Impact of the Nursing Crisis on the Health Workforce

Submission to the Productivity Commission Health Workforce Enquiry 

MARLENE  EGGERT, RN
PhD Scholar
Australian National University, Medical School

Contact details: Marlene Eggert, Australian National University, Medical School, Canberra ACT 0200. Email: marlene.eggert@anu.edu.au ph: 02/62843699

_____________________________________________________________

Contents: 

Executive Summary
Key influences on nursing workforce participation and job satisfaction
Dissatisfaction with the health workplace
Immigrant nurses
Economic cycles
Recommended Action
Federal
State
Hospital
Workforce planning and demand
Nursing is essential to bed based health care and community care
The ageing population will require nursing services
Education and training
Recommended action
Regulation of the health workforce
Reference list

Executive Summary

A poor management culture and unsupportive management policies and practices in the healthcare system are the primary causative factors for nurses’ dissatisfaction with their workplace and their consequent abandonment of the profession. 

Today, referral of patients to bed based services occurs only if nursing is required in conjunction with medical treatment, otherwise outpatient services are utilized. This makes nursing an essential part of the health workforce. 
The ageing of the Australian population will significantly increase the demand for nursing mainly because of an expected rise in chronic health conditions.  

Encouraging the immigration of nurses will only provide a temporary alleviation of the problem as these nurses will acculturate to Australian workplace expectations and are also likely to leave.

Nurses’ availability for employment has coincided with economic downturns, but within the next 10 years the size of the young and the aged nursing workforce will shrink due to the lower numbers of young people entering the workforce and older nurses retiring. 

It is argued that nursing as a profession is not educationally well prepared for the expected changes in health care needs and that nursing courses need to include chronic illness care and community based care in their curricula.

All nurses and care workers, regardless of level of educational preparation, should be registered to protect a vulnerable population from unsuitable or impaired carers.

Key influences on nursing workforce participation and job satisfaction

Management culture, policies and practices in the healthcare system are key influences for nurse workforce participation and job satisfaction. In the following section it is argued that employers within the healthcare system do not meet the legitimate workplace expectations of contemporary nurses and that this is a fundamental, causative factor for the nurses shortage.  The following section deals with the topics of:
•	dissatisfaction with the health workplace,
•	the influence of economic cycles on future nurse supply, 
•	the temporary alleviation of labour shortages by employment of immigrant nurses and  
•	some recommendations.

Dissatisfaction with the health workplace

Nurses report their health workplaces to be an unpleasant environment, where nurses feel undervalued, where they experience a lack of management support and are expected to sacrifice their own plans and aspirations to the demands of work rosters. (Commonwealth of Australia 2002 b).

Young nurses leave the profession not long after they have completed their training. This is confirmed by recent government reports into nursing which have identified that all nursing training places on offer are taken up or overenrolled (Commonwealth of Australia 2000 a) but the data on the age of the nursing workforce shows that the average age of nurses is 42 years (Australian Institute of Health and Welfare 2003).   

The management of the nursing workforce in Australia has been characterized by a wasteful attitude towards nurses.  Historically, nurses were trained in large numbers and their departure from the workforce was expected due to the overwhelmingly female gender of nurses (Nay and Pearson 2001). This attitude has not changed and organizations employing nurses still lose many members of their nursing workforce to work dissatisfaction and injury (NSW Minister for Health 2000).

There are structural-organizational reasons why nurses feel undervalued and lacking management support in the workplace.  One organizational element is the hierarchical structure of nursing, historically derived from the military model.  A hierarchical structure built on a chain of command does not sit well with the professional self-image taught in nursing courses at universities which values professional autonomy and responsibility (Woodham-Smith 1955; Game A & Pringle R. 1983; Daniel A 1990).
The other structural reason for the nurses’ shortage is the power structure in the employing organization, where the power of the health administrators and the medical profession combine (Willis 1989) to starve nursing of much needed resources in an effort to achieve budgets.  This results in many nurses experiencing their work situation not just as physically and emotionally draining but also as a professional moral dilemma as they are unable to care appropriately for their patients and this undermines their commitment to the profession (Johnstone, Da Costa et al. 2004).  
The opportunity cost of having achieved budgets by diverting funds from nursing to other areas of health care has been great as nurse employees respond to their working conditions by leaving the profession.

Research derived data are available on factors which make workplaces attractive to nurses.  These data are from a series of research studies conducted in the USA commencing in 1981 and indicate that nurses value high professional autonomy and responsibility, clinical advancement opportunities, a participatory management style and access and emphasis to continuing education (Buchan 1999).  These factors are culturally specific to the USA, therefore may not smoothly translate into Australia but they may provide an insight into what sort of end result the change needs to be aimed at. It is clear however, that clinical nursing needs to be provided with organizational resources such as structural empowerment in order to address the issues (Spence Laschinger 2004).

Immigrant nurses

Attracting immigrant nurses to Australia will provide a short to medium term alleviation of the shortage, however, migrant nurses must acculturate to their Australian environment if they want to become successful members of society and the nursing profession. This means that they will eventually experience the same degree of dissatisfaction with nursing as their Australian trained counterparts. From an economic point of view it appears to be irrational to first commit resources to train required numbers of nurses in Australia to meet forecast demand, then to spend further resources to recruit and register immigrant nurses to the country because of the failure to retain Australian nurses. 

Economic cycles  

Nursing in Australia has undergone periodic shortages which coincided with economic up cycles.   However, because of the ageing workforce and the high work intensity it is unlikely that an economic downturn will encourage sufficient numbers of nurses back into nursing, and if they return, it can be expected that the hours they choose to work will be fairly reduced. At the same time the number of young people entering the job market is expected to drop and workplaces will need to be attractive to be competitive in the job market.

Urgent measures need to be taken to address the nursing retention issues.  These measures all lie in the domain of the employing health care organizations on a state level.  The nursing workforce issues have been lost between the divided responsibilities of state and federal governments. There are governmental actions at federal and state level which can address some of the issues.

Recommended Action
Federal 
Federalise the health system.  Together with many other health issues which cross the federal/state divide, nursing’s issues as a profession have remained unresolved.  A federally based health system enables a national approach be taken to a national problem.
State
State chief nurses and hospital nurse executives need to have resource responsibility for their nursing workforce.

Fully funded re-entry courses for nurses, as currently nurses cannot look forward to well paid career opportunities where they are able to offset the expense of retraining.    
Hospital
The perceived poor management in nursing may be improved through extensive management and leadership training to shift the traditional hierarchical management style and implement a more professional model of staff supervision and leadership.

A significant number of nurses are lost to clinical practice due to injuries sustained by manual handling.  The purchase and continued maintenance schedule for care  equipment can prevent many injuries.

Clinical nurses need to be structurally empowered in their work organizations through:
•	Management and supervisory systems which support high professional autonomy and responsibility 
•	Clinical career structures 
•	Participatory management styles 
•	Access to and rewards for continuing education.  Rewards should be financial and also include organizational rewards such as committee memberships and advisory roles. 
Workforce planning and demand

In this section it is argued that the significance of nursing is recognized neither at the policy nor the operational levels of health care in Australia and that the importance of nursing to the healthcare system will increase in the near future because of the ageing population.

Nursing is essential to bed based health care and community care

An important point to realize in today’s health care environment in Australia is that patients are referred to hospitals primarily because they need nursing in conjunction with their medical treatment.  Patients not requiring nursing will be treated through an outpatient service.  Nursing is therefore essential to all bed based health care service and to community based nursing services.

The ageing population will require nursing services

The impact of ageing on the utilization of health services is well documented in the Productivity Commission’s 2005 progress report on the “Impacts of Medical Technology in Australia.”  However, what has not been realized is that the ageing population will bring about changes in health care needs, which require and respond mainly to nursing interventions.  
This is because aged people experience a prevalence of chronic conditions such as dementia, arthritis, diabetes, post stroke conditions and chronic heart failure.  The care of chronic conditions has four main components of nursing care: treatment care (e.g. pharmacological treatment), self management education (e.g. cardiac rehabilitation or diabetes education), supportive care (e.g. with the monitoring of the chronic condition) and rehabilitation nursing (e.g. facilitating physical mobilization).  
The chronicity of the conditions which the ageing Australian population is expected to experience will require nursing input to meet the health care needs of this population.  Nurse specialist groups whose expertise will be required are:

Aged care nurses
Community nurses
Mental health nurses
Diabetes nurse educators
Rehabilitation nurses
Orthopedic nurses
Wound specialist nurses
Cardiac rehabilitation nurses

This list of specialist nurses who are equipped to deal with the particular chronic  health problems of the ageing population is not exhaustive. Of particular concern is however, that Australian nurses as a professional group are not necessarily educationally prepared with the right training and skills to meet this certain future demand.

Education and training

Nursing will require expanded knowledge and skills training to deal with the future nursing needs of the chronic conditions experienced by the ageing population.
Nursing training in the practice setting occurs mainly in the tertiary sector.  However, community based nursing is a significant component of nursing and its significance will rise as the population ages and aims to remain resident in the community.  
Community nursing training has almost ceased in Australia in spite of the shift from hospital based care to community based care (Commonwealth of Australia 2002 b) leaving Australia without an adequately prepared workforce for this role.  Community nurses require special expertise in aged care nursing, wound care, identification and support for commonly occurring mental health conditions such as depression, chronic disease self management skills (Lohrig 1994) and they also require training in family systems nursing, rehabilitation nursing and health promotion.   

Recommended action
Nursing Education
Negotiate with all state nursing boards to include chronic disease self-management education skills and community nursing skills into the educational curriculum.

Instigate the setting up of postgraduate community nursing courses at tertiary education level.
Regulation of the health workforce

A last point to be raised which is of particular concern to the nursing profession is the employment of unregulated health workers.  All health workers employed in a nursing role should have completed the basic certificate III training course as minimum educational requirement and be registered as base level health workers to ensure the protection of a vulnerable population from unsuitable or impaired workers.

Reference list    

Australian Institute of Health and Welfare (2003). Nursing labour force 2002. Canberra, AIHW (Health Labour Force Series no 29).
Buchan, J. (1999). "Still attractive after all these years? Magnet hospitals in a changing health care environment." Journal of Advanced Nursing 30(1): 100-108.
Commonwealth of Australia (2002 a). Our duty of care. Canberra
Commonwealth of Australia (2002 b). The patient profession.  Time for action. Canberra.
Daniel A (1990). Medicine and the State: Professional Autonomy and Public Accountability. Sydney, Allan & Unwin.
Game A & Pringle R. (1983). Gender at work. Sydney, Allan & Unwin.
Johnstone, M.-J., C. Da Costa, et al. (2004). "Registered Nurses and Enrolled Nurses' experiences of ethical issues in nursing practice." Australian Journal of Advanced Nursing 22(1): 24-30.
Lohrig, K., Holman, H.,& Sobel, D., (1994). Living a Health Life with Chronic Conditions. Palo Alto, Bull Publishing Company.
Productivity Commission (2005). Impacts of medical technology in Australia. Canberra
Nay, R. and A. Pearson (2001). "Educating Nurses to protect the past or to advance health care?: A polemic."Australian Journal of Advanced Nursing 18(4): 37-41.
NSW Minister for Health (2000). Our Commitment.  NSW Nursing Workforce. Sydney, NSW Government: 1-7.
Spence Laschinger, H. K. (2004). "Hospital nurses' perceptions of respect and Organizational Justice." Journal of Nursing Administration 34(7/8): 354-364.
Willis, E. (1989). Medical dominance: the division of labour in Australian Healthcare. St. Leonards, Allan & Unwin.
Woodham-Smith, C. (1955). Florence Nightinghale. Harmondswoth, Penguin.