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The Nursing Workforce - 20104. ProjectionsAs noted at the outset we construct a number of scenarios, using both models we have developed. We then contrast the ‘demand scenarios’ (projections based on the shift-share analysis) with the ‘supply scenarios’ (projections based on the dynamic model).The issue that is of paramount concern is the number of nursing graduates required to satisfy the needs of the labour market. At one level this is a nonsense question, since the labour market can react in various ways. For example, changes in wages and working conditions will affect the number of qualified nurses who choose to work as nurses and the number of hours they are willing to work. Similarly the way health care is delivered can be varied. For example, some tasks carried out by nurses can be carried out by other health workers, and the mix of registered nurses, enrolled nurses and personal care workers can be changed. However, differences between demand and supply projections do give an indication of the likely size of changes that will need to occur, whether in terms of increases in nurse graduate numbers or changes in the way health care is organised. It must be emphasised that these projections and scenarios are not predictions of what will happen. They are constructs based on certain assumptions and their use is in stimulating discussion on the issues, not in predicting the future. The first scenario is generated using the demand model. In the absence of any information about the internal operation of health care we use simple assumptions that reflect demographic factors and a simple assumption that the trend in average working hours that we observed 1993-1999 continues. Thus these projections are neutral in terms of occupational shifts, morbidity and length of stay. Table 4.1 Assumptions and projections for registered nurses, based on the demand model, 2000-2010 (average annual percentage change)
Table 4.2 Assumptions and projections for enrolled nurses, based on the demand model, 2000-2010 (average annual percentage change)
The supply model uses 1999 data for new nursing graduates (that is we assume that the output of nursing schools and migrant nurse intakes remain constant at 1999 levels) together with the historical exit rates derived earlier. In the case of registered nurses, the age dimension of the model allows the aggregate exit rate to increase as the workplace becomes more concentrated among older age groups. Our data for enrolled nurses do not allow this, but we adjust for this deficiency that the exit rates of enrolled nurses will be more in a similar manner. The supply model does not disaggregate by sector. Table 4.3 Assumptions behind the projections derived from the supply model
For registered nurses the model enables us to project the age distribution. Figure 4.1 shows clearly the ageing of the workforce. As we have already noted that this ageing of the workforce leads to higher aggregate exit rates as we move along our projection period (see Figure A2.1 in the Appendix 2). Figure 4.2 gives the corresponding aggregate nurses. Figure 4.1 The projected registered nurses at 2010 and 2020, based on the supply model
Figure 4.2 Projections of registered nurses, based on the supply model, 2000-2020
We bring these various projections together in the following figures. 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 extra demand that we would expect demographic factors to bring. Figure 4.3 Projections of the number of registered nurses, 2000-2020
In addition, the ageing of the nursing workforce has a continuing effect, at least until 2020. To get some idea of the size of the gap between our demand and supply projections we show what happens if we increase the number of new graduates by 60 and 120 per cent. As can be seen from Figure 4.4 and increase of the order of 120 per cent would close the gap. However, it would not seem to be feasible to expand the education sector by this sort of magnitude. Figure 4.4 Projections of registered nurses, allowing for an increase in the number of new graduates, 2000-2020
The picture for enrolled nurses is rather different (Figure 4.5)9, and we can say broadly that supply and demand are fairly well in balance, assuming that factors other than demographic changes and working hour trends do not come into play. However, an undersupply is apparent by 2010 that would worsen over the subsequent 10 years as the ageing of the workforce takes effect. Figure 4.5 Projections of the number of enrolled nurses, 2000-2020
If the number of new enrolled nurses were to increase by 17%, the excess demand at 2010 would be cleared. However, such an increase could potentially create an oversupply over the next ten years unless the health sector increased its demand for enrolled nurses over our base projection. Figure 4.6 Projections of enrolled nurses, allowing for an increase in the number of graduates, 2000-2020
What conclusions can be drawn from these scenarios? The first is that we cannot assume that the nursing workforce is presently in some sort of equilibrium. Changes will have to occur to bring likely demand and supply into balance. These changes could be varied. Clearly, increased output of nursing graduates by the universities and the vocational education and training sector would help, but it is difficult to see that this by itself would solve the issue. One would have to assume that very significant changes in work organisation would have to take place. It seems that the roles of registered nurses, enrolled nurses and other health carer occupations will have to be modified, because the ratio of nurses to the other health carers will inevitably decline. It would also seem likely that the declining role of enrolled nurses may need to be reversed. It is easier (in the sense of involving less training) to expand the number of enrolled nurses than to expand the number of registered nurses. Perhaps a strategy could involve developing stronger articulation arrangements between the different skill levels. However, it is beyond the scope of this paper to speculate on exactly how these challenges will be resolved. Foot Notes: 9.The projection is based parameters calculated in the Case I, i.e., assuming that 75% commencements graduates and 95% of graduates enter the nursing workforce (that is an inflow of 3336 new enrolled nurse per annum), and a net aggregate exit rate of 0.074. The picture is not markedly different from that based on the Case II projection, which assumes that 70% commencements graduates and 85% of graduates enter the nurse workforce (that is a smaller inflow of 2782 new enrolled nurse per annum), and a lower net aggregate exit rate 0.065.
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