Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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. NSW HEALTH – Nursing Workforce Issues wforce\2383\jm June 2001 Page 2 of 12 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; NSW HEALTH – Nursing Workforce Issues wforce\2383\jm June 2001 Page 3 of 12 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. NSW HEALTH – Nursing Workforce Issues wforce\2383\jm June 2001 Page 4 of 12 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. NSW HEALTH – Nursing Workforce Issues wforce\2383\jm June 2001 Page 5 of 12 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. NSW HEALTH – Nursing Workforce Issues wforce\2383\jm June 2001 Page 6 of 12 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 NSW HEALTH – Nursing Workforce Issues wforce\2383\jm June 2001 Page 7 of 12 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- NSW HEALTH – Nursing Workforce Issues wforce\2383\jm June 2001 Page 8 of 12 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 NSW HEALTH – Nursing Workforce Issues wforce\2383\jm June 2001 Page 9 of 12 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 NSW HEALTH – Nursing Workforce Issues wforce\2383\jm June 2001 Page 10 of 12 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 NSW HEALTH – Nursing Workforce Issues wforce\2383\jm June 2001 Page 11 of 12 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. NSW HEALTH – Nursing Workforce Issues wforce\2383\jm June 2001 Page 12 of 12