Download Submission - Inquiry into Nursing

Submission
to the
Senate Community Affairs References Committee
Inquiry into Nursing
From the
Nursing Council
South Eastern Sydney Area Health Service
Introduction
The preparation of this submission involved several meetings of the membership of the
Nursing Council of South Eastern Sydney Area Health Service. In these meetings the
main points to be included were discussed and a draft of the submission was reviewed.
The nurses who provided input for this submission are involved in clinical nursing,
nursing education and nursing management in both the service and tertiary sectors and
these perspectives are reflected in the submission.
In our submission we wish to comment on the two specific matters that the Senate
Committee has been asked to focus on and recommend a number of strategies to
address the shortage of nurses and the opportunities to improve current arrangements
for the education and training of nurses.
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Nursing Workforce – current challenges and opportunities
The current shortage of nurses must viewed in its historical context and be understood
as a chronic and intermittently exacerbating phenomenon. Indeed there have been
cyclical and recurrent concerns about the adequacy of the nursing workforce to meet
service demands expressed over at least the last two decades. Even describing the
problem as a “shortage of nurses” may not be accurate. There is a high level of declared
vacancies. However, there are no accurate figures for the total pool of nurses,
incorporating nurses working in casual employment.
This perspective of the problem invites different and more comprehensive strategies
than would be necessary if the shortfall in the available nursing workforce could be
linked to specific isolated and immediate threats or factors. Ongoing factors that have
been identified as affecting the nursing workforce availability include, but are not
limited to, the following:
 Decreasing levels of school leavers commencing nursing degrees at university;
 Nurses retaining registration (in New South Wales) but choosing to work in
positions outside of nursing;
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
The maturing/ageing of the workforce, particularly in regional areas and country
areas;
 Lower levels of remuneration, relative to other professions with similar levels of
responsibility and education;
 Occupational health and safety issues, such as increasing violence against healthcare
professionals; and
 Workplace conditions, including shift work, the increased acuity of patients in
hospitals, the decreasing numbers of nurses on hospital wards and a perceived lack of
support for nurses from both nursing and general administration.
There is a growing body of evidence to support the view that societal changes are also
currently impinging upon the current availability of an ongoing nursing workforce.
Widespread and irrevocable changes in community values have impacted on the
available prospects for women in the year 2001. Women, who still comprise the
majority of nurses, today have unprecedented opportunities available to them in relation
to career and workplace conditions. New, previously unavailable or unacceptable,
career possibilities are now open. There is also increased access to part-time and casual
work as a consequence of workplace and industrial reform. The incentives that have
previously tipped the balance in favour of full-time employment have, as a consequence
of demands from the female population, been switched to now favour casual and parttime employment, particularly during those years when women will continue to take the
greater responsibility for home and family care. One clear indication of this change is
the increasing attractiveness of casual or agency nursing. It is perceived as a way of
working with greater control over working hours and less added responsibilities and
burdens.
Combined with local factors that impact on the availability of an adequately prepared
and sufficient nursing workforce, the current and historical nursing situation in
Australia is linked to wider, global factors affecting the nursing profession. Many of
the current issues identified in relation to the Australian nursing workforce have been
identified, and in some cases explored, in an international context in both the UK and
the USA. In a review of many studies undertaken in the USA and around the world Dr
Claire Fagin identified three major causes of what she has described as caring becoming
a burden. They are: (a) the change in the nature of hospitalisation with the acuity level
of inpatients being much higher, shortened lengths of stay in hospital and patients being
discharged home at an earlier stage in their illness requiring ongoing acute care from
community nurses and family members; (b) the reorganisation of hospitals with nurses
spending greater time attending to paperwork and administrative details and first level
nurses being replaced by second and third level nurses; and (c) the lack of generally
accepted expectations of the responsibility for and type of care to be provided by the
family, by healthcare professionals and by others, such as friends.1
It is not argued here that these changes are necessarily unacceptable or undesirable to
the nursing profession. What is clear is that there has been a lack of commitment to
serious research into the actual issues impinging on the availability and preparedness of
a nursing workforce and to an ongoing monitoring and evaluation of the actual and
potential impact of broad social and policy changes on nursing practice and the nursing
Fagin, Claire M., “When Care Becomes a Burden: Diminishing Access to Adequate Nursing”, Milbank
Report February 2001, accessed at www.milbank.org/010216fagin.html, May 4th, 2001, p. 4.
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workforce. To date many single evaluations have been undertaken and numerous reports
and submissions prepared by the nursing profession and other bodies (e.g. NSW
Ministerial Nursing Recruitment and Retention Taskforce Report 1996, NSW Profile of
the Registered Nurse and Enrolled Nurse Workforce 1998, Nursing Labour Force 1998
– a report prepared by the Australian Institute of Health and Welfare, ‘Rethinking
Nursing’ – a National Nursing Workforce Forum convened by the Department of
Health and Aged Care 1999 and the NSW Government Nursing Workforce Strategy
2000).
In the face of a chronic and escalating workforce crisis there has been no
acknowledgement or acceptance of the need for an independent nursing body to monitor
and report on the characteristics and issues affecting nursing. Currently, a number of
health and medical advisory committees have been given the responsibility for
providing data to the respective Ministers (for example through the Australian Health
Ministers Advisory Council (AHMAC) and Australian Health Workforce Advisory
Committee (AHWAC) at Commonwealth level). These groups have little (if any)
formal and ongoing nursing representation. Nurses themselves are best positioned to
understand the workforce implications of the complex issues that arise from both wider
societal and clinical service changes, and how such changes impact on nursing practice.
An independent national nursing council would enable serious research into the factors
affecting the availability of a nursing workforce able to provide the care needed in the
current health care system. Such research needs to include studying the impact of the
casualisation of work, the scope of nursing practice at all levels, the relevant roles for
nurses at different levels and the links with the education sector. A permanently
established council would be in a position to undertake detailed analysis of the impact
of major policy and health service changes on the future capacity of the nursing
workforce and to provide all levels of government with useful data on nursing issues.
The complexity and chronic nature of the problems confronting nursing require that
nursing research and monitoring be undertaken on an ongoing basis.
The level of nursing input on high level decision and policy-making committees and
working parties should be actively supported and promoted by the Commonwealth and
State Health Departments. This will ensure that nursing workforce issues (or the
capacity of the nursing profession to respond to the planned changes in service delivery
or policy) are addressed in the planning and development phases rather than presented
as a requirement that the nurses (in their industrial and professional collective) must
necessarily accept and subserviently respond to. Inherent in promoting such
involvement is the requirement that the processes for nominating and selecting nursing
representatives be transparent and under the control of nurses to ensure that their
collective views are best represented in these forums. This will need to include
representation by nurse clinicians, nurse managers and nurse academics, all of whom
have a particular and overlapping but not necessarily single perspective to contribute.
RECOMMENDATIONS
1. That an independent and separately funded body (Australian Nursing
Advisory Council - ANAC) be established to monitor, evaluate and report upon
issues impacting on the nursing profession, and it’s ability to meet current and
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future service requirements in relation to both the scope of nursing practice
and healthcare service requirements. Such a Council would have a specific subcommittee addressing workforce issues.
2. That responsibility for providing advice to the Australian Health Ministers’
Council be transferred to the ANAC from the current arrangement where
nursing workforce issues are referred to the AHMAC and AHWAC.
3. That the terms of reference for the ANAC include responsibility for the
evaluation of, and reporting on, the potential impact of new policy and service
initiatives and include analysis of the workforce and quality of care issues
related to non-regulated healthcare workers and second level nurses.
4. That the ANAC be responsible for the provision of advice relating to nursing to
all levels of Government.
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Partnership and Integration – Advancing Nurse Education into
the 21st Century.
Nurses and others have articulated significant concerns about the adequacy and
responsiveness of current educational arrangements for both undergraduate and postgraduate nursing education. Of primary concern has been the increasing perception of
the separation of nursing education and nursing practice – reflected in concerns over the
adequacy of preparation of new graduate nurses and nurses entering specialist areas of
practice.
There has also been widely publicised debate about the adequacy of the current tertiary
based education arrangements, debate mainly led by the call of some members of the
medical profession for the return of hospital (or industry based apprenticeship style)
education for nurses. Care needs to be exercised however in the introduction of
regressive and simplistic solutions. Much benefit has been derived from the transfer of
nurse education to the tertiary sector. However, as with most human endeavors, there
remains room for improvement. Implementing practical steps that derive from the
concepts of partnership and integration will address many of the concerns currently
expressed about the system and process of nurse education.
Currently many forms of locally agreed and/or informal partnerships exist. In general
these have been implemented at a local level by nurses within the academic sector and
the clinical or service sector seeking to restore the necessary relationship between
theory and practice. This relationship is critical to the development of competency
within the nursing workforce and also establishes and creates a mechanism by which
each may inform the other. The artificial and organisationally structured separation of
these two integrally linked aspects of nurse education compromises both the quality and
capacity of the education programs themselves and of the graduates they produce.
Local and informally negotiated arrangements between individual universities and
health services are subject to vagaries in the political and management structures of
these organisations and are insufficiently secure in the current situation.
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One of the main problems for nurses undertaking further study under the current
arrangements is the cost of such study, a cost usually borne by the individual nurse.
While most undergraduate nursing courses attract a HECS or HECS equivalent fee,
increasingly post graduate study in nursing is directly fee paying. The disincentive
introduced as a consequence of these fee-related issues has led to a reduction in the
availability of a skilled and competent nursing workforce in several specialist areas of
practice, for example mental health, operating theatre and intensive care nursing. There
are negligible benefits available to nurses to encourage them to even consider further
post-graduate study. The health care sector will continue to experience difficulties in
maintaining specialty prepared nurses unless the industry acknowledges its shared
interest in the development of such skills by nurses. In many cases the capacity of the
health service to provide care to patients is predicated upon the availability of nurses
who are skilled and competent in the required care. It would seem appropriate for the
health care industry to recognise the benefit it gains from employing well educated
nurses, and accept some responsibility for this through visible support for further study.
Articulated pathways that are based on principles of life-long learning and greater
industry-tertiary collaboration should be developed that link subjects taught within the
service and tertiary sectors as well as providing an overarching framework that
recognises and values workplace learning. These articulated programs can only be
developed through formal and contractual arrangements at all levels between the
education sector and industry. These partnership arrangements are consistent with
policy directives in both the higher education and health sectors. (e.g. DETYA, VET
(Dept Health))
RECOMMENDATIONS
1. That the Commonwealth Departments of Education and Health undertake to
develop and establish a Heads of Agreement document that will form the basis
of a formal partnership arrangement for the delivery of nurse education at a
National level. This agreement must specify, and adequately resource, the
agreed levels of accountability and responsibility for the Education and Health
portfolios. Such an agreement would form the policy framework for the
organisation of nurse education at the State and local level and as such would
mandate certain obligations of each sector under the partnership agreement.
These would include the establishment of structural and industrial mechanisms
to support meaningful and effective collaboration and coordination.
2. Such partnership agreements should include a detailed and comprehensive
account of the specific responsibilities of each sector for the education of nurses
at undergraduate and postgraduate levels.
3. Partnership agreements at State level should specify and create opportunities
within each sector for structural and operational integration of the various
accountabilities of the service and tertiary sector. These should include
frameworks for the appointment of clinical academics, joint appointments and
cross-sectoral practice opportunities for nurses.
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Conclusion
It may never be possible to make nursing fully family friendly or to address some of the
incompatibilities or difficulties that arise between the requirements of the health service
and the capacity of nurses to meet those needs. It is clear however that it is less likely
that there will be a satisfactory resolution of these dilemmas unless nurses are given the
opportunity and responsibility for self determination and regulation. It is equally
imperative that opportunities are created for nurses to contribute to policy and health
planning, especially as such planning relates to the creation of the health service of the
future. Nurses will undoubtably comprise the most significant element of the workforce
of that health service and will be required to provide professional care across the 24
hours of each day.
Some of the conditions affecting nursing, including salary levels and staffing levels, are
driven by the economics of health care and need to be addressed at health care policy
level. This includes studying the full professional, social and economic impact on
patient care of replacing registered nurses with enrolled nurses and assistants in nursing.
Many nurses are leaving nursing after only two or three years in the profession. They
often express disappointment and dissatisfaction with their experience where the reality
of nursing has not met their expectations. Some of this has to do with external factors
impinging on nursing, but it also has to do with the way in which nurses collectively
handle and respond to the challenge of the changes that are arising within nursing.
In the study cited above Dr Fagin2 found that shortages in nursing in America had lead
to experiences of both fear and anger by patients and their relatives. Patients
experienced a discontinuity of care and felt that the care given by nurses lacked
sympathy and compassion simply because the nurse was too busy. Many people were
fearful that hospitals were no longer safe places and relatives indicated that they had
remained with the patient to ensure that she or he received the necessary care including
medications being given on time and other treatments. In some cases people were so
fearful that relatives sought to remain with the patient across the full 24 hours. It will be
a sad indictment of the entire Australian health system if the same situation arises in
Australia when it need not.
Ms. Reta Creegan
Chairperson
Nursing Council
South Eastern Sydney Area Health Service
PO Box 430
Kogarah NSW 2217
2
Ibid., p. 7.
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