The Australian nurse and midwifery workforce: Issues, developments and the future
Article Outline
- Summary
- The current nursing and midwifery workforce
- The concepts of ‘attachment’ to the profession, and ‘separation’
- Development since the 1960s
- Age profiles over the decades
- The developments of the early- to mid-1990s
- Pre-registration course completions and net migration
- Estimating future requirements
- Redesigning work and extending roles
- Increasing pre-registration course intakes and completions
- Conclusion
- Acknowledgements
- References
- Copyright
Summary
The paper is concerned with data, concepts and analyses necessary for understanding the nurse and midwifery workforces at a macro-level, and for developing policies and plans that can best assure the quality and sufficiency of those workforces in the future.
The size, composition and age profile of the nurse workforce are set out first. This is followed by an outline of the notions of ‘attachment’ to and ‘separation’ from a profession. Data on the population with professional nurse qualifications, whether working in the profession, in another occupation, or not working illustrates the patterns of ‘attachment’ and ‘separation’ over the working age range. Historical developments since the 1960s are then considered, including the workforce size and age profile, the nurse labour market, pre-registration course completions, and movement in and out of Australian of nursing professionals. The nature and impact of the ‘oversupply’ of nurses in the early- to mid-1990s is discussed.
Six matters are outlined that need to be taken into account when estimating future requirements. A discussion of the potential for quantitative impact on the overall nurse labour market from work redesign and role extension concludes that there is no easy solution for macro-level nurse workforce shortages, and that some otherwise very positive initiatives may exacerbate shortages. It is clear that further increases in pre-registration (and pre-enrolment) intakes and completions will be necessary, as least for a further 8–12 years. Some of the barriers to such increases are noted and suggestions for the future made.
Keywords: Workforce, Separations, Education, Migration, Age profiles
The current nursing and midwifery workforce
In 2005 there were 285,619 nurses and midwives registered or enrolled in Australia. This was a small increase from 282,702 in 2004. Of those registered or enrolled, 86% were employed as nurses or midwives. Table 1 provides additional detail. For comparison, there were around 60,000 registered medical practitioners in 2005 (Australian Institute of Health and Welfare, 2008a).
Table 1. Enrolled and registered nurses, and registered midwives, 2005.
| Number employed in the occupation | Number enrolled or registered but not employed in the occupation | Number employed per 100,000 population | |
|---|---|---|---|
| Enrolled nurses | 46,044 | 8,998 | 227 |
| Registered nurses | 198,315 | 32,263 | 976 |
| Registered/authorised midwivesa | 55,992 | – | – |
aMost midwives are also registered as a general nurse. Source: Australian Institute of Health and Welfare (2008b). |
The age profile of employed nursing professionals1 in 2006 is illustrated in Fig. 1. There is a clear peak of around 7000 individuals at age 47 (which by 2009 would have moved to about age 50). This peak reflects the peak period of recruitment of currently employed nurses around the early-1980s. The dip in numbers around age 37–42 indicates the dip in recruitment in the early- to mid-1990s.
Figure 1.
Number of nursing professionals in each single year age range between 20 and 64, Australia, 2006. Source: Australian Bureau of Statistics (ABS) 2006 Census custom tables.
The age profile of those aged from the mid-20s to mid-30s is complicated by movements in and out of Australia of nursing professionals. If there had not been such a high rate of net movement of recent graduates out of Australia in recent years there would be more nursing professionals in those age ranges, and the total age profile of the workforce would be bimodal, with a minor peak around the early-30s—perhaps up to around 6000 (with fewer numbers in some other age ranges).
The concepts of ‘attachment’ to the profession, and ‘separation’
‘Attachment’ to a profession refers to the level at which those with relevant qualifications are working in the field for which they are qualified (‘home occupation’). It appears that around 70% of those aged 20–64 who have professional nursing qualifications are working as professional nurses. Of those not working as nurses, between a third and half are not in the workforce (Fig. 2).
Figure 2.
Percentage of all persons with a professional nursing qualification as their highest qualification at each year age 21–65 and over, who are working as nursing professionals, working in other occupations or not working, 2006. *Nursing qualification (ASCED Field of Education 0603) at bachelor degree (or equivalent) or higher (ACED Level of Education Classification). This includes the qualifications of registered nurses and midwives obtained in earlier years through hospital training or 3 year higher education diplomas. Source: ABS 2006 Census custom tables.
The attachment rate of around 70% for nursing professionals is much higher than is commonly assumed, and contrasts with comparable data for school teachers (Preston, 2008, p. 7). At all ages, the attachment rate of school teachers is around 20% points below that of nursing professionals. There are a number of possible explanations for this difference (each of which may play a part—for some individuals and in some situations)—these include:
‘Separation’ from a profession refers to the total number who are qualified but not working in the occupation for which they are qualified, and ‘separation rate’ refers to those who are leaving the occupation for which they are qualified. ‘Net’ separation rates include many (if not all) of those who are re-entering after a period not working in the home occupation, as well as those leaving. The purposes of analyses and the nature and quality of data sources determine which categories of re-entrants (and some new entrants) are included as a component of ‘net separation’, and which are treated separately as measurable re-entrants or new entrants. In this discussion ‘net separations’ is a wide definition, covering re-entrants and new entrants who are not covered by recent graduates, and, to some extent, by net overseas arrivals.
Separation rates are among the most important variables necessary for estimating future requirements for new recruits to any workforce, including nursing and midwifery. Separation rates are difficult to measure, and more so to estimate for the future, and all methods for doing so are controversial.
It is clear, though, that the pattern of net separation rates varies according to age. This is illustrated for the nursing profession by Fig. 2, which provides data from the 2006 ABS Census—the pattern has been similar for earlier Censuses (Preston, 2002, p. 16; Preston, 2006, p. 94).
The graph indicates that a high proportion of those who gain professional nursing qualifications (and remain in Australia) enter the professional nursing workforce. By the early-30s age range around 30% are not working in those occupations—equally divided among those in other occupations and those not working. There is a high rate of net separation (around 4–5% per year) among those under 30 as some beginning nurses realise that the profession is not for them and move into other occupations, and as others leave to have a family. Net separation rates then reduce sharply through the 30s age range to around zero as those for whom nursing is unsuitable have mostly left and the number returning from full time family responsibilities progressively increases as the number leaving reduces. By the late-30s the proportion not working declines, and those in other occupations steadily increases. The net separation rate in the late-40s age range begins to gradually increase, and it then sharply increases from the mid-50s age range.
Development since the 1960s
The size of the professional nursing workforce increased rapidly through the 1960s and, especially, the 1970s and through the 1980s. Then there was a sharp slow down in the early- to mid-1990s with the recession and major cutbacks in state government expenditure. There has only been gradual expansion since (Table 2).
Table 2. Employed nursing professionals, selected years 1961–2005.
| Number of employed nursing professionals | Number per 1,000 population | Average change per annum in number from previous period (%) | |
|---|---|---|---|
| 1961 | 63,821 | 5.9 | – |
| 1981 | 106,565 | 7.1 | 3.3 |
| 1991 | 164,500 | 9.9 | 5.4 |
| 1994 | 172,434 | 9.7 | 1.6 |
| 1996 | 174,770 | 9.5 | 0.7 |
| 2005 | 198,315 | 9.8 | 1.5 |
Over the period to around the early- to mid-1980s there was a very high level of recruitment and an associated high level of training for the professional nursing workforce. The high level of recruitment was necessary to cover both the expansion of the workforce outlined above, and the need for replacements for the large numbers leaving while a high proportion of the workforce was younger than around 30.
From the mid-1980s those recruited over the period to the early-1980s who stayed in the profession became a large cohort moving into their 30s—the age range with very low net separation rates. Therefore the requirement for replacement for those leaving the profession was reduced, though there continued some need for additional nurses because the expansion of the total size of the workforce continued. The net result was a reducing need for new recruits (not including re-entrants).
The enrolled nurse workforce declined from the mid-1990s to around 2001, and has generally increased since then (Table 3).
Table 3. Employed registered nurses and midwives and enrolled nurses, Australia, selected years, 1994–2005.
| 1994 | 1997 | 1999 | 2001 | 2003 | 2005 | |
|---|---|---|---|---|---|---|
| Registered nurses and midwives | 172,434 | 175,937 | 179,389 | 183,224 | 189,071 | 198,315 |
| Enrolled nurses | 52,676 | 46,274 | 45,424 | 45,006 | 47,574 | 46,044 |
| Total nurses and midwives | 225,110 | 222,211 | 224,813 | 228,230 | 236,645 | 244,359 |
Age profiles over the decades
The pattern of age profiles and associated net separation rates for the nursing profession can be tracked over the decades.
The peak number of new recruits around the decade to the mid-1980s is reflected in the age profiles since then of the registered nurse workforce, and of all those in the population with professional nursing qualifications. In 1989 the peaks for both were in the 25–34 age range, while in 2006 they were in the 45–55 age range (Fig. 3).
Figure 3.
Percentages of all persons with professional nursing qualifications and of all employed nursing professionals aged 15–64 in each 10-year age range, 1989 and 2006. Note: Data should be taken as indicative only as the data was collected on a different basis in the two datasets. Source: 1989 data: Australian Bureau of Statistics (1990), p. 8; 2006 data: ABS 2006 Census custom tables.
The peak will move through retirement age over the coming decade and dissipate. In comparison with the situation in 1989, it is currently a diminished peak as a proportion of the total workforce, because the proportion who are in the younger age ranges (especially 25–34) is much larger than the proportion who were in the older age ranges (especially 45–54) in the late-1980s, as well as a proportion of those aged 25–34 who were working as nurses in 1989 are no longer working as nurses.
The developments of the early- to mid-1990s
In the early-1990s the recession and state government cutbacks and other factors (such as a slowing of the population growth rate) sharply slowed expansion in the total number of employed nursing professionals (even reversed it in some jurisdictions). The peak in the age profile of nursing professionals had moved from the late-20s age range to the early-30s, reducing overall net separation rates. The recession further reduced separations as alternative employment opportunities became scarcer. Thus there was little demand for new recruits for either expansion or replacement, and a high proportion of graduates of pre-registration programs were unable to gain positions.
As the requirement for new nurses picked up in the mid-1990s, graduates of earlier years competed with recent graduates for available positions, and thus the ‘surplus’ continued from 1 year to the next even when the number of graduates available became in broad balance with requirements for new recruits.
Fig. 4 illustrates the impact of the recession on all graduates, but shows that it was much more severe for those entering nursing and teaching—two occupations with staffing levels largely reliant on state government funding, and with age profiles in the early-1990s with high peaks in the early-30s age range where net separations are especially low.
Figure 4.
Bachelor degree graduates working full time as a percentage of those available for full time employment, pre-registration nurse education, initial teacher education, and all fields of study, 1986–2000. Source: Graduate Careers Australia, various publications.
The lack of employment opportunities for so many nursing graduates over the years from 1991 to 1994 had a great impact on many involved in pre-registration nurse education, including potential students. That was also the time of major rationalisations and re-organisations in higher education. Many former Colleges of Advanced Education were amalgamating with universities or sought to become universities with broad and ‘balanced’ course provision. In general, the very large pre-registration nurse education (and initial teacher education) programs of many former CAES were considered undesirable in the new institutional structures. The ‘oversupply’ of nursing and teaching graduates thus fitted seamlessly into the rationales for reducing very substantially the size of teacher and nurse education programs in some major institutions. There was no serious attempt to understand the particular causes of the oversupplies—they were assumed to be a continuing, structural result of expansion of CAES from the mid-1970s.
Fig. 5 indicates the effect of the reaction to the oversupply of nurse education graduates. There was not only a sharp reduction in provision of places, but also low demand by potential students and high attrition. The low point in the number of completions occurred in 1998, 6 years after the low point in employment opportunities for nursing graduates.
Figure 5.
Pre-registration nurse education: undergraduate degree graduates available for full time work who were working full time, 1986–2006; domestic completions, 1993–2006. Source: Graduate Careers Australia, and Department of Education, Employment and Workplace Relations (DEEWR).
The reduction in places occurred as the peak in the age profile of registered nurses began to move into the 40s age range, and consequently net separation rates and requirements for replacements began to increase. In addition, in the late-1990s staffing levels began to improve. Thus the declining supply of graduates became insufficient for increasing demand, and, as the accumulated surpluses dissipated, the shortages developed that have continued into the current period.
Pre-registration course completions and net migration
Fig. 6 shows the pattern of actual and projected completions from 1994 to 2009. International (on-shore overseas) students have played a small, but increasing part, and it appears that most international students who complete pre-registration courses go on to work in Australia (CDNM, 2008, p. 3). In 2007 completion numbers had still not returned to the level they were in 1994, and it has only been the recent increase in international student completions that has taken the total above the 1995 level.
Figure 6.
Pre-registration nurse education completions, domestic, overseas and all students, actual 1994–2007, and projected 2007–2009, Australia. Source: Actual completions from DEEWR and projections from Preston (2006) p. 110.
It has been increasing levels of net migration into Australia of nursing professionals that has prevented more serious shortages occurring. Fig. 7 shows this net movement, and Table 4 its components. There is a high level of movement both in and out, by Australian residents and long term visitors, as well as settlers.
Figure 7.
Net movement in and out of Australia of nursing professionals, 1995–1996 to 2006–2007. Source: Department of Immigration and Citizenship.
Table 4. Permanent and long term arrivals and departures of nursing professionals, financial years, 2004–2005 and 2006–2007.
| Permanent arrivals | Long term resident return | Long term visitor arrivals | Total arrivals | Permanent departures | Long term resident departures | Long term visitor departures | Total departures | Net arrivals | |
|---|---|---|---|---|---|---|---|---|---|
| 2004–2005 | 1677 | 1831 | 2811 | 6319 | 944 | 1806 | 1309 | 4059 | 2260 |
| 2006–2007 | 2082 | 1832 | 4616 | 8530 | 1103 | 1756 | 1780 | 4639 | 3891 |
The significance of net migration is shown by re-presenting the data in Figure 6, Figure 7 on the same scale in Fig. 8. The annual net additions to those in Australia with professional nursing and midwifery qualifications from completions plus net migration from 1995 to 2006 is also shown in Fig. 8. Table 5 provides the data for selected years. In 2006–2007 more than one-third of the ‘new’ potential entrants to the Australian professional nursing workforce were from net migration, and less than two-thirds from graduates of pre-registration courses. A decade earlier the contribution of net migration was well under 10%.
Figure 8.
Net migration, pre-registration course completions, and total net additions to those in Australia with professional nursing and midwifery qualifications, 1995–2007. Source: Department of Education, Employment and Workplace Relations higher education statistics; Department of Immigration and Citizenship.
Table 5. Net migration, pre-registration course completions, and total net additions to those in Australia with professional nursing and midwifery qualifications, selected years, 1995–2007.
| 1995–1996 | 1998–1999 | 2001–2002 | 2004–2005 | 2005–2006 | 2006–2007 | |
|---|---|---|---|---|---|---|
| Net migration | 703 | 379 | 1094 | 2418 | 3338 | 3,891 |
| Course completions | 6796 | 5698 | 5222 | 5976 | 6103 | 7,011 |
| Total net additions | 7499 | 6077 | 6316 | 8394 | 9441 | 10,902 |
Migration does not affect all jurisdictions equally. 2006 Census data on location of residence 5 years earlier indicates that 11% of nursing professionals in Western Australia and the Northern Territory were overseas 5 years earlier, while only 5 and 3%, respectively, of South Australian and Tasmanian nursing professionals were overseas 5 years earlier (Fig. 9).
Figure 9.
Percentage of employed nursing professionals who were overseas 5 years earlier, states and territories, and Australia, 2006. Source: ABS 2006 Census custom tables.
Nationally, 7% of nursing professionals, or around 14,000 individuals, were overseas 5 years earlier. This is roughly consistent with the DIAC data for net migration over the period (see Fig. 7 and Table 4).
Those who were overseas 5 years earlier tend to be substantially younger (Fig. 10). This may reflect the international mobility of young Australian residents as well as the age profile of immigrants and international visitors working in Australia.
Figure 10.
Age profile of employed nursing professionals who were in Australia or overseas 5 years earlier, Australia, 2006. Source: ABS 2006 Census custom tables.
In addition, those who were overseas 5 years earlier are much less likely to be working part time (Fig. 11). These differences between those who were in Australia or overseas 5 years earlier are interesting, but their significance for workforce planning will not be further investigated here. What is important is the marked difference in hours worked by age for the total professional nursing workforce (solid line in Fig. 11). This is further discussed in the following section.
Figure 11.
Percentage in each 5 year age range who are working 1–24
h a week, all nursing professionals, and those living in Australia 5 years earlier and those living overseas 5 years earlier, 2006. Source: ABS 2006 Census custom tables.
Estimating future requirements
Adequate and comprehensive projections and analyses of future requirements for new nurses and midwives are beyond the scope of this paper. However, a number of significant matters will be briefly considered.
First, there is projected population growth over the next couple of decades of around 1.6% a year (Australian Bureau of Statistics, 2008), indicating a growth in the nurse workforce (enrolled and registered nurses and midwives) of around 4000 a year to maintain current levels of staffing.
Second, requirements for new recruits are likely to increase substantially over about 5–10 years as a consequence of the peak in the age profile around age 50 in 2009 passing through retirement age. The separation rate from retirements alone is likely to be more than 3.25% of the total workforce for more than a decade, perhaps peaking at around 3.5%, which is almost 9000 individual nurses and midwives. Then requirements will reduce (other things being equal) as retirements drop back to around 2% again (around 5000 individuals). The peak in requirements to replace those retiring can be delayed or spread out by a few years through strategies to delay retirement or recruit back retirees (and many may prefer to delay retirement because of the loss of value of retirement savings). But retirement generally cannot be put off for long. To the retirement separations need to be added the separations of employed nurses and midwives leaving at other ages, especially their 20s, to move into other occupations, out of the workforce or overseas—either permanently or for some years. This would add several thousand more to total annual replacement needs.
Third, the ageing of the Australian population will require increasing staffing levels of professional nurses per 100,000 of the population if current levels of care for older Australians are not to be diminished. There may not be much room for adjustment in broad requirements through changed professional roles and practices or changed settings for care and support after the very substantial changes over the past two decades (though the quality of care and support at a local level could be enhanced by changes in roles, practices and settings). The very different age profiles of the general population in different states and territories indicates that higher levels of staffing are currently appropriate in some states relative to others. It is a separate, but related point, that the projected rate of increase in the proportion of older people (especially those over 85) is greater in some states than others, and in some cases is greater in states that currently have lower proportions of their population in the older age ranges. The greater rate of increase leads to a greater annual increase in the number of new nurses required, and thus greater annual increases in the necessary number of completions of pre-registration courses and/or net migration of qualified nurses into the state. These matters are discussed in detail in Preston (2006), pp. 77–92.
Fourth, as the age peak moves into retirement a higher proportion of the total workforce will be in those age ranges in which fewer hours are worked on average, especially the over 55 and the 30–44 age ranges (Fig. 11). This is likely to substantially reduce average hours worked across the workforce, and thus a greater number of individual nurses will be required to meet the same level of full time equivalent staffing.
Fifth, the substantial net international movement of nursing professionals into Australia cannot be relied on as a continuing solution to shortages—from an ethical as well as practical point of view. The Australian National Health Workforce Strategic Framework, endorsed by the Council of Australian Governments in February 2006, calls for ‘national self-sufficiency in health workforce supply, while acknowledging that Australia is part of a global market’. This indicates that continuing movement in and out of Australia by health professionals is acceptable (even desirable), but that net movements should be close to zero. This is very different from the current situation, where net migration contributes around one-third of new nursing professionals each year. To make up the shortfall if the net level is to be reduced to zero would require an increase in completions of pre-registration courses of more than 50% (at 2006–2007 ratios of net migration to completions—see Table 5). Completions are projected to increase by almost 80% over the current decade (1999–2009—see Fig. 6), so a further increase of around 50% to compensate for ‘national self-sufficiency’ is not beyond the realms of possibility, but will still be difficult without very substantial policy changes and initiatives.
Sixth, those with nursing qualifications who are currently not working as nurses cannot be relied on to make any substantial new contribution to the future workforce. There will continue to be movement out of and back into the workforce, but a substantial change from the current underlying level cannot be expected. A wide range of initiatives over the past decade have sought to attract back to nursing (or into nursing) those with qualifications who were in other occupations or not working—especially those who had been unable to find the nursing positions they wanted during the years of ‘oversupply’ from the mid-1990s. Some of these initiatives were successful, and the pools of potential re-entrants have diminished. Net separation rates for early- and mid-career nurses, and consequently of the numbers of former nurses of working age, have often been ever-estimated. While retention in particular settings and locations can be very poor (and a serious problem for quality of care and quality of the work-lives of nurses and midwives), it is not so for the profession as a whole. Census data referred to earlier (Fig. 2) indicates that up to age 50, around 70% or more of those in Australia with professional nursing qualifications (as their highest qualification) are working in the profession, and only around 15% are working in other occupations. Thus retention strategies should be based on the issues for particular settings and locations, with a focus on improving quality of care and work-lives, and thus easing the disruption of high turnover and shortages for those settings and locations.
Once these six matters are taken into account, we must conclude that there almost certainly will be substantial increases in the requirements for new nurses and midwives if current levels of care (staffing levels per population age cohort) are to be maintained, let alone improved. There are two major sets of strategies in response to such expected increases in requirements (following a baseline of current shortages). The first is to reduce future requirements through a range of measures associated with job redesign and role extension. The second is to increase pre-registration and pre-enrolment course intakes and completions. (Improvements in the attractiveness of a career in nursing – in the working conditions, salaries and status of nurses – may improve retention and re-entry, but the magnitude is unlikely to be great, though such improvements can have a very positive impact on quality. However, such improvements in the attractiveness of nursing may substantially improve the number and quality of potential recruits to nurse education programs—discussed further below.)
Redesigning work and extending roles
Flexible work, more effective team work, and role extension have been discussed as beneficial to care and as possible responses to particular local and more widespread shortages in some health professions.
There is a need to be clear about, and to differentiate, the qualitative improvements sought (better health promotion and prevention of illness, better care, better job satisfaction and career paths, and greater cost-effectiveness) from the quantitative effects on alleviating or exacerbating particular shortages in particular professions. Three sets of initiatives that have implications for macro-level nurse workforce planning are discussed here.
First, and often commented on, is the extension of the roles or work settings of registered nurses so that they undertake some current duties of medical practitioners. While such extensions of roles and work locations may well be effective and efficient ways of providing quality health care, any significant substitution of registered nurses to alleviate shortages of medical practitioners are most likely to exacerbate shortages of registered nurses.
The second strategy is to extend the roles of enrolled nurses so that they may undertake duties currently undertaken by registered nurses. Again, there appear to be qualitative benefits. However, there has not been a sufficient increase in enrolled nurse numbers so that they can take on such expanded roles without exacerbating the existing shortages of enrolled nurses, and any increases in course length (or additional training in work time) to prepares enrolled nurses for expanded roles (or for national consistency) will reduce enrolled nurse availability over the period of course extension or additional training time. The number of enrolled nurses declined between 1994 and 2005 (Table 3), and while the number of enrolled course completions is increasing (to around 6000), around 10% (1500 individuals) of commencing students in pre-registration nurse education courses in universities have enrolled qualifications (CDNM, 2008, p. 7). That is, a number equivalent to around a quarter of enrolled nurse graduates are entering courses to prepare to become registered nurses, and, if successful, those enrolled nurses will be lost to the enrolled nurse workforce.
A third strategy for greater flexibility and role extension is increasing the number of individuals with multiple capabilities, and, in many cases, multiple professional qualifications, through completion of double degree programs. More than one-third of students commencing pre-registration nursing and/or midwifery courses in 2007 were undertaking double degree programs. These double degree programs are in a wide range of fields—of the students commencing double degree programs, around a sixth (117) are taking nursing and midwifery, and nearly as many in each of paramedic/emergency and nursing; psychology and nursing; health management and nursing. There is also public health, rural health, human movement, arts, science, early childhood education, and commerce with nursing (or midwifery) (CDNM, 2008, p. 2). While someone qualified to be both a nurse and an early childhood teacher, or a nurse and a psychologist, may be a more flexible and effective professional, especially in rural and remote locations and some other particular settings, they remain one individual, with only so many hours available for work in a day. They may become a full-time member of the non-nursing professional workforce for which they are also qualified, and thus be lost to the nursing workforce. Projections for future availability of graduates of such double degree programs will need to discount for the possibility of them entering those other professions, as well as qualitative workforce planning take account of their potential multiple capabilities.
In summary, redesigning work and extending roles may be valuable initiatives for improving the quality of care, efficiency of practice, and professional satisfaction and career development, but these initiatives appear to have little relevance to dealing with shortages in the short term.
Increasing pre-registration course intakes and completions
There are a number of potential limitations on a substantial expansion of pre-registration and pre-enrolment course intakes and completions. These vary among institutions and states and territories, and some will only become serious issues if there is substantial expansion in particular institutions or jurisdictions.
The potential limitations cover difficulties in the provision of a sufficient number of good quality new places, and the recruitment of a sufficient number of students with potential to become highly competent nurses and midwives.
The most significant difficulty in the provision a sufficient number of places is the difficulty in obtaining clinical places—for student enrolled nurses as well as student registered nurses and midwives. Substantial increases in funding per student will be necessary for any substantial increase in the provision of quality clinical places across all settings and geographic locations. In addition, the quality as well as adequacy of places may be enhanced by changes in course structures, curriculum and pedagogy, greater collaboration between institutions and sectors, and other innovations. There are also some current and possible future academic and general staff shortages in nurse education. Nurse education is at a lower funding band than comparable higher education fields (such as science), and a reasonable increase in funding would make a great difference to the number and quality of places that can be provided in the future.
If sufficient places in high quality courses can be assured, it will still be necessary to fill those places with students with strong potential to become safe and effective professionals, performing to the highest standards. There has been concern for decades about the purported low academic achievement of some commencing students, and that too many students had a first preference for an unrelated course (and career). These matters can be dealt with in part within broader strategies to promote the conditions, attractiveness and status of the profession and its training. It is also important that debate on these matters does not become self-fulfilling by highlighting purported negatives in student nurses, nurse education and the nursing profession. The evidence is complex, and there are some positive indications of high demand from potential students of quality (DEEWR, 2008). Data on qualified applicants, offers and acceptances indicates substantial variability between the states and territories, which can inform decisions about where strategies to improve demand from potential students should be directed.
Conclusion
The most important strategy for responding to current nurse workforce shortages and avoiding future shortages will continue to be to increase intakes and completions in university and VET pre-registration and pre-enrolment courses, at least for around 8–12 years. This cannot be done effectively without adequate levels of funding, especially for clinical placements.Appropriate, policy-directed, high quality research, which is updated periodically, is necessary to determine the magnitude of necessary increases, and how they should vary among jurisdictions, institutions and types of courses. Actual policy and practice then needs to be evidence-based, and take such work into account.
Acknowledgements
This is an edited version of a paper prepared as background to the panel presentation by Barbara Preston at the Australian Financial Review Health Conference 2008, ‘Health Reform—Aligning Policy and Funding with Reality’, 24–25 June 2008, Park Hyatt Hotel, Melbourne.
References
- Australian Bureau of Statistics (1990). March to July 1989: Career paths of qualified nurses in Australia. Cat. No. 6277.0. Canberra: Australian Bureau of Statistics.
- Australian Bureau of Statistics (2008). 2006 to 2101 Population Projections Australia. Cat. No. 3222.0. Canberra: Australian Bureau of Statistics. Retrieved November 16, 2008, from http://www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/0E09CCC14E4C94F6CA2574B9001626FE/$File/32220_2006%20to%202101.pdf.
- Australian Institute of Health and Welfare (2000). Australia's health 2000. Canberra: Australian Institute of Health and Welfare. Retrieved June 16, 2008, from http://www.aihw.gov.au/publications/index.cfm/title/5742.
- Australian Institute of Health and Welfare (2008a). Medical labour force 2005, National Health Labour Force Series No. 40. Canberra: Australian Institute of Health and Welfare. Retrieved June 16, 2008, from http://www.aihw.gov.au/publications/index.cfm/title/10548.
- Australian Institute of Health and Welfare (2008b). Nursing and midwifery labour force 2005, National Health Labour Force Series No. 39. Canberra: Australian Institute of Health and Welfare. Retrieved June 16, 2008, from http://www.aihw.gov.au/publications/index.cfm/title/10475.
- Council of Deans of Nursing and Midwifery—Australia and New Zealand (2008). Pre-registration nurse education data collection and publication project 2007. Melbourne: Council of Deans of Nursing and Midwifery—Australia and New Zealand. Retrieved June 16, 2008, from http://www.cdnm.edu.au/pdfs/DOHAReport080303.pdf.
- Department of Education, Employment and Workplace Relations (2008). Undergraduate applications, offers and acceptances 2008. Canberra: Department of Education, Employment and Workplace Relations. Retrieved May 13, 2008, from http://www.dest.gov.au/sectors/higher_education/publications_resources/profiles/Undergraduate_App_Offers_Acceptances_2008.htm.
- . Australian nurse supply and demand to 2006: A projections model and its application. Melbourne: Australian Council of Deans of Nursing; 2002;
- Preston, B. (2006). Nurse Workforce Futures: development and application of a model of demand for and supply of graduates of Australian and New Zealand pre-registration nursing and midwifery courses to 2010. Melbourne: Council of Deans of Nursing and Midwifery—Australia and New Zealand. Retrieved June 16, 2008, from http://www.cdnm.edu.au/pdfs/Nurseworkforcefutures.pdf.
- Preston, B. (2008). Planning for the Australian teaching workforce: Issues and experiences. A background paper for a meeting with a delegation from the South African Education Labour Relations Council. Faculty of Education, University of Canberra, 30 September. Unpublished manuscript.
- 1 Midwives are included with registered nurses in most of the datasets used in this paper. The terms ‘nursing professionals’ and ‘nursing profession’ are generally used for registered nurses and midwives, but not enrolled nurses—though of course much of the practice of enrolled nurses is ‘professional’. Where appropriate, ‘ENs’, ‘RNs’ and ‘RMs’ are used for ‘enrolled nurses’, ‘registered nurses’ and ‘registered midwives’, respectively.
PII: S1322-7696(08)00073-5
doi:10.1016/j.colegn.2008.12.002
© 2009 Royal College of Nursing, Australia. Published by Elsevier Inc. All rights reserved.
