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ATTACHMENT ONE
Submission to Senate Inquiry
NURSING IN NEW SOUTH WALES
WORKFORCE ISSUES
OVERVIEW
PREPARED BY
JUDITH MEPPEM
CHIEF NURSING OFFICER
NEW SOUTH WALES
Updated June 2001
INTRODUCTION
The New South Wales (NSW) health system provides high quality service. Our
public system is one of the strongest in the world, built on the foundations of
universal entitlement and access. It is the result of the outstanding
commitment of all who work in it and have built it over the generations.
The system continues to undergo significant change and development as it
experiences increasing levels of activity including increased admission rates,
increased patient acuity, increased day of surgery and day only admissions,
reduced length of stay and increasing consumer expectations.
Approximately 40,000 nurses are employed in the NSW public health system.
Together with nurses employed in the private, community services and aged
care sectors nurses make up the largest section of the health and community
services workforce. A significant number of nurses now work outside the
traditional hospital setting and there is a growing need for all nurses to remain
abreast of current nursing and health issues and to proactively participate in
health planning and decision making processes.
Health systems need well educated nurses and midwives who can function
across a diverse range of practice settings, utilising evidence based nursing
practice within a multidisciplinary model of health care.
There is a direct relationship between length of stay and nursing workload and
trend data over the past few years indicates an increase in overall nursing
productivity, both in terms of quantum (number of patients treated per nurse)
and intensity (severity of illness of patients treated).
Nurses generally feel undervalued and believe that they are hearing two
messages. One that says we need nurses and the other, at a more
operational level, where they are continually being asked to do more with
fewer resources.
Recruitment and retention of nurses continues to be a high priority of NSW
Health. However, it must be recognised that a number of the issues are
‘societal’ issues and are not ‘nursing workforce’ specific. As such they
continue to present major challenges for the health system.
Examples include:1. Nurses, like all other workers are now strongly influenced by lifestyle
choices and are demanding much more access to part-time and casual
employment to enable them to balance family, study, and the social
elements of their lives. This presents significant challenges for nurse
managers, who are required to staff health services over a 24 hour day,
seven days per week.
2. The majority of nurses are women, many who leave the workforce for
varying periods, to have and raise children and manage other family
responsibilities.
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3. The mobility of nursing qualifications (both interstate and internationally)
which is a central attraction of the career, facilitates travel and the
movement in and out of the workforce.
1.
RECRUITMENT AND RETENTION OF NURSES
A range of complex and interrelated issues (Tab A) impact on: recruitment into our undergraduate educational programs;
 recruitment, support and retention of registered/enrolled nurses; and
 attracting nurses who have left, to return to the system.
Issues such as casualisation and ageing of the nursing workforce are two of
the significant factors in recruitment and retention, as is the mobility of nurses
between the public/private sectors and interstate/international arenas. While
this mobility is one of the central attractions of nursing as a career choice, at
the same time it presents a challenge for health systems.
The health system, in some sections, has responded slowly to the recognition
of the multiple roles of spouse, parent, student, nurse and individual, which
describes many nurses across NSW. Skilled nurses leave the system in order
to access the flexibility they require.
Casualisation of the workforce is a factor in that more nurses (like other
occupations) want to work part-time and casual shifts to enable them to do
other things (eg. study, parenting, spouse’s business etc). This creates
tension with full-time staff who are then required to work the more
“undesirable” shifts.
Other issues include: The nature of nursing work itself. While nursing is a very rewarding
career, it is physically, mentally and emotionally demanding;
 Nursing care is essential yet it is still relatively invisible;
 Increase in technology;
 Relatively little influence over patient activity;
 Access to and financial support for education. Nurses believe that
they are disadvantaged (as compared with medical officers) with
access to leave and financial support for educational activities;
 Workload, staffing levels and skill mix issues, including staff/patient
ratios, increased patient acuity and shorter length of stay;
 Flexibility/working conditions. For example, the need for job sharing,
remote area incentives, time in lieu, bonus schemes are all raised
by nurses from time to time;
 24 hour nature of nursing services and the requirement for shift
work, including ‘unsociable hours’;
 Impact of changes to support staff;
 Workplace culture. Bullying is a ‘system wide’ issue between staff
categories as well as within professional streams. This is
exacerbated by ‘hostility’ and aggressive behaviour by patients and
their relatives;
 Consumer expectations;
 Safety and security of both persons and possessions eg. vehicles;
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 Telecommunication black spots;
 Nurses are the systems’ greatest resource yet they are seen as the
greatest cost;
 Power structures - within nursing and between medicine/nursing and
nursing/administration;
 Recognition of nursing and midwifery’s input at every level in the
system;
 Ineffective communication;
 Lack of good clinical and staff management information systems
and research on nursing and midwifery workforce;
 Access to affordable child care and before and after school care;
 Professional isolation in rural NSW;
 Impact of seasonal fluctuations on the availablity of nursing staff eg.
winter, school holidays, harvesting etc;
 Local community expectations in rural towns;
 Access to affordable accommodation. Lack of appropriate
accommodation (and financial support) for undergraduate students
on clinical placement are also critical issues. Accommodation is also
a problem for recruitment of staff to remote areas;
 Collaborative practice. Some nurses believe that they are not valued
as part of the team. Nursing care is not isolated from other providers
but complementary to the skills, knowledge and care provided by
other health professionals and health care workers. Collaborative
planning, practice and evaluation should be the foundation of
relationships across professional boundaries within the multidisciplinary team;
 The non availability of appropriately skilled and readily available
relief staff is recognised as being an overriding issue, not only in
relation to access to study leave but in terms of recruitment/retention
and access to all leave entitlements and the need to keep services
open;
 Negative image of nursing portrayed in the media. We rarely hear
the good news about the extraordinary things that are happening in
nursing and midwifery practice, education and research;
 There is increased ‘competition’ between many occupations in
recruiting school leavers;
 School leavers and society have very different expectations of how
they will be treated; and
 Nurses find their qualifications are an excellent stepping-stone to
other work and career opportunities.
All other Australian States are facing similar issues related to their nursing
workforce, as are many international health systems.
Immigration
Nurses have always been able to travel the world and work as a nurse gaining
valuable experience in different cultures. Australia attracts a significant
number of overseas nurses who come out on working holidays and who also
wish to immigrate to Australia. The processes are complex and could be
simplified.
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For example, ‘working holiday maker visa’ conditions require that the working
holiday maker must not be employed in Australia by any 1 employer for more
than 3 months without the permission in writing of the Secretary. However this
process requires an extensive and detailed application to DIMCA with
assessment being made on an individual basis.
The requirement that the nurses change employers after such a short period
of time requires them to leave the hospital just as they are becoming familiar
with the service and environment. In view of the ongoing shortage of nurses it
is suggested that nurses holding ‘working holiday maker visas’ could be
permitted to stay employed by the one hospital continuously for 6 months
without the need to apply to Immigration for extension of this period.
In addition to assisting with our nursing shortage this strategy would enhance
the skilled migration program as many of these skilled nurses may apply to
return to Australia as immigrants at a later date.
2.
EDUCATION
NSW Health supports the undergraduate and postgraduate education of
nurses in the tertiary (university) sector. However, it is important that the
programs adequately prepare both beginning and advanced nurses for the
reality of the health system.
A full education issues paper is available. Attachment 2
SUMMARY
2.1
Undergraduate
There are significant issues relating to enrolment numbers, reporting
mechanisms, funded places, clinical practicums, clinical relevance of
programs, exposure to different specialty contexts and the ability of new
graduates to make the transition into the health system across a diverse range
of practice settings and specialties.
Despite many efforts by NSW, a number of these issues remain unresolved.
2.2
Postgraduate
The move of undergraduate (U/G) education into the tertiary sector has also
seen the parallel move of postgraduate education into the tertiary sector.
Access to clinically relevant specialty programs is a significant problem for
registered nurses due to fees, release from work/maintenance of the service
and the quantum numbers wishing to access the different programs.
2.3
Midwifery
A midwifery qualification is a pre-requisite for an authority to practice midwifery
under legislation in all States of Australia. In that context it is not an ‘add on’
qualification.
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All of our midwifery programs have been transferred to the tertiary sector and
it is critical that Department of Education Training and Youth Affairs (DETYA)
sponsored places for midwifery programs are maintained in order to meet our
workforce needs. Universities are having some difficulties in recruiting and
retaining sufficient students in the midwifery programs. We are advised by the
nursing faculties that this is in part related to fees payable for the programs,
given they are classified as postgraduate study. It would appear that all
universities may be moving to ‘full fee paying’ status.
There are also issues relating to the call for ‘direct entry’ midwifery programs
by some midwives. This is in tandem with their call (in line with International
developments) for recognition as a separate profession to nursing.
We believe that special attention needs to be paid to the midwifery workforce.
2.4
Pre-enrolment
NSW Health supports the enrolled nurse education (TEN) program at
Certificate IV level. It is currently provided in the Technical and Further
Education (TAFE) sector. It is acknowledged that other educational providers
and registered training organisations are interested in providing alternative
options.
NSW Health has a contract with TAFE for the theoretical component of the
TEN program over a 12 month period. The trainees are employed by health
services and undertake their clinical placements in a variety of settings.
Attempts to increase the numbers over the last few years have only been
marginally successful. This is due to a number of factors including: Registered nurse/enrolled nurse (RN/EN) ratios in health services
 Need for supervision of TENs
 Non supernumerary status of TENs
2.5
Post-enrolment
Similar access problems exist for enrolled nurses as per 2.2.
2.6
Assistants in Nursing (AIN)
NSW Health supports the entrance point of a Certificate III qualification for the
AIN.
3.
IMAGE OF NURSING and MARKETING OF NURSING AS A
CAREER CHOICE
There is a poor image of “nursing” as a career choice and there needs to be a
coordinated National effort to counteract and reverse this situation.
Marketing is seen by NSW as a multi-dimensional activity. Tab B.
We rarely hear or see in the media any positive news about the extraordinary
things that are happening in nursing and midwifery education, practice,
management and research.
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4.
ROLE DEFINITION OF NURSES
There are a number of issues in this area. They include:4.1
Specialisation
Recruitment and retention of skilled nurses across all nursing specialties
remains an issue and with the trend of increasing patient acuity and
decreasing length of stay, there is an increasing demand for more highly
skilled nurses in all specialty areas including community nursing and the aged
care sector. Information provided through the Department of Health Reporting
System (DOHRS) by Area Health Services identifies that the consistent top 10
specialities for which positions are actively being recruited represent
approximately 70% of the total and include:
Generalist
Emergency Department

Aged Care
Paediatrics

Community Health
Cardiac/Cardiothoracic

Midwifery
Mental Health

Intensive Care
Operating Theatre
4.2
Models of Care/Skill Mix
Difficulties continue to be highlighted by nurses in relation to skill mix (RN/EN)
compounded by the number of TENs, AINs, U/G students on clinical
placement and other ‘students/staff’ who need to be supervised. Nurses are
also concerned at the growth of additional levels of carer who are taking on
what is seen by the nursing profession as nursing care.
Issues are evident regarding the balance between the expanding role of the
RN at one end of the care continuum eg. advanced nursing roles, nurse
practitioner and surgical 1st assistant roles, and at the same time reluctance
by some nurses to the extension of the EN role or the expansion of the role of
the AIN as the third level nurse.
There is much debate throughout the system about the need for new models
of nursing care, given the changing health service contexts and the varying
intensity of nursing care required. However there is a lack of ‘Australian’
research on which to base informed decisions about nursing skill mix and
other related issues.
5.
RURAL AND REMOTE ISSUES
All of the issues highlighted in this paper relate to rural and remote nurses.
However there are some specific issues that impact on the rural/remote
nursing workforce that deserve special mention.
Nursing services constitute the largest percentage of the rural and remote
health workforce and in most areas comprise the first line contact to health
care services. In many of the smaller towns/communities, nurses provide a
range of services, supported by medical officers and allied health staff
employed on an on-call or part-time basis. In the more remote centres, nurses
act as sole primary health care providers and are often required to extend their
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skills due to community demand. The role of the nurse working in rural and
remote locations is recognised as being extensive, diverse and unique.
5.1
Rural and Remote Area Specialty Nursing Practice
The development of rural/remote nursing expertise until recent years has been
less readily seen as a primary nursing focus, compared with the development
and definition of other nursing specialities, for example emergency care,
intensive care and midwifery. There is however a growing body of knowledge
and expertise in rural and remote area nursing. The development of such
expertise is considered a critical element in the development and
implementation of strategies to effectively balance the challenging
demographic profile of rural and remote NSW. This is characterised by a high
Aboriginal and Torres Strait Islander population; a growing aged population;
increasing mental health issues; difficulties in accessing services, transport
and accommodation; variable economic situation and isolation for both
consumers and staff.
5.2
Multiple Role Responsibility of Rural and Remote Area Nursing
Staff
The broad scope of the role of the rural and remote area nurse draws the
nurse into providing care, dealing with situations external to the health
environment and making decisions about the wellbeing, development and
safety of the local community in which he/she works. Additionally the
geographic isolation of many rural and remote communities directly influences
the varied demands for health care, community interaction and service
provision expected of nursing staff. The day-to-day practice for the remote
area nurse encompasses all or most aspects of primary health care in the
provision of comprehensive and coordinated health care to that population.
5.3
Role Expectation of the Rural and Remote Area Nurse
Employers and local communities often have greater expectations of practice
than allowed for in legislation. The demand for the provision of a
comprehensive range of services can present challenges for the nurse
working in rural and remote areas. The balance between the demand for the
nurse to respond to presenting situations and to practice within the legislative
framework can sometimes be inconsistent. All rural and remote nurses, as
professional nurses, are expected to be aware of their own limitations and
competence and only practice within these bounds in accordance with
relevant legislation. The extended practice role placed on many rural and
remote area nurses requires that legislation/protocols and education support
this expanded role and function.
5.4
Recruitment and Retention of the Rural Nursing Workforce
Rural and remote health services experience increased difficulty in the
recruitment and retention of appropriately qualified nurses. Related to the
primary health care role and services provided by many rural and remote
health facilities, is the knowledge that nursing staff are required to be multi-
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skilled. Specialist skill maintenance, education and training are issues of
concern for nurses working in rural and remote areas.
5.5
Isolation
Isolation is an issue which can have a significant impact on the professional
growth, practice and wellbeing of staff working in rural and remote
communities. Professional isolation raises specific difficulties related to skill
and knowledge development, intellectual stimulation and professional
‘burnout’. The development of strategies to overcome the issues surrounding
professional and geographic isolation poses a major challenge for the nursing
profession.
The cost of living and the costs associated with travel/accommodation are
continually raised by nurses as being the major problems related to nursing
recruitment in geographically isolated areas. Other problems experienced by
nurses, associated with geographical isolation include:- absence from families;
lack of professional support; recruitment; harassment; security; reluctance of
staff to travel and replacement of staff on leave.
5.6
Postgraduate and Continuing Education
Professional growth and development are issues of interest to all nurses
regardless of work environment. For nurses working in rural and remote
areas, primary issues commonly faced relate to access to, timing and cost of
education. Postgraduate nursing education is now available in a range of
modes, including distance education, which has made education more
accessible for nurses. However, for nurses working in rural and remote areas,
issues surrounding continuing education and professional development relate
not only to access but also to the need to professionally network with
colleagues to discuss and debate research findings and developments in best
practice. Access to technology is also an issue in rural and remote areas.
5.7
Community Expectations
Community expectations and the visibility of nurses are two significant issues
that continue to be raised by rural and remote nurses. Whilst there are
advantages to being an integral part of the community, nurses perceive that
they are never ‘off duty’, as they are so well known and come into contact with
past, current and future patients as they move around their community.
LACK OF NATIONAL NURSING COORDINATION
This has contributed to the issues, notwithstanding individual State
responsibilities in relation to nursing practice, regulation, service delivery
contexts and industrial frameworks.
National Coordination is required for all professional and related activities
given the many stakeholders at both Commonwealth and State levels
(Commonwealth Health Divisions, State Health Departments, AIHW, DETYA,
Universities, Aged Care, Veteran Affairs and Private Sector) together with
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Professional Organisations (ANF, RCNA, ANCI, ACCDNS) and other specialty
nursing groups. A Commonwealth Chief Nursing Officer would add value to
decisions being made by the Commonwealth in relation to nursing.
In addition there has not been an Australian Government nursing
representative at International and British Commonwealth meetings.
DISCUSSION
Over the last eight to ten years NSW Health has funded and progressed a
significant number of initiatives to address the nursing workforce situation.
A few examples include: Recruitment and Retention Taskforce 1996
 Rural and Remote Nursing Summit 1998
 Significant annual funding for Nursing and Midwifery Education
 Promotional Material and Ongoing Marketing Strategies
 Strategy 2000
 Ministerial Tour/Media Campaign
 NSW Nursing Scholarship Fund
 Rural Undergraduate Scholarships
 Rural Clinical Placement Grants
 Postgraduate Scholarships
 NSW Ministerial Standing Committee on Nursing Workforce
 Research into NSW Nurses Registration Board data base
Significant recommendations have been endorsed for implementation.
A full progress report is available.
PRIORITIES FOR ACTION
NSW believes that the priority areas are:1. Marketing/Image of Nursing as a Career
2. Education:2.1 Undergraduate
2.2 Postgraduate (priorities Midwifery, Critical Care and Mental Health)
2.3 Enrolled Nurse
3. Recruitment and Retention Strategies for Specialty Areas including:3.1 Mental Health
3.2 Midwifery
3.3 Intensive Care/Critical Care Areas
3.4 Emergency
3.5 Operating Room
3.6 Aged Care
4. Rural and Remote Issues
5. Nursing Roles/Skill Mix/Models of Care/Workload Research
6. National Coordination
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TAB A
ISSUES IMPACTING ON NURSING RECRUITMENT AND RETENTION include:Service
Security
Deliver
y Changes
Rural and
Midwifery
Cultural
Environmenta
l
Remote
Issues
Communication
Resources
Managerial
Practitioner
Nurse
Professional
Expertise
Bullying
Isolation
Flexibilit
y
Child Care
Study Leave
Undergraduate
education
Infrastructure
24 Hour Service
Ageing
Community
Expectations
New Graduates
Patien
t
Acuity
Workforce
Workload/Staffing
PostGraduate
Education
Industrial
Marketin
g
Patient Throughput
Casualisation of
Workforce
Role Extension
Skill Mix
Workforce Planning
Teamwork
Legislative Framework
Role Creep
Accountability
Evidence Based
Practice
Specialisatio
n
Budget
Information Systems
Models of Care
July 1999
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TAB B
MARKETING POLICY
Marketing of nursing is an important element of the activities of the New South
Wales (NSW) Health System.
We believe that it is a multi-dimensional activity.
2 Streams: 1 x nursing as a career choice for school leavers and those wishing to
make a career change.
1 x specialty areas available for registered and enrolled nurses.
and
Five levels
1.
At a Departmental level we allocate significant funds to the development,
maintenance and review of ‘generic’ marketing material which is
disseminated widely to the Health System, Nursing Education Sector and
the Department of School Education, free of charge.
“Nursing – you can make a difference” is the current theme of that
material. We also promote ‘good news stories’ through the media.
The Department also provides a comprehensive ‘careers advisory service’
through telephone, electronic (e-mail and internet), written and personal
contact.
2.
At the Health System employer level, the responsibility includes: attending career market days at schools, universities and Technical
and Further Education (TAFE);
 facilitating work experience programs;
 promoting ‘good news stories’ through local media;
 hosting open days; and
 advertising for vacant positions.
3.
Education providers have a responsibility to market their courses and the
reasons why applicants should indicate it as their number one choice.
4.
Department of School Education Careers Advisers have a significant
influence on school children (and parents) when they are reviewing their
options and can also have significant influence on the perceptions of
nursing
as
a
career
choice.
5.
Specialty Nursing Organisations. It is the nurses who are experienced in
each specialty who can have the most impact. They know what their
specialty is about - they know the good things as well as the challenges.
They can influence newly registered and enrolled nurses to choose their
specialty by: influencing curriculum content;
 attending university/TAFE open days to promote their specialty;
 developing specialty specific promotional material; and
 fostering good media coverage.
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