursing nomenclature across jurisdictions hinder development of national time series and comparisons. The AIHW is pursuing ways to improve the currency and comparability of nursing workforce information for Australia. 8.4.5 Areas for improvementReview submissions, consultations and research have highlighted several problems that need to be addressed in improving Australian nursing workforce planning. Data problems include:
Methodological problems focus on the inherent difficulties associated with workforce projections and related studies and contestability of results. Structural problems are evident in conclusions that often have little influence on or relevance to policy or practice and that lack strategic policy focus. The workforce needs of the private sector and community and aged care sectors are often overlooked. Many respondents commented on the lack of effective structures or means for feeding nursing workforce needs into the supply of education and training places loop, lack of a national picture, and lack of understanding of particular needs such as those for specialist nurses. 8.4.6 Future needsNumerous reports have emphasised the need for a national approach to nursing workforce planning strategies and processes. A national approach to addressing nursing workforce planning is essential to securing a sustainable workforce for the future. AHMAC and AIHW play important roles and the establishment of the AHWAC is a significant development in attaining a national approach. Effective national nursing workforce planning requires:
Recommendation 31—Workforce planning and data Workforce planning is a vital component of future policy processes. It needs to be based on reliable valid data. Consequently the following are supported: a) AHMAC’s ongoing work on nursing workforce planning which should proceed as a matter of priority to determine:
b) The ongoing work of the Australian Institute of Health and Welfare (AIHW) to establish and analyse data on the nursing workforce (including action to improve its currency) should proceed as a matter of priority. Proposed responsibility: Implementation taskforce in consultation with AHMAC Recommendation 32—Health workforce research funding Australia’s workforce planning needs to be based on an integrated view of the workforce, developed using quality research tools. At the same time, recognition of the unique contribution of particular professions, such as nurses, must be understood. To promote this approach: a) funding should be provided for further development of a robust methodology for all health workforce planning (including nursing), with consideration being given to the establishment of a research centre to undertake this work. Funding should be provided for five years in the first instance, subject to review b) the methodology employed should draw on overseas research to further develop nursing indicators that are applicable in the Australian context. Proposed responsibility: Implementation taskforce 8.4.7 Retention—the keyEvidence from a variety of sources (Shah & Burke 2001, Pearson et al. 2002, and Karmel & Li 2002) clearly indicates that increasing the supply of nursing education and training places will not address Australia’s nursing workforce needs for the foreseeable future. This was a constant message in Review submissions and consultations. Losses of recent graduates are reported to be high. Research on nursing workforce projections by Karmel and Li (2002) shows that the highest exit rates are for 19–21–year-old nurses and that any increase in the overall exit rate of nurses will have a significant impact on registered nurse numbers in the near future. Nursing is competing with a wide range of career options for women, the group most likely to be nurses. There are long lead-times in nurse education and training. Retention of highly skilled and professional nurses in the health, community and aged care workforce is the key factor in ensuring a sustainable nursing workforce for the future. The disappearing questions Retention of nurses and why nurses leave nursing are not new questions. A number of studies have examined the various aspects of nurse education and nursing that have made it difficult to retain nurses, and have advised on retention strategies. Studies include Ministerial Taskforce. Nursing Recruitment and Retention (Queensland Health 1999), Nursing Recruitment and Retention Taskforce – Final Report (NSW Health 1996b), Attracting Nurses Back to the Nursing Workforce (Health Department of Western Australia 1997), Factors influencing the recruitment and retention of nurses in rural and remote areas in Queensland (Hegney et al. 2000) and Nurse Recruitment and Retention Committee: Final Report (Department of Human Services [Victoria] 2001). The reasons nurses leave nursing are well documented (Aitken et al. 2001) and consultation with nurses and nursing organisations during the Review confirmed many of them. Most relate to different aspects of working conditions such as:
In their recent study on recruitment and retention of nurses in residential aged care, Pearson and team (2002) indicate that most nurses who have left the aged care nursing workforce have done so for personal or family reasons, with a significant number also citing low pay, low staffing levels, excessive documentation and poor status. The matter of nursing retention will not disappear. Some action is being taken in parts of Australia and parts of the health, community and aged care sectors to address reasons for leaving and to encourage nurses to stay in nursing (see Attachment 6.1). A coherent national strategy and national action are vital. The price of inaction is high. There are real social, economic and personal costs associated with nursing losses and inaction. An education and training supply strategy will be of little effect if retention is not addressed. Each highly skilled nurse lost to the system will take at least four years’ investment in education to replace. The costs of high turnover are enormous. For example, the Northern Territory Health Service (2001) estimates that the replacement cost for one year of Registered Nurse Level 1 (RNL1) turnover for Alice Springs hospital was $300 000. Moreover, the small proportion of the workforce aged less than 30 years of age means that those who might be interested in a long-term career in nursing will be sourced from fewer nurses than in the past. Loss of much of the educational expertise in the clinical environment means that some students are not receiving good quality learning experiences in that environment. The system is already showing signs that it is unable to support the demands on clinical education that current numbers of students are making. New graduates are unable to complete a transition period without facing the demand to take on high levels of responsibility while completing graduate programs. Producing a specialist nurse builds on the foundation of initial education, training and experience. As generalist nurses are in short supply, taking from their ranks to produce specialist nurses only shifts the problem of shortage. If employers wish to encourage the retention of new graduates, they could offer support with the payment of HECS. As an incentive, this would provide encouragement not just to study nursing but to practise nursing and increase the attractiveness of a career as a nurse. Arrangements between employer and employee are particularly powerful in this regard. Incentives may take many forms, and may actually decrease the costs to employers of the high turnover and replacement evident in some places. If employers chose to assist with the payment of HECS, they could take advantage of the 15 per cent discount for voluntary repayments of $500 or more. 8.4.8 Re-entryRe-entry strategies focus on addressing nursing shortages by tapping into a resource of inactive nurses. Review respondents identified promoting the recruitment of nurses who have left the profession as another important strategy for addressing nursing shortages. Provision of refresher and re-entry facilitates the return of nurses. Some States and Territories have embarked on significant re-entry recruitment and training efforts in recent times (see Attachment 6.1). Concerns about refresher and re-entry courses seldom arose during Review consultations. Matters that were raised included the costs of courses (especially when delivered by universities), lack of flexibility for those with family or work commitments, and the need for nurse registration bodies to have a process to ensure standards of these courses. Re-entry strategies are enrichment strategies. They recognise the richness that experienced and older workers bring to nursing teams and workplaces and the benefits of combining nurses of different ages and experience into teams. Pearson and team (2002) examined a range of matters associated with recruitment of nurses who have left the Australian residential aged care sector. Following a review of the available literature on nurse re-entry programs and courses, the authors noted that:
Courses provide additional benefits to participants including regaining self-esteem and confidence in practice. Pearson and colleagues concluded that re-entry courses provide a cost-effective and prompt solution; however, the number of nurses graduating is low. They developed a model re-entry training program in aged care and recommended the establishment of a national nurse re-entry program in aged care to address current deficiencies. We support the broad thrust of these recommendations and observe that they are part of a set of recommendations before the Commonwealth Department of Health and Ageing aimed at addressing recruitment and retention of nurses in residential aged care. While nurse re-entry programs may provide a cost-effective and prompt solution to nursing shortages, they should not be viewed as the sole solution. 8.4.9 SupplyThe current difficulties in attracting and retaining nursing staff need to be addressed immediately. A major investment in the retention of the existing workforce, recruitment of nurses not currently employed in nursing, recruitment from overseas and investigations about how work could be better organised are necessary. Until there are improvements in these areas there will continue to be problems with the provision of clinical education and the transition of new nurses into the workplace, as well as problems in attracting new members to the profession and retaining current members. There are three recommendations dealing with increases in the numbers of places in nursing courses and training for care assistants (Recommendations 33–35). Those related to nursing (Recommendations 33 and 34) should be read as contingent on progress in the areas of retention, immigration and work redesign. Additional numbers of nursing places above those recommended in the following recommendation (Recommendation 33) should be based on research about the appropriate numbers and skill mix for evolving models of care. A number of studies undertaken recently support the view that the current levels of supply of registered nurses from universities are insufficient to meet demands. These include the work commissioned by the Australian Council of Deans of Nursing (ACDON), yet to be published, the Shah and Burke (2001) report and the study of Karmel and Li (2002), both of which were commissioned for this Review. The trends in relation to trained care assistants are confused due to the lack of a single nomenclature and classification grouping. Some are identified within the nursing workforce by AIHW, others are in completely separate workforce categories. Enrolled nurses, while currently in shortage, do not appear to present the same difficulties in terms of supply as registered nurses under current work organisation. These three studies all use different methodologies based on different assumptions. All the studies provide projections which ‘are constructs based on certain assumptions and their use is in stimulating discussion on the issues, not in predicting the future’ (Karmel and Li 2002). The ACDON report deals specifically with university graduates. The Shah and Burke (2001) study examines job growth and replacement needs. They project from 2001–2006 net job openings of 21 100 for registered nurses, 1900 for enrolled nurses, 2900 for personal carers and assistants in nursing and 20 500 for aged and disabled person carers. Registered nurses Karmel and Li make the following observation based on their projections: What is stark is the size of the disparity between the demand and supply projections for registered nurses. In 2010 the difference is of the order of 40,000 registered nurses, That is, the current output of nurses is insufficient to maintain the current workforce (assuming the reasonably benign exit rates of 1995-96 are maintained), let alone cope with the extras demand that we would expect demographic factors to bring. (Karmel and Li 2002) Consequently, we argue for an increase in funding for undergraduate nursing load, initially for two years, until further work on both new models of work organisation and retention strategies can be assessed. We suggest an increase of 5–6 per cent each year. There are currently difficulties finding clinical placements for some students and this needs to be considered when increasing places in undergraduate nursing programs. A faster output of graduates can be achieved by accepting into the program people who can gain advanced standing or credit toward a nursing degree. It is therefore in the interest of the workforce to focus additional places on this group, rather than on recent school leavers. In the longer term, strategies to increase the numbers of graduates with nursing degrees need to be linked to the demands of the health, aged and community care sectors and the capacity of the system to provide quality education including clinical education. Retention of new graduates by providing appropriate transition support is also essential. Commonwealth commitment to additional funding for undergraduate nursing education after the initial two years should be considered within the context of more reliable workforce data and other strategies to encourage the retention of the current nursing workforce. Recommendation 33—Commonwealth funding for additional undergraduate university places An increased supply of registered nurses is essential due to current shortages and the rapidly ageing nursing workforce. An initial short-term measure to achieve this outcome should include the following actions: a) A benchmark for nursing commencement load based on the 2002 equivalent full-time student units (EFTSU) for non-overseas nursing commencements in each university (including direct-entry midwifery) should be set as the target for the following two years, with under-target load to be re-distributed to universities which have provided additional nursing EFTSU above the 2002 benchmark. The results to be reviewed after two years. b) An additional minimum of 400 EFTSU for undergraduate nursing commencements should be provided for two years, beginning if possible in 2003, on the basis that:
Proposed responsibility: Commonwealth Department of Education, Science and Training Expansion of enrolled nurses and VET-in-schools Since both the school sector and the vocational education and training (VET) sector are State and Territory responsibilities, the following recommendation relies on the support of the State and Territory education portfolios. In recent years there has been an expansion of the number of commencements in enrolled nurse training across Australia (see Table 2.9). Universities also report high levels of interest in enrolled nurses wishing to complete nursing degrees. We encourage this pathway because it both provides career advancement opportunities for enrolled nurses and a quicker supply of registered nurses in times of shortage. As noted in Chapter 2, there has been a shift in the composition of the nursing workforce away from enrolled nurses to registered nurses in some settings and care assistants in other settings. Karmel and Li (2002) indicate that projections for enrolled nurses show a reasonable balance between supply and demand. They also make the point that there will need to be structural changes in work organisation. Key to these changes will be the enrolled nurse. An increase in supply of enrolled nurses and in the numbers of those upgrading to registered nurses is necessary to support this change. Enrolled nurses are currently in shortage in all States (see Table 2.2). A range of training options for enrolled nurses is available. One, traineeships, offers potential for rural and regional areas in particular. We reported in our Discussion Paper that there were trainees in Victoria and Tasmania in 2001 and have also documented an example of a program that uses this model of training in Port Pirie in section 6.3.1 of this report. To support these processes as well as to build the educational capacity in different services, we propose that nurses be offered workplace trainer and assessor courses. Further, to encourage interested senior school students in a course related to nursing we support the development of VET options based on the Community Services and Health Training Packages. These offer school students alternative pathways into nursing, which may be attractive to some students since they do not rely on a sufficient TER to gain university entry. The success of some of these initiatives is demonstrated in section 6.3.2. Although it is possible in many States to build these options into the school curriculum, we found only one example where the system had developed an option that could then be accessed by all schools and this was in South Australia. This option is the Care and Health Industries Pathways for Schools, which is also explained in section 6.3.2. We encourage other school curriculum authorities to assist the expansion of VET courses based on the Community Services and Health Training Packages to broaden the options for those students interested in this essential industry. Recommendation 34—Expansion of opportunities in VET and VETin-schools States and Territories should expand opportunities for entry to enrolled nursing and occupations that do nursing work by: a) providing additional training places for enrolled nurses to replace those upgrading to registered nurse within the State/Territory, and to meet shortages of enrolled nurses b) promoting employment of student enrolled nurses through models of education and training such as traineeships c) working with the Commonwealth to expand traineeships in rural areas as an entry to care work and nursing d) supporting the expansion of VET-in-schools programs based on the Community Services or Health Training Packages e) offering workplace trainer and assessor courses to nurses and recently retired nurses willing to assist in training or supervision of student nurses or trainees, particularly those in rural areas. Proposed responsibility: Commonwealth, State and Territory ministers for education and training Training places for care assistants In earlier sections of this report we identified the need for care assistants to have appropriate training for the work they do. The following recommendation supports Recommendation 7, which requires all workers without relevant recognised training who are employed in care of patients/clients to have a minimum competency standard of Certificate III from the appropriate Community Services or Health Training Package. While there has been substantial progress in the number undertaking training, particularly in aged care (see Table 2.10), the growth has not been even across all the States and Territories. Table 8.1 compares enrolments in the various certificates by States and Territories. The numbers enrolled in Certificate III in aged care work are most encouraging, particularly in Victoria and South Australia. The enrolments in disability and community work certificates are far lower than those in aged care work. This suggests there will need to be a concerted effort in these sectors. Table 8.1 Enrolments in Certificate III in Community Services training packages across Australia for 1999, 2000 & 2001
We recognise that there are workers in all of these industries with long-standing experience through which they have developed competencies at the level required to perform their work. Those workers should be able to be assessed in the workplace rather than undergo unnecessary training. Our recommendation recognises this and suggests that part of the strategy should be to increase the number of workplace assessments as well as expanding training places. The strategy will require negotiations with the aged, community and disability care sectors, particularly as there is little known currently of the numbers of workers who will require this up-skilling. Recommendation 35—Training places for Certificate III To ensure that those workers involved in direct care work in the health, aged and community care sectors achieve a level of at least Certificate III in the appropriate Community Services or Health Training Package by 2008, a strategy should be developed to expand workplace assessment and the number of training places for Certificate III in the appropriate training packages. Proposed responsibility: Commonwealth, State and Territory ministers for education and training 8.5 Support processesEffective support processes are important elements of a culture and environment that values nursing work. The need for improvement was a common theme during Review consultations. Review respondents sought improvements on two fronts: effective leadership in workplace management and in clinical settings, and effective leadership in promoting and representing the nursing profession. 8.5.1 Leadership and management in the workplaceLeadership, staff development and analysis of values and beliefs must be considered in nurse education today. Jones and Cheek (2001) report that both registered nurses and enrolled nurses across this study required management and, to some degree, leadership skills: You have to have management skills … you’ve got to know about project planning, you’ve gotta know about quality improvement, you’ve got to know about budgeting, you’ve gotta know about employee human resource management, staff training, those are all really important elements … I’m trying to organise the police to come and do safety awareness for our nurses, now that’s not particularly my role, because I’m community . But because you know, the assaults and everything on nurses, I’m actually liaising with the local police… The current healthcare environment is complex, with management tools, financial systems and human resource allocation part of most everyday practice for nurses. Nurses are leaders of teams within given settings—for example, enrolled nurses are seen to lead teams of trained care assistants in aged care settings, they manage stock and finances linked to a general practice or theatre and are required to manage not only their time but to maintain efficiency with the system. Registered and enrolled nurses expressed the need to have good time management skills to progress through the requirements of the day and to meet the needs of those in their care or those to whom they provide a service. Currently, there is a diversity of courses available. Programs include postgraduate programs in functional nursing specialties, leadership and management programs and initiatives such as the ICN Leadership for Change, Health Leaders Network and others (see Attachment 8.1). National collaboration between the education and health sectors in the development of educational postgraduate programs to prepare nurses for clinical leadership and management is vital. Strategies should cover:
We also note the development of work environments where nurse leadership is visible and supportive of staff. One example is magnet hospitals where positive characteristics of clinical nursing include autonomy in practice, status within the organisation and collaboration. 8.5.2 Professional leadership at all levelsLeadership and representation of the Australian nursing profession nationally and internationally also plays an important role in the valuing of nursing. Development of responsible and responsive policies relating to nursing practice requires drawing on the expertise and knowledge of the nursing profession. Many submissions commented on deficiencies in current policy advice arrangements. Recommendation 36—Nursing leadership and management For nursing leadership and management to be enhanced: a) governments should ensure improved representation of nurses on bodies which advise on both health and health education issues, so as to use more fully the expertise and knowledge of the nursing profession b) workplaces should recognise and support the development of future nurse leaders and managers, using initiatives such as:
Proposed responsibility: The NNCA |
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