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Towards a better health system

The Australian College of Nursing’s submission to Treasury provides many ways to help the profession meet consumer needs. 

On January 31, the Australian College of Nursing (ACN), along with other Australian professional organisations, submitted its Federal pre-Budget Submission 2014–2015 to the Treasury. The submission reflected input from our nursing membership and offered evidence-based recommendations. These recommendations highlight what it would take to sustain and expand the profession in order to meet the health needs of the Australian community into the future. There is now considerable empirical evidence that identifies the key role nurses have in quality care outcomes. We focused on the issues facing all nurses and sought to highlight cost-effective opportunities that translate into better consumer care.

The concerns we addressed included:

  • workforce flexibility
  • efficiency and retention of nurses
  • issues specific to rural areas
  • the need for reliable nursing metrics
  • nursing leadership development
  • healthcare productivity.

ACN is aware of the numbers of newly registered nurses entering our workforce and the need to provide the best possible work environment, nurturing confidence and a desire to remain in the system over the longer term. It is also necessary to provide support to existing nurses so they can effectively transfer their knowledge and skills, learnt and honed over time, to the new cohorts and support and mentor them as they grow in practice themselves.

A National Transition Framework, designed to support nurses who are new to the profession, and also practising nurses who wish to move from one setting or area of practice to another, would contribute to long-term retention as well as flexibility and productivity. The proposed framework should offer support across the health system, including primary care and aged care, and should engage nurses at any stage of their career.

The framework would acknowledge avenues to support transition, such as mentoring and educational requirements, and provide project materials for employers offering supported clinical transition. Consultation workshops would be required to develop and design the framework, but the benefits go beyond nursing, into all health services and the Australian community. The framework would cultivate health services responsive to changing population needs and ensure the quality of nursing care, whilst supporting nurses’ efforts to practise with confidence to the full scope of their education. The outlook for such a framework would include the increased competence of, and confidence in, clinical transition, and positive effects on nurses’ job satisfaction and care outcomes.

Those working in rural and remote areas face some additional challenges. The Australian Institute of Health and Welfare’s (AIHW) Hospital Statistics 2011–12 states that the nursing workforce within these rural health services is ageing, and they have had difficulty in recruiting new staff. The AIHW’s Nursing and Midwifery Workforce 2012 indicated that rural nurses are older than their metropolitan counterparts. This data calls for action towards the renewal of this workforce to ensure that rural health consumers have access to the same standard of care as people in metropolitan areas.

Early-career nurses often experience working in rural health services as stressful. Many services have limited or no staff to provide clinical decision support or mentoring. As a result, quite a few young nurses choose to leave rural areas, undermining local consumers’ access to healthcare. The implementation of a rural scholarship scheme would enhance the early experiences of nurses through their participation in a structured, clinical learning experience tailored to their relevant setting. A transitional support scholarship scheme would attract newly registered and enrolled nurses to work in rural health settings, build their clinical competence, develop their confidence in their clinical judgement and practice, and promote retention in rural health. A three-year trial of transitional support scholarships would enable health services to support these nurses in undertaking three months of structured clinical learning at the beginning of their initial year of practice in a rural health service. An evaluation of the impact on the individual nurse, staff retention and care outcomes could be incorporated into the trial.

Addressing healthcare issues specific to rural areas is an important point for the government’s agenda. The significant cost of postgraduate and professional development studies can be a burden for many nurses and even more so for many in rural and remote areas. It puts in place barriers to nursing skill development. ACN called for funding to be made available to provide scholarships for postgraduate study and professional development for nurses already working in these locales. This proposal ensures rural communities have access to expert and specialised nursing care by supporting nurses in updating and extending their skills.

ACN’s pre-budget submission also included the recommendation for an independent, national system for collecting, analysing and comparing Nurse Sensitive Indicators (NSIs). Research has consistently shown that nurse staffing levels and skill mix directly affect the health outcomes of hospital patients (Duffield et al, 2011). NSIs assist in understanding the relationship between the number and skills of nurses deployed, the number of patients per nurse and the quality of care achieved, broadly measuring the impact of nursing practice on patient care.

The establishment of a national system for collecting, analysing and comparing NSIs as a metric would clearly articulate the successes of the nursing workforce in the delivery of care. This data would provide an evidence base to inform health system and workforce strategies so they can achieve optimal care outcomes.

An important focus for ACN in 2014 has been the development of nursing leadership in Australia. With this in mind, ACN called for resources to be allocated for a national leadership education program targeting nurse managers. Experience has shown us that strong nursing leadership within health services improves nurses’ job satisfaction and retention. Many programs in the current environment focus on generic leadership and there remains a space to develop leadership and management programs that specifically address the issues nurses face in clinical settings.

ACN proposed the development of tailored, specific leadership programs. At a clinical level, these programs would foster innovation, patient-centred care and staff recognition. Targeted at early-, mid- and late-career nursing leaders, the program would support improved leadership skills and provide the opportunity to link with formal award courses. The encouragement of strong nursing leadership would go towards stabilising the healthcare system, leading to better patient outcomes.

The Productivity Commission’s 2013 research paper An Ageing Australia Preparing for the Future argued that improving healthcare is an effective way to alleviate the fiscal pressure of our ageing population and their consumption of healthcare. With this in mind, in our pre-budget submission, ACN highlighted the role of nurse practitioners (NPs) and called for the allocation of funding to increase the number of Medicare Benefits Schedule items and rebates for eligible NPs.

In the United States, NPs play a predominant role, contributing to the accessibility of healthcare. However, in Australia, more can be done to promote and develop the role of NPs to provide accessible, specialised care. The establishment of MBS provider rights for eligible NPs has been a strong step in the right direction, but innovation relating to the role of NPs is stifled by the narrow scope of MBS items available to support care delivery. ACN believes that changes to the MBS system would increase access to services and bolster the health workforce.

Finally, ACN proposed the implementation of a 12-month project to map the roles of non-acute nurses. These roles exist largely to promote a primary healthcare framework, maintaining the health of the community through prevention and early-intervention, and by assisting clients with the self-management of chronic conditions. These nursing roles can vary quite significantly. Some are well established, such as community nurses, school nurses or maternal health nurses. However, along with these long-standing positions, the proliferation of new roles has led to a need for greater definition concerning their areas of responsibility, potential overlaps, the gaps that remain within the system, and the capacity these roles have in improving accessibility to healthcare.

In an effort to meet the growing health demands of populations, aged-care nurse practitioners, breast care nurses, IVF nurses and wound care nurses, amongst other roles, have developed, funded through diverse schemes. This varied funding of the clinical settings in which non-acute nurses are employed has made the tracking of nursing roles in the non-acute setting difficult. No systematic overview exists of these differing roles, practices and professional issues of nurses working in the non-acute sector; nor is there such a record of their number, location and funding sources.

A map of these clinical roles would provide invaluable information for policymakers about the nursing workforce and its, to date, hidden capacity. This would promote an understanding of nursing roles and provide a guide for communities as they approach the Australian health system.

In looking forwards, we are looking towards an equitable Australian health system. ACN’s recommendations promote a deeper understanding of nursing roles and encourage the support of our nursing workforce. They look to the use of Australia’s predominant health professional to provide the best care for the Australian health consumer, advocating for nursing’s role in accessible, quality healthcare.

Adjunct professor Debra Thoms is CEO of CAN.


Duffield, CD; Diers, D; O’Brien-Pallas, L; Aisbett, C; Roche, M & King, M, et al. 2011, ‘Nursing staffing, nursing workload, the work environment and patient outcomes’, Applied Nursing Research, vol. 24, no. 4, pp. 244-55.

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