Nursing and midwifery workforce issues are matters for both Commonwealth and state governments. As the major employer of nurses and midwives, the states and territories are primarily responsible for recruitment and retention. The Australian Government is responsible for funding the delivery of health services and for university education of nursing and midwifery students.231 The Commonwealth’s wider function in planning and investing in the nursing and midwifery workforce of Australia has only emerged relatively recently. Initially, the majority of funding and policy initiatives were directed through the Education portfolio driven by the transition of nursing to the tertiary education sector in the early 1980s. Later, investment through the Council of Australian Governments’ (COAG) 2006 Health Reform Agenda has resulted in a much broader role for the Commonwealth with the ability to impact on the workforce through education and training reform.
Historically, nursing education in Australia was public hospital based, with an apprenticeship style system whereby the students were paid under conditions which included full board and lodging. Gradually, regulatory bodies for nursing were established in each state and territory. This resulted in the introduction of minimum standards for both the theory and clinical components of nurse training and the accreditation of schools for general nursing education. These agencies or authorities also maintained a register of those who had met the required standards and were eligible to practice as registered nurses. Admittance to the register was controlled by state-based examination near the end of the training period.232
By the 1980s, many of the schools of nursing in the smaller, regional and rural hospitals had closed as they did not have the capacity to meet the stringent educational requirements of the state-based nursing registration boards. The 1980s had seen a rapid increase of technology in the health sector and this in turn placed demands on all health professionals to expand their scope of practice with the nursing curriculum increasing from 1,000 to 1,200 hours over the three years training period. When the registration boards proposed an increase to 1,500 hours in order to include the theoretical components necessary for a nurse to be educated to meet the increasing demands of health care, it rendered this type of education no longer viable outside of the larger metropolitan centres.
Ultimately, it was agreed by the majority of stakeholders that the delivery of a contemporary curriculum reflective of the changes in the health system could only be delivered in the tertiary education sector. The legislation to enable the transfer was passed on 24 August 1984. States and territories moved at various speeds in establishing timetables to implement the transfer. NSW moved quickly and had completed the transfer by 1987 while other jurisdictions embarked on programs to complete the transfer by 1991. Queensland was the last state to enact the reform finally commencing its transfer in 1991 with a three year completion date. All jurisdictions established teams to manage the process and there was an Inter-jurisdictional Committee established at the Commonwealth level.
During the period of transfer from 1985 to 1993 the funding of nursing in higher education was shared by the state and territory governments (75%) and the Commonwealth (25%).233 As part of the agreement for the transfer, the Commonwealth proceeded on a program of infrastructure grants to jurisdictions to provide nursing education facilities at universities. These facilities were mostly in the form of buildings for classrooms, clinical laboratories and offices. The state and territory health departments retained the funding used for hospital based nursing training or re-directed it to clinical supervisor positions in anticipation of the changed model of education and training. From 1 January 1994, the Commonwealth assumed responsibility for full public funding for tertiary nursing education.234
As discussed in Chapter 7, at present the qualifications and skill level required for registration or enrolment as a nurse reflect the various types of work and level of responsibility in the workplace. For registered nurses, a 3-year bachelor or postgraduate degree in nursing (or the equivalent) is usually required. This degree includes both theoretical and clinical aspects. Enrolled nurses usually work with registered nurses to provide patients with basic nursing care, doing less complex procedures than registered nurses. Enrolled nurses must have completed an appropriate vocational education and training (VET) course or equivalent, lasting between 1 and 2 years, providing a theoretical base as well as supervised clinical experience. At present, 1 year courses for enrolled nurses are being phased out.
Nurse practitioners also train as registered nurses but undergo additional tertiary education at Master’s degree level and training in nursing at an advanced level, in line with their additional responsibilities. Working autonomously in an advanced and extended clinical role, authorised nurse practitioners may perform some specified functions traditionally done by a medical practitioner, such as prescribing some medications, ordering diagnostic tests and making referrals when operating within approved guidelines. Nurse practitioners are currently a small group, with 731 registered in Australia in 2012, according to the Australian Health Practitioner Regulation Agency.
The formalisation of midwifery training in Australia began with the Diploma of Midwifery issued by the Women’s Hospital in Melbourne from 1893, undertaken after ‘general’ nursing training.235 Transition to a degree based qualification began at Flinders University in Adelaide, which offered the first Bachelor of Midwifery for registered nurses in 1997.236 However, the traditional model of midwives possessing nursing qualifications has been altered in the last 15 years.
Direct entry midwifery degrees at undergraduate level are now available in most Australian states, with at least four such degrees planned or in existence since 1998. These new degrees differ in that they do not require pre-registration as a nurse to be accepted into the course, although alternative more streamlined pathways have been maintained for nurses who wish to obtain midwifery qualifications. Direct entry midwives, as with other midwives, must be registered with the Nursing and Midwifery Board of Australia to practise.
As of December 2010, under the Commonwealth Grants Scheme for funding of university places, nursing courses of study were listed as a national priority and specific purpose funding is available for nursing clinical placements.237 For students commencing in 2008, nursing was in the lowest band of HECS-HELP ‘national priority’ for student contributions.
From 1 January 2010, the maximum annual student contribution amount for commencing Commonwealth supported students undertaking nursing units of study increased from the 'national priority' rate to the Band 1 rate. This was due to the Bradley Review of Australian Higher Education which found that student demand was not impacted by lower student contribution incentives and recommended increasing the maximum student contribution for nursing study from the “national priority” rate of $4,249 to the Band 1 rate of $5,310 from 2012 and indexed.238 This has been implemented with an associated reduction in HELP debts for eligible nursing graduates who work in the nursing profession. A maximum reduction of $1,558.50 (indexed) is available for up to 5 years of eligible employment to encourage graduates to remain in the nursing workforce.
The nursing and midwifery workforce
Australian Institute of Health and Welfare reports that:
- In 2011, the total number of nurses and midwives registered in Australia was 326,669, a 6.8% increase since 2007 (305,834).
- Between 2007 and 2011, the number of nurses and midwives employed in nursing or midwifery increased by 7.7% from 263,331 (86.1% of registrations) to 283,577 (86.8% of registrations).
- Of these people employed in nursing and midwifery, 36,074 were midwives (including 1,517 people registered as midwives but not nurses), though only 15,523 reported working in midwifery as the principal area of their main job.239
Data on students completing courses leading to registration as a nurse from 2001 to 2011 have been provided by the Australian Government Department of Industry, Innovation, Climate Change, Science, Research and Tertiary Education. Figure iv.1 indicates that overseas student numbers have been increasing rapidly, doubling from 2005 to 2007 and doubling again from 2007 to 2011. Domestic graduates showed similar growth.
Figure iv.1: Students completing courses leading to registration as a nurse, 2001 – 2011D
Source: Australian Government Department of Industry, Innovation, Climate Change, Science, Research and Tertiary Education
Overseas trained nurses and midwives
The Nursing and Midwifery Board of Australia (NMBA) assesses internationally qualified nurses and midwives against criteria that will align them with the requirements for Australian qualified applicants for registration, as specified in the NMBA’s registration standards and the board approved course accreditation standards.
Though New Zealand nurses and midwives registered with the Nursing Council of New Zealand and the Midwifery Council of New Zealand may apply for registration under the National Law, they are also eligible to apply for registration under the Trans-Tasman Mutual Recognition Arrangement.
Registration for nurses and midwives is the responsibility of the NMBA. The NMBA replaced the previous state and territory nursing and midwifery boards on 1 July 2010 as part of the National Registration and Accreditation Scheme (NRAS) for health professions. The NMBA operates as an independent authority and its functions include:
- overseeing the registration of practitioners;
- development of professional standards, codes and guidelines;
- handling of notifications and complaints in relation to the profession;
- assessing overseas trained practitioners who wish to practice in Australia; and
- approving accreditation standards and courses of study.
Under the NRAS, nurses can be registered in two divisions: registered nurse (Division 1) or enrolled nurse (Division 2). Midwife registrations have no division, though most midwives are also registered as nurses in Division 1 (registered nurses). The term 'registered nurse' has been preserved in the NRAS and in the preceding state systems even though enrolled nurses are, in fact, 'registered' to practice as enrolled nurses.
Registered nurses (Division 1) include registered nurses, registered midwives, direct entry midwives, nurse practitioners, and midwife practitioners. Enrolled nurses (Division 2) include enrolled nurses and enrolled nurses (mothercraft). To approve registration or enrolment, registration boards must be satisfied that the applicant has completed an appropriate nursing or midwifery course, is fit and competent to practise, has a state of health such that he or she can practise safely, and has sufficient command of the English language to ensure safe practice.
A national approach to registration and resourcing has permitted collection of national data for the first time, provided a platform for quality and safety and opened up new policy avenues such as nurse practitioner and midwife prescribing. The current data set is subject to many caveats in terms of accuracy, but most stakeholders agree that it represents a considerable advance on the material previously available for workforce planning.
Commonwealth programs and budget measures
In 1994, the Report of the National Review of Nurse Education in the Higher Education Sector (1994 and beyond) was released. The impetus for the review was the transfer of pre-registration nurse education to the tertiary education sector which was due for completion by the end of 1993. Recommendations of the review included: that mental health be included in the undergraduate nursing curriculum with the termination of direct entry mental health nursing programs, that AHMAC provide funding for centres for rural and remote areas nursing located in university schools of nursing or health science, and that infrastructure and support be provided for Aboriginal and Torres Strait Islander nursing students and nursing students from a rural background.
In response to ongoing concerns about national nursing shortages and the adequacy of undergraduate training places, the National Review of Nursing Education was initiated in April 2001 by the then Department of Education, Science and Training (DEST). The aim of the Review (2002) was to examine the future nursing educational needs of the health, community and aged care system in Australia and to provide advice on appropriate education policy and funding frameworks.
The terms of reference included initial registered nurse preparation, enrolled nurse education, education for specialisation, continuing education and the relationship of nursing with other groups in the health workforce. The final ‘Our Duty of Care’ report was released in 2002 with 36 recommendations supporting three main strategies to address the issues arising from the review:
- building a sustainable workforce,
- maximising health outcomes through quality education; and
- capacity building.
The DEST-led Review ran in conjunction with the Senate Community Affairs References Committee Inquiry into Nursing. The final Report ‘The Patient Profession: Time for Action’ was released in June 2002. Recommendation 12 was that the Commonwealth provide additional undergraduate nursing places to meet the workforce requirements set by the states. In the 2002-03 Budget, $26.3 million had been provided for up to 250 aged care nursing scholarships annually at rural and regional universities. The universities were responsible for marketing the scholarships and for making additional nursing places available.
As a result of the 2002 National Review of Nursing Education, the Commonwealth increased the amount of funding per place given to institutions for nursing in the 2003-04 Budget. This increased funding was directed towards the cost of clinical practice in nursing with an additional 210 nursing places funded in regional institutions which rose to 574 places by 2007 as students progressed through their courses.
In November 2003 the National Nursing and Nursing Education Taskforce (N3ET) was appointed to implement a number of recommendations from the ‘Our Duty of Care’ report. In essence the role of the taskforce was to drive major nursing education and workforce reforms with responsibilities for the recommendations assigned to the groups or organisations best positioned to take on that work. Key work referred to the taskforce included increasing Commonwealth funding for additional undergraduate university places, developing a national classification of nursing and midwifery specialties, promotion of a nationally consistent scope of practice and enhancing nursing leadership and management.
In response to the Productivity Commission’s 2005 Report, Australia’s Health Workforce, COAG announced a package of key health workforce reforms on 8 April 2006 which included $93 million over four years to fund 1,000 new higher education nursing places. The subsequent COAG 2008 Health and Hospital Workforce reform package built on the investments made under the COAG 2006 agenda. Also in 2008 the first Chief Commonwealth Nursing and Midwifery Officer was appointed, as a result of the commitment made by the Government in the 2007 election.
Health and Hospital Workforce Reform COAG 2008
- A Health Reform package of $1.1 billion of Commonwealth funding was committed, of which $500 million was for additional funding for undergraduate clinical training, including increasing the clinical training subsidy to 30% for all health undergraduate places. The package also provided for the establishment of a national health workforce agency (Health Workforce Australia) and a health workforce statistical register to drive a more strategic long-term plan for the health workforce.
As part of the National Partnership Agreement on Hospital and Health Workforce Reform, the Bringing Nurses Back into the Workforce program was announced on 15 January 2008. $39.4 million was committed over 5 years to provide 7,750 extra nurses and midwives in public and private hospitals and 1,000 nurses in residential aged care homes with the aim of supporting the nursing workforce by increasing workforce numbers, reducing the need for excess overtime and casual replacements and, in turn, allowing nurses to undertake more professional development.
However, this program was slow to demonstrate results and in the 2009-10 Budget funding was redirected to new measures aimed at ensuring the retention of the existing nursing workforce and increasing recruitment into the aged care sector. Eligible nurses who were already participating on 11 May 2010, continued to receive incentive payments under the Bringing Nurses Back initiative. No new applications were accepted beyond 11 May 2010.
In 2008, the Chief Nurse and Midwifery Officer, Dr Rosemary Bryant led the National Review of Maternity Services. It was conducted as part of the Government’s 2007 election commitment to provide a National Maternity Services Plan. The final report of the review – Improving Maternity Services in Australia – wasreleased in February 2009 and provided recommendations for the future of maternity services in Australia.
The Government responded to the report through the Improving Maternity Services Budget Package (2009-10), providing $120.5 million over four years. A range of initiatives have been funded to support the maternity services workforce, and specifically to make better use of the midwifery workforce in providing safe, high quality maternity care in Australia. In the development of the National Maternity Services Plan, states and territories were asked to make complementary commitments and investments, particularly around the provision of birthing centres and rural maternity units.
The Commonwealth initiatives include:
- A Government-supported professional indemnity insurance scheme for eligible, privately practising midwives working in collaboration with doctors;
- An expansion of the Medical Specialist Outreach Assistance Program (MSOAP) to provide more services in rural and remote communities;
- Extra scholarships for GPs and midwives to expand the maternity workforce, particularly in rural and remote Australia with 20 scholarships available each year for midwives to obtain the formal qualifications needed to be able to provide Medicare-subsidised services and access to the Pharmaceutical Benefits Scheme (PBS);
- An expansion and improvement of the existing National Pregnancy Telephone Counselling Helpline to deliver a new 24 hour, seven days a week telephone helpline and information service to provide women, their partners and families with greater access to maternity information and support before and after birth;
- Funding for improvements to national maternity data collection and for a small program of research aimed at improving the safety and quality of maternity services; and
- Medicare Benefits Scheme (MBS) and PBS benefits for services provided by eligible, privately practising midwives, working in collaboration with doctors.
It is important to note that policies which increase nurses’ access to the MBS have evolved over time. Initially measures supported nurses through “for and on behalf of items” for specific tasks such as immunisation. Later initiatives included incentives paid to general practice through the Practice Incentives Program to take on a practice nurse, MBS access for mental health nurses through expended primary care items, or a non-MBS incentive to take on a mental health nurse.
Most recently, the measures flowing from the 2009-10 Budget give eligible nurse practitioners and midwives direct MBS and PBS access for the first time, allowing them to deliver a range of subsidised services in non-acute settings including primary care, aged care and rural and remote settings. This access is provided for by the Health Legislation Amendment (Midwives and Nurse Practitioner) Act 2010 and has been available from 1 November 2010.
Prior to the passage of the legislation, nurse practitioners (NPs) were already performing in an advanced nursing role and had been able to order certain tests and prescribe certain medications under existing state and territory legislation. The 2009 Budget measure did not enable NPs to provide services beyond their scope of practice but was aimed at enabling eligible NPs to provide certain services on a subsidised basis through the MBS and PBS.
Aged care reform was a 2010 election commitment of the Government, informed by the recommendations of the Productivity Commission’s Inquiry into Aged Care (2010). On 20 April 2012, a comprehensive 10 year package to reshape aged care was announced. Under the reform package, the Government will provide $1.2 billion over five years in additional funding to aged care providers who take steps to improve the terms and conditions of their workers (the Addressing Workforce Pressures Initiative). An Aged Care Workforce Compact has been developed by the Aged Care Strategic Workforce Advisory Group chaired by Commissioner Anne Gooley from Fair Work Australia.
The Aged Care Workforce Compact will improve the capacity of the aged care sector to attract and retain staff through:
- higher wages
- improved career structures;
- enhanced training and education opportunities;
- improved career development and workforce planning; and
- better work practices.
On 19 October 2012, Commissioner Gooley presented her Final Report to the Government. The Strategic Workforce Advisory Group recognised that a clear distinction can be made between commitments for the sector as a whole that are best expressed in the Compact, and those which are more appropriately agreed by employers and employees through bargaining at the enterprise level. The report details areas of agreement and disagreement from the Advisory Group on the requirements to be met by providers in order to access the additional funding under the Addressing-workforce-pressure initiative.
Policy and program activity
|1970s||The establishment of three nursing education programs at diploma level in Sydney, Melbourne and Adelaide.||Campaign begins for nursing education to be transferred from the acute setting to the classroom.|
|1973||Aim of the nursing community to develop clear goals for nurse education in Australia.||Establishment of a working party with representatives from all major Nursing organisations across Australia.|
|1975||Goals in Nursing: Part 1 published||The working party led to a comprehensive strategy outlining positive actions to achieve change, with a revised policy statement being circulated to nurses, health authorities and governments.|
|1978||The Sax Report||Commonwealth report on nurse education, committee recommendations included transfer of nursing education into the tertiary sector.|
|1980s||Nursing registration boards||Nursing education began to be confined to major hospitals in the capital cities as smaller rural hospitals could not meet the requirements of the nursing registration boards.|
|1984||Interjurisdictional Committee established at the Commonwealth with jurisdictions creating teams to manage to transfer process.||Consensus reached on education of registered nurses at tertiary levels. The Legislation to enable the transfer to University based training passed on 24 August 1984|
|1994||Australian Health Ministers’ Advisory Council||Nursing education in Australian universities : report of the national Review of Nurse Education in the Higher Education Sector - 1994 and Beyond|
|1997||Department of Employment, Education, Training and Youth Affairs.||National Review of Specialist Nurse Education.|
|2001||Department of Health and Aged Care.||Scoping study of the Australian mental health nursing workforce; Final report.|
|2002||Senate Community Affairs Inquiry into Nursing.|
Report on the Inquiry into Nursing - The patient profession: Time for action
|Identified aged care as a priority area for reform. Recommended the appointment of a Commonwealth Chief Nurse.|
|2002||Department of Health and Ageing||Recruitment and Retention of Nurses in Residential Aged Care; Final Report.|
|2002||Department of Education Science and Training||National Review of Nursing Education|
|2003/04||National Review of Nursing Education||Additional CSP places for nursing as a priority area.|
|2003||‘Our Duty of care’ recommendations.||National Nursing and Nursing Education Task Force (N3ET) appointed.|
|2006||Australian Health Ministers’ Advisory Council||N3ET Final Report.|
|2007||Australian Nurse Practitioners Conference||Minister indicates support for nurse practitioners|
|2008||Strategy to build the Nurse Practitioner workforce in rural and remote areas||Minister announced $2.1m for scholarships for Nurse Practitioners|
|2008||Senate Community Affairs Inquiry into Nursing.||Appointment of the Chief Commonwealth Nursing and Midwifery Officer.|
|2009||Maternity Services Review|
|2008/09||Budget||MBS and PBS access for nurse practitioners & midwives|
|2010||COAG 2006||National Registration and Accreditation Scheme commences|
|2010/11||Budget||$18m over 4yrs to explore appropriate models of practice for Nurse practitioners in Aged Care.|
|2010||Australian Health Ministers’ Conference||The National Maternity Services Plan was endorsed by the Australian Health Ministers’ Conference in November.|
|2010||Medicare access||New MBS items available for eligible Midwives and Nurse Practitioners. Health Legislation Amendment (Midwives and Nurse Practitioner) Act 2010.|
|2010||PBS prescribing||Nurse practitioners endorsed to prescribe under state or territory legislation can apply for approval as PBS prescribers.|
|2011||Productivity Commission – Caring for Older Australians Report.||Living Longer Living Better aged care reform package provides $3.7 billion over five years. Includes the Aged Care Compact announced in 2012.|
231 Council of Australian Governments’ Communique 14 July 2006 at http://archive.coag.gov.au/coag_meeting_outcomes/2006-07-14/index.cfm
232 Extract (2005) from Russell, L (1990). From Nightingale to Now: Nurse Education in Australia
233 Nursing education in Australian universities: report of the national Review of Nurse Education in the Higher Education Sector - 1994 and Beyond
235 Thornton, A. (1972). The past in midwifery services. Australian Nurses Journal 1, March (9):19-23
236 Flinders University, 2011. http://www.flinders.edu.au/courses/undergrad/bmidu/
237 Department of Education, Employment and Workplace Relations. Administrative information for providers: Commonwealth Grant Scheme.
238 Review of Australia Higher Education: The Bradley Review Report 2008
239 Australian Institute of Health and Welfare: Nursing and Midwifery Workforce 2011