The nursing workforce
- The nursing workforce comprises 3 regulated groups: Nurse Practitioners (NPs), Registered Nurses (RNs) and Enrolled Nurses (ENs). Nurses recognise that other unregulated groups of healthcare workers (for example Assistants in Nursing (AINs)) perform nursing care, and the research is clear that they require support from registered nurses (Duffield et al, 2014). Other regulated health professions, including general practitioners (GPs) have also regularly performed various aspects of nursing care. In General Practice over the past twenty years, practice nurses have been increasingly employed to perform those nursing aspects of care (Merrick et al, 2011).
- The scope of practice for nurses is not defined by the tasks nurses perform, but by the acuity of the people they are caring for and the concomitant range of skills that they will require for their practice. For example, assisting a person who is acutely ill and haemodynamically unstable with their personal hygiene may well require the assessment and clinical management skills of an RN, but the same personal hygiene skills may be performed by an AIN if the person is convalescent.
- Nurses will perform their skills across a continuum from novice to expert (Benner, 1984) at different stages of their career development and according to the different levels of registration: NPs perform all of their skill-sets at a highly complex level (NMBA, 2014), whereas ENs may perform only some of their skill sets and to a less complex level (NMBA, 2016).
The current situation
- Australia is confronting a range of healthcare challenges, including greater demands on existing health services posed by an ageing population with a concomitant increase in chronic and complex diseases. These challenges are exacerbated by existing and projected shortages and/or maldistribution of healthcare professionals and an aging workforce (Graham et al, 2015; HWA, 2013a).
- Currently there is an oversupply of newly graduated registered nurses looking for transition programs, particularly in acute care (Stewart, 2014).
- There are two reasons for this:
- The Baby Boomers did not retire when anticipated –in part due to the GFC and in part due to the fact they are Baby Boomers and see themselves as chronologically younger (Hudson and Gonyea, 2012).
- The increase in student places due to the significant investment from Health Workforce Australia leading to an oversupply of new graduates (HWA, 2013b).
- There is still an undersupply of nurses in mental health, aged care and some rural and remote areas (HWA, 2014a).
- There is a projected shortfall of registered nurses by 2025, initially 109, 000 (HWA, 2013a). It is not as large as originally projected now 85,000 (HWA, 2014a). However, both reports provide strategies taken to ameliorate the shortfall significantly.
Solutions and strategies
- The projected shortfall can be significantly reduced (down to 20,000) if we could improve nursing retention by 20% -that is, if we could get ONE IN FIVE of the nurses who are currently leaving to remain (HWA, 2013a; HWA 2014a).
- That means we also need to retain the new graduates who are currently unemployed. Attracting them to underserved areas may be a strategy to address both present and future retention and current shortfall (Christopher et al. 2015).
- Forty years of reviews into the nursing workforce reveal that nurses leave for two reasons: they feel unable to deliver the scope and quality of care they have been educated to deliver because of workload constraints, and more importantly, they feel their contributions are not valued (Chiarella, 2002). The role of the nursing unit manager and nurse executives (both roles at risk in restructuring) in retention cannot be underestimated (Roche et al, 2015; Duffield et al, 2011).
- Retention requires enabling all levels of nurse (NPs, RNs, ENs) to work to full scope of practice and to value their contribution to health care through strong support mechanisms and adequate funding (HWA, 2014b).
- With appropriate funding models, nurses could take a central role in
- A primary health care (PHC) model focused on the needs and best interests of the individual, especially those in underserved areas –rural and remote, mental health, aged care. There is evidence to suggest that privately practising NPs are drawn to these areas and would proliferate there given better funding support (Currie et al, 2016).
- A model that incorporates transdisciplinary approaches to healthcare, recognising the role of other healthcare professionals (HCPs) in the provision of nursing care
- Prevention of ED and hospital presentations due to the impact of skilled nursing care enabling patients with complex needs to be cared for in the community and aged care facilities (Satherley et al, 2013).
- Educating nurses and other HCPs in such models, with a focus on the delivery of nursing care in the community setting (ANMF, 2009).
- NPs could play a far more active role in PHC, aged care and mental health with appropriate funding models (HWA, 2014a). They are highly effective and demonstrably safe, but current private practice nursing models have significant difficulties relating to funding (Currie et al, 2016) and collaboration (Currie et al, 2013)
Professor Christine Duffield is Director, Centre for Health services management (UTS) and Professor of Nursing & Health Services Management US and Edith Cowan University.
Professor Mary Chiarella, Professor of Nursing, Sydney Nursing School, University of Sydney.
ANMF (2009) Primary Health Care in Australia: a nursing and midwifery consensus view [Online] http://anmf.org.au/documents/reports/PHC_Australia.pdf
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