Time to work it out

Australia may well be in trouble without a co-ordinated approach to adequate staffing; a professor puts into focus the importance of looking past the short term on costs, and developing a national strategy. 

A leading WA nursing professor is calling for a nationally consistent approach to current workforce issues.

Di Twigg, professor of nursing at Edith Cowan University, has told Nursing Review there is a need for a significant push to generate a national focus for the nursing profession in order to avoid predicted shortages and retain the current workforce.

“Without a nationwide approach to address both the supply and retention of nurses to meet the demand, as well as the employment of new graduates, we will be facing significant shortages in the not-so-distant future,” Twigg says. “Some of the work that Health Workforce Australia did was to look at national data on what our workforce is and what it is likely to be. This was extremely useful because it was the first time we had a national picture.

“As most nurses work in hospitals – and hospitals are funded by the states – there doesn’t seem to be a lot of commonwealth traction in wanting to look at the broader nursing workforce issue. But we do need to have a national strategy to meet the challenges ahead.”

She says the most critical element is a co-ordinated and agreed-upon national strategy.

“We need a better understanding of what level and type of nurse is required within discrete patient populations to provide high-quality, cost-effective care. To achieve this aim, we need funding support to examine nursing roles and innovative staffing models,” she says.

Here, Twigg outlines the current approach to overcoming workplace stress and the future consequences, should we not develop a national solution.

NR: What is the state of play across the country in regards to workforce issues and the approach to nurse staffing?

DT: It varies a lot from state to state. For example, [look at] the staffing in Victoria and Western Australia. In Victoria, hours are mandated through ratios, and in WA and NSW it’s nurse hours per patient day, so there are industrial agreements that set those staffing levels.

In other states, however, it is not as well developed. There has been some work looking at ways of managing nurses’ workload but not with an accepted or formalised approach to staffing.

There is a lot of variation across the states. And it is obviously in times like now – where we are in economic difficulties – that health budgets usually get [affected]. Certainly nursing is affected because it is the largest part of any hospital workforce, as they are with patients 24/7. So, they are often the first ones to look at in terms of trying to find savings, despite their critical role in patient safety.

There are some real high-level policy issues here because we know that better staffing gives you better patient outcomes. There is an economic argument [for getting] your nurse staffing levels right, as well as a quality argument.

We know that by reducing those adverse outcomes overall the healthcare system would save money, even though the hospital might not because they will just replace this patient with another one because of the pressure on beds all the time.

Although with activity-based funding you would hope that there is more incentive to make those sorts of sensible decisions about what’s the best staffing mix because the patient’s length of stay is less with less adverse events and you save money.

What will happen if the problem isn’t fixed?

The biggest issue, if you look forward from 2016, is the projected nursing shortages in Australia and most Western developed countries, like America where I think it gets up to about half a million by 2025. We haven’t looked at countries like China – which has a growing economy and increased health demands as well.

The best thing we can do to improve is to retain our nurses more effectively and one of the big drivers for nurses not to stay in nursing is their workload – which is associated once again with the staffing levels.

These are hard arguments to get any traction with in a time where everyone is more worried about expenditure, without seeing that overall [better staffing] does improve the cost-effectiveness and the productivity of our health service.

We also have a problem at the moment where although we know in two years’ time we are going to be short of nurses – we have now got new graduates coming into the workforce, particularly on the eastern seaboard – not getting jobs.

So we have just invested three years in their education. But when we need them, we may find that they have had to find alternative work and they may not come back. Plus it is hard to keep that three years of education in the front of your thought processes if you haven’t been able to practice for two years.

Without a broader approach, what will happen to future nursing workforces?

History teaches us that if we don’t manage nurses’ workload – which we saw moving into the turn of this century in 2001–02 – it will become a major issue.

At that time there was massive use of agency staff. You couldn't recruit permanent nurses because the work environment was almost toxic. The workload was excessive and there was no real support or recognition of the problems on the amount of shortages that were around.

Fixing nurses’ workload helped address that in WA and certainly we saw a return to the workforce of a number of nurses, which addressed the shortage problem. Now it would seem to me, if we focus too much on the dollar over the next few years as we move towards future shortages, we will just end up not being able to deliver the healthcare system we want to because you won’t have enough staff. It becomes a real cyclical problem of boom and bust in terms of the supply of nurses and the demand for them.

What would a successful system look like 10 years in the future?

Success would be Australia continuing to enjoy positive key indicators of health (compared with other OECD countries) because we have an adequate nursing workforce. Supply and demand would be in balance, turnover would be low, and workload would be managed effectively.

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