Future force

Predicted shortages could have a serious effect on healthcare; here, we look at how the profession can continue to attract and retain personnel. 

Renee Callender moved three hours’ drive from her rural hometown to study a bachelor of nursing at the University of Wollongong. She was attracted to nursing because she believes it to be “the most valued and needed profession, no day is ever the same and, most of all, it’s a career that will take me in any direction”.

After completing her studies, Callender was confident about obtaining an RN position. However, she wasn’t successful in securing a role in the NSW Health graduate program, a recruitment scheme for public hospitals and some not-for-profit hospitals.

What’s more, the local hospital where she was working as an assistant in nursing withdrew an offer to employ her as an RN on completion of her degree because, Callender says, “there was an opinion that first-year registered nurses were not practice ready – after three years of full-time study and six months of full-time clinical practice in a variety of settings”.

After an extensive search for a graduate position, Callender was offered a role in the aged-care industry. “I applied for every RN position that was suitable to my level of experience, which proved to be very few, as most other employers required the same level of paid experience,” Callender says. “Finally, I approached a local aged-care provider who agreed to take another newly graduated nurse and myself into a supported and guided registered nursing position.”

Callender’s job search isn’t an isolated experience yet it stands in stark contrast to the predicted nursing shortfalls in Australian hospitals by 2025. According to well-publicised research by the now obsolete Health Workforce Australia (HWA), Australia faces a potential shortfall of nurses that will affect the community’s ability to access health services. The shortage is expected to reach 27 per cent of the nursing workforce by 2025.

So what is being done to address the potential shortfall and ensure that nurses such as Callender can access employment and enjoy a long, successful career? How will the profession continue to attract and retain nurses? And what role do employers, educators and governments have in averting a staffing shortage?

 An integrated approach 

HWA’s Health Workforce 2025 Doctors, Nurses and Midwives report – providing the first long-term national workforce projections for nurses and midwives – found an integrated approach is required to address the predicted shortfall.

Key themes identified were the need to: reform training and entry into the workplace; maximise productivity and efficiency without compromising quality and safety; and build the capacity of nurses to lead, co-ordinate and provide care.

In the May budget, the Federal Government announced the closure of HWA, transferring essential functions to the Department of Health in August. The jury is out on what effect this will have on counteracting the predicted shortfall, but in the meantime recruitment and retention continue to be key issues for all areas of nursing in Australia.

Workplace newbies

At a university level, Christine Duffield, professor of nursing and health services management at the University of Technology, Sydney, and Edith Cowan University, believes adequate numbers of nurses are being educated and prepared for the workforce in response to typical fluctuations in the number of positions available.

“I don’t think we can increase supply much more at the universities – we’re probably supplying close to what we need,” she says. “The health workforce goes through peaks and troughs. We’re at a bit of a peak now, there are nurses who can’t get jobs, so we’ve got a slight oversupply and that’s probably [affected] the new graduates most.”

Callender is concerned that employers may believe new graduates aren’t ready for the workforce, but believes insufficient bridging programs are a bigger issue.

“If this is the case, then a serious look at the accreditation behind the bachelor of nursing degrees must be conducted,” she says. “But to be honest, those whom I personally know who were unsuccessful within NSW Health were promising nurses and we were all deemed competent by all of the standards set by our university to obtain our degree, so we must look towards the shortages of supported new graduate positions within the system.

“Governments simply do not provide the funding for support staff to assist the massive output of nursing graduates stemming from the opening of university places a number of years ago.”

Because of limited alternatives to graduate positions within state departments such as NSW Health and reduced employment within the private hospital system, Callender believes disciplines such as aged care, general practice, disability services and other private institutions should create graduate positions.

“Not only will they gain fresh, enthusiastic, well-trained nurses, they will also gain a loyal employee who will appreciate the opportunity to advance their nursing career,” she says. 

Productive and high quality 

The link between staff retention and productivity is well understood but Debra Thoms, CEO of the Australian College of Nursing, says employers could do more to improve workplace culture – a key ingredient in staff retention.

“Everyone needs to fully appreciate the role that workplace and organisational culture play in the retention of staff,” Thoms says. “If we do not have environments that nurses want to work within, then we are going to find addressing workforce shortages even more difficult, if not impossible.

“Merely saying that an organisation, for example, has a set of values that may be supportive of staff will not make much impact unless there is tangible evidence that these are being put into practice.”

Duffield says keeping staffing levels low can be a source of stress for nurses, and believes employers could better examine workloads – which she acknowledges are inherently difficult to measure.

“We could put far more emphasis on looking at the workloads that nurses have,” she says. “There are constant complaints about nurses’ workloads. We see increasingly the number of RNs in facilities going down and they’re replaced by, in many instances, the unregulated workforce.

“We don’t know how to measure nurses’ workload, as we can’t measure it like a factory floor where you can measure the number of cars you produce. It’s very hard to measure the acuity of the care that’s required for patients so we never really know precisely how many staff we require and what mix of staff we require and how many we require for that patient for that shift.

“So I think we tend to staff at the lowest possible level and when something starts to go wrong, someone calls in sick or patients are less well than we thought they were going to be, that’s when things start to tip over and that’s when nurses start to get stressed,” Duffield continues. “Their workload rises and they get stressed because they can’t provide the care they want to provide. I don’t know if there’s much acknowledgement that that’s the case with many employers.”

Care providers 

Thoms believes building the capacity of nurses to provide care starts with a positive attitude towards new graduates. “The workforce needs to embrace and nurture new members of the profession,” she says.

“I have met some truly amazing and inspirational new nurses who are making a wonderful contribution to the health system but even they can recount stories of the negative way they have been received by some nurses and the challenges they faced in the first 12 months that could have been much more positive if the existing workforce were to change some of the attitudes that still seem to exist towards these new members of the profession.”

When it comes to experienced nurses, Thoms says it’s crucial for organisations to understand how career opportunities – up the ladder as well as sideways – can affect recruitment and retention. “Some staff are seeking extension and challenge and perhaps promotion, while others are more focused on a specific area or unit.”

She says it’s also important to make the most of contributions of older, more experienced nurses. “We have an ageing workforce that may be finding some aspects of work difficult but have an enormous wealth of knowledge to share,” Thoms says. “We need to try and find ways to enable all staff to make the best of their talents.” 

Graduate nurse Patricia Fox – whose mother and grandmother both worked as nurses – says she was attracted to the diversity of the profession and believes offering broad career opportunities is key to building an experienced, talented workforce.

“The diversity of nursing needs to be continually promoted to attract new nurses and this same diversity needs to be made more available to assist in nursing retention, such as ward rotations and ease of training access, to allow nurses to try new lines of work and avoid burn out and compassion fatigue,” Fox says. 

The future of nursing 

It’s impossible to predict whether these recommendations will be put into practice – or indeed whether they are the best solutions. But fast forward to 2025 and what do the experts believe nursing in Australia will look like?

Duffield believes the workforce will change in line with government policy that will begin to focus on primary care. “I assume that in the next 10 years we will get to a place where we have more of the patient population managed at home or managed in their local community,” she says. “So I would anticipate that we would see more nurse practitioners and more practice nurses in GP services providing a lot of frontline care for those people.”

Thoms agrees that nursing will keep up with service delivery changes. “We may see nurses working with a wider range of assistive staff and also more nurses working to their full and extended scope,” she says.

Duffield cautions that projections such as those HWA released are subject to change and believes the nursing shortfall may occur before 2025. “The projections to 2025 are just projections and you only have to change one little thing to have an impact on them – like the global financial crisis and suddenly we didn’t have a shortage anymore. So I would think we would probably have a shortage before then – it’s about peaks and troughs.”

As for Callender and Fox, both are hopeful that access to healthcare will have improved for all Australians – especially those in rural and remote areas – and that they will be practicing a higher standard of nursing by 2025.

“We are now the most autonomous we have ever been and continuous improvements to standards and research mean our practice will only get better,” Callender says.

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