Review of Australian Government Health Workforce Programs

7.2 Nursing and midwifery retention

Page last updated: 24 May 2013

Workforce retention is a complex and potentially controversial issue confronting governments, employers and the nursing and midwifery professions. HWA modelling for HW2025 took into account an annualised nursing and midwifery workforce exit rate of around five to six per cent in the future. This takes into account both permanent and temporary exits. Currently, exit rates are estimated to be historically low, at around two per cent per annum.

Some assumptions made to explain this low rate include the global financial crisis and its impact on retirement incomes, and recent increases in the retirement age. People born after 1 January 1957 will have to reach the age of 67 before they are eligible for the aged pension. The superannuation savings of many nurses and midwives is also considered to be inadequate to retire earlier.

It is of high importance that the modelling assumptions used for HW2025 are carefully examined in the light of changing retirement decisions. Future exit rates are likely to be volatile, given their dependence on a range of factors, including the economic circumstances described above, as well as potential changes to industrial frameworks and employment conditions. This presents challenges for workforce planners in terms of relying on previous data to make assumptions about the future workforce.

Figure 7.3 below notes the changing demographics and age profile for cohorts of nurses and midwives from 1995 to 2011. Of note however, is that the last category is 55+. In the future, given advances in the retirement age, this cohort may need to be divided into 55–64 and 65+ categories to identify any longer term trends in workforce participation and assist with nursing and midwifery workforce planning.

Figure 7.3: Age comparison of nurses

Figure 7.3: Age comparison of nurses D

Source: AIHW Nursing and midwifery labour force 1996, 2001, 2007 and National Health Workforce Dataset: nurses and midwives 2011

Early indications are that the exit rate applied by HWA may have been an overestimate and the scenario to 2025, which has gained such wide currency, may not be as severe as first predicted. HWA has committed to revisit the modelling over the period following subsequent and more reliable data releases. This may potentially downgrade the original 2025 scenario. Nevertheless, the potential workforce shortages identified in the HW2025 report require serious investigation and appropriate policy responses across governments.

HWA’s report indicates that the nursing and midwifery workforce supply is adequate until 2016. It needs to be noted that there are current concerns about the immediate employment prospects of newly graduated registered nurses and the potential impact on both the individuals and on future workforce supply if these qualified professionals fail to find employment on graduation and leave the profession. In keeping with the imperative to retain nursing and midwifery staff, as well as trying to increase intakes, various initiatives have been or are being rolled out. Most do so through the offer of further career development. Assistance with further career development may also provide the opportunity to adopt more advanced roles such as an eligible midwife or nurse practitioner, which not only benefits the individual from a career point of view but also increases access to health care for the population. These programs include:

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  • the Nursing and Allied Health Scholarship and Support Scheme (NAHSSS), which facilitates the continued professional development of nurses and midwives and encourages the pursuit of a health career in both geographic areas and professions where there are shortages. There are particular streams applicable to practice nurses, nurse practitioners, midwives and those working in Aboriginal and Torres Strait Islander communities;
  • the Nursing and Allied Health Rural Locum Scheme (NAHRLS) has been established to enable rural nurses and midwives to take short-term leave from their positions in rural Australia in order to access continuing professional development;
  • UDRHs, which provide postgraduate rural training services. With further resources there is the potential for them to play a greater role in delivering support in areas like nursing re‑entry programs, particularly in more remote areas such as Broken Hill; and
  • the Rural Health Continuing Education (RHCE) program provides access to professional training and support in rural and remote areas for nurses (as well as for medical specialists, allied health professionals, general practitioners and Aboriginal and Torres Strait Islander health workers). Funding is allocated through competitive grant processes. (Note that this program is more fully discussed in Chapter 4.)

Scholarship funding for postgraduate education can provide an incentive to undertake additional professional education but in general, most students will have already decided to pursue a particular course of study before successfully applying for Commonwealth scholarship support. However, financial support for these postgraduate students may enable more students to complete their advanced education, or undertake the study more quickly (i.e. full-time study instead of part-time).

Postgraduate scholarship education programs and investments in continuing professional development have the potential to provide workforce retention benefits by encouraging nurses to upgrade their skills and move into more challenging and rewarding roles, including extended scope of practice roles. These retention benefits have not been conclusively measured to date and there would be value in analysing how successful this approach has been by developing better longitudinal data. This activity could be undertaken by the proposed National Nursing and Midwifery Education Advisory Network (NNMEAN), once established.

There are two other main activities that are aimed at retaining nurses and midwives within the workforce in general practice and primary care settings, where nurses and midwives can develop a range of clinical and leadership skills. These activities are in line with action to provide a sustainable health care sector by providing more population health activities and managing care in the community primary health care setting (as opposed to within the acute care or tertiary hospital environment). These activities are:

  • the Nursing in General Practice Program (NiGP), implemented in 2001-02, which aimed to build the capacity of the nursing and midwifery workforce within general practice. It provides practice nurses with education and support, supports general practices to recruit and retain suitably qualified nurses and promotes the role of practice nurses to others in the community and within the health professions; and
  • The Practice Nurse Incentive Program (PNIP), which commenced on 1 January 2012. This program is designed to improve patient access to clinically appropriate primary health care services and help ease the pressure on GPs. It specifically aims to expand and enhance the role of practice nurses. Payments are made to eligible GP practices, Aboriginal Community Controlled Health Services and Aboriginal Medical Services which employ one or more registered nurses or midwives, enrolled nurses or a qualified Aboriginal health worker. Allied health professionals may also be supported under this program.

The NiGP was funded under the 2001-02 Budget measure, Additional Practice Nurses for Rural Australia and Other Areas of Need. Funding was renewed in the 2005-06 Budget. In 2009-10 NiGP was rolled into a consolidated Nursing Education and Recruitment program to produce efficiencies. In 2011-12, NiGP became an activity funded under the Health Workforce Fund.

An analysis of NiGP over recent years indicates that over the last two funding agreements the administrators of this program had difficulty fully expending the available funding, which has resulted in significant underspends. In 2010-11, as a result of the underspend, the department authorised the Australian Medicare Local Alliance (AMLA) to fund a number of Practice Nurse Incentive Program Workshops. These were designed to provide information on PNIP to medical practitioners, practice managers and nurses to ensure the 2010-11 NiGP funding was expended in line with its policy purpose of supporting nurses and midwives in general practice settings.

In 2011-12 AMLA advised the department that there was an underspend in the vicinity of $300,000 for the program. The 2012-13 funding agreement has an expected value of $2.5 million and there are concerns that these funds will again not be fully expended. In light of the introduction of both PNIP and Medicare Locals, the appropriateness of the current NiGP funding is questionable. With PNIP becoming better established, further investment in communication activities (such as workshops) is unlikely to be necessary.

This review’s analysis of the NiGP indicates that there are concerns about its effectiveness and this funding could be more effectively used on other activities to support nurses in general practice or other community settings. Administrative costs have increased substantially (19% of expenditure in 2012-13), reflecting the redirection of activities towards Medicare Locals. The direct flow of funds to support individual practice nurses, or even the wider GP practices in which they are employed, appears to be relatively low.

During the consultations, stakeholders suggested that NiGP has now been superseded by PNIP. PNIP has been very well received by general practices, as well as the nursing and midwifery professions and has provided a significant increase in funding to promote nursing care in the general practice setting.

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There is a strong argument that NiGP funding should now be ceased and those activities rolled into the functions performed by Medicare Locals, with the funds redirected to new activities to promote the roles of the nursing and midwifery professions in the primary health sector, including some health prevention and health educational roles in the primary care setting. This would provide additional opportunities for nurses and midwives in primary care, as well as wider health promotion and/or illness prevention benefits, thus reducing strain on acute care service delivery settings.

The following case study, paraphrased from a recent article from the Nursing Review, outlines the way in which the PNIP can operate to produce a positive effect on both general practices and on the nurses and midwives whose employment it helps to support. This case study highlights the training opportunities and potential career pathway that is now available as a result of the investment in PNIP.

Box 7.1: Case study – enhancing practice nurse roles and skills development

A Medical centre in Sydney’s inner west provides opportunities for enhancing practice nurse roles and skills development supported by the Practice Nurse Incentive Program (PNIP).

The clinic caters to a diverse demography, from the socio-economically disadvantaged to young professionals and is open seven days a week.

The practice nurse at this setting has just completed a course in women’s health at Family Planning NSW, which has allowed her to expand her scope of practice at the centre, qualifying her to perform breast examinations and pap smears. The course was part funded by the clinic she works at and part by a government subsidy. The medical practitioners at the practice state they encourage the practice nurses to improve their skill set and believe that it is an investment in their staff.

The nurse in this example states that it is a completely different skill set in working as a practice nurse. She says being a practice nurse means less drama than working in the hospital system, but it offers a work/life balance that suits her better.

Practice nurses at this clinic perform additional services that the doctor may not have time for, including checking vaccines, ordering them and administering them, particularly to children, they also provide the opportunity for patients to ask questions and have things explained in a manner they understand. In this practice patients generally see the nurse before they see the doctor and half the work is done. This frees up the doctors to see more patients and helps to ensure patients get a complete holistic care experience.

This nurse states that she is positive about her career and the medical practitioners and the article used for this case study suggests that the Australian Practice Nurses Association (APNA) agrees that there are good career opportunities for practice nurses in these sorts of situations.

This case study demonstrates that there are a gamut of roles within private practice and opportunities for nurses to expand their skill sets and do more procedures in women’s health, chronic disease management, diabetes, etc. Further, if the practices are large enough nurses will run and manage clinics, overseeing junior nurses. There are opportunities to become senior nurses and practice managers.

It is also suggested that many GPs have now had nurses in their clinics for a long time and that many have indicated that their practices wouldn’t survive without them.161

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There is some research support for the proposition that the main driver in retaining nurses and midwives in the workforce is the appropriate recognition of expertise and experience, as well as the promotion of leadership and management styles which encourage nurse autonomy and empowerment in decision-making processes.162

There are many factors that may also influence workforce retention. This is reflected in the evidence raised during the consultations for this review. These include:

  • Trying work conditions;
  • Inadequate remuneration and industrial relations issues;
  • Professional burnout, work related stress, and lack of management action to address these issues;
  • Lack of opportunities for career progression, including lack of opportunities to participate in continuing professional development;
  • Increasing workloads;
  • Decreased job satisfaction due to lack of autonomy;
  • Lack of professional and skill development opportunities; and
  • Occupational violence.

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The nursing and midwifery professions and their representing unions have, over the years, advocated that nurses and midwives are under-remunerated given the degree of training, professional responsibility that they face and the challenging nature of their workplace environments, leaving them vulnerable to stress, overwork and professional burnout. The recent decision by the Western Australian Government to grant nurses a substantial pay increase of 14% (over three years) appears to be an example where some of these concerns have been identified and addressed, which may assist to maintain the competitiveness of nursing as a career option compared to other sectors, such as the mining and related industries.

Appropriate nursing and midwifery leadership education is also suggested, as good clinical nurses and midwives may be promoted to leadership positions without skills, qualifications and/or support to undertake this important role.

Much research has been conducted, both in Australia and internationally, on the principles of nursing retention and its application to workplace cultures as a driver of change to reverse some of these trends.

A central pillar of labour force retention and increasing productivity is that of skills utilisation. Workforce development to enhance skills utilisation has been defined as:

“Policies and practices which support people to participate effectively in the workforce and to develop and apply skills in a workplace context where learning translates into positive outcomes for enterprises, the wider community and for individuals throughout their working lives.”163

The challenges facing the nursing and midwifery professions are multifactorial. Nurses and midwives are seeking to find a balance between the need to continue to provide strong leadership within effective health care teams and maintain an appropriate level of autonomy and empowerment as a professional group. At the same time individual nurses and midwives need continuing opportunities to enhance their mix of skills by having enough time within their increasingly busy service delivery roles to invest in professional development, with the opportunities this brings for career progression and recognition of their expertise.

Changes to practice and workplace environments such as enabling nurses and midwives to work at their full scope of practice as well as workplaces that offer flexible work arrangements and are supportive of family responsibilities may assist in retaining nurses in the workplace. Positive practice environments have been shown to improve nurse retention. However, relieving the burden of performing non-nursing tasks, such as clerical and cleaning activities, and offering professional development opportunities and career pathway options would also assist retention efforts.

In order to provide the environment for nurses and midwives to work at the top of their scope of practice, the development and employment of a trained assistant workforce that will perform more routine tasks must be considered. This may also increase the retention rates of nurses and midwives within the workforce. (This is further discussed in the nursing and midwifery workforce sustainability section, later in this chapter.)

The behaviour of an employee’s manager has been identified as a highly significant factor impacting on employee turnover in the nursing profession.164 Nursing and midwifery leaders confirmed that within the overall organisational culture, many of the standard practices within the work environment need to evolve further. One of the keys to improvement is the development of strong and supportive leadership to drive more supportive and collaborative action. This can lead to enhanced contemporary clinical practice and improved staff work experiences.

Effective leadership can significantly affect employee satisfaction, trust in management, commitment, individual and team effectiveness and, collectively, the culture of the organisation. While other factors are influential, leadership plays a central role in mobilising people towards a common goal, achieving outstanding health outcomes and creating a positive practice environment that attracts and retains nursing staff.

Many developed countries around the world have grappled with nursing shortages for many years and have applied nurse retention strategies to varying degrees of success. The “Magnet hospital” principles have been employed in the US since 1990 and have been affiliated with success in this area internationally.

Box 7.2: Magnet hospital status

Magnet status is an award given by the American Nurses' Credentialing Center, an affiliate of the American Nurses Association, to hospitals that satisfy a set of criteria designed to measure the strength and quality of their nursing. A Magnet hospital is stated to be one where nursing delivers excellent patient outcomes, where nurses have a high level of job satisfaction, and where there is a low staff nurse turnover rate and appropriate grievance resolution. Magnet status also indicates nursing involvement in data collection and decision-making in patient care delivery. The Magnet nursing leaders value staff nurses, involve them in shaping research-based nursing practice, and encourage and reward them for advancing in nursing practice. Magnet hospitals are supposed to have open communication between nurses and other members of the health care team, and an appropriate personnel mix to attain the best patient outcomes and staff work environment.165

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Three hospitals in Australia have achieved Magnet hospital status: the Princess Alexandra Hospital (Brisbane), Sir Charles Gairdner Hospital (Perth) and St Vincent's Private Hospital (Sydney). The Princess Alexandra Hospital reduced nursing staff turnover from 25% in 1999 to just over 10% two years later.

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Another nursing and midwifery leadership initiative that has significant traction in Australia is known as the Essentials of Care. New South Wales Health introduced this program in February 2008 and all Local Health Districts are now at various stages of implementation. The implementation of this initiative is enabling nurses and midwives to focus on the development of clinical environments that enhance patient care, teamwork and individual work satisfaction.

Box 7.3: Essentials of Care initiative

Essentials of Care is a framework to support the development and ongoing evaluation of nursing and midwifery practice and patient care. It is underpinned by the principles of transformational practice development. This approach to practice requires that all stakeholders – patients, carers, staff and families – have opportunities to participate and are included in decisions about effective care using approaches that respect individual and collective values. Nurses and midwives have been enthused by this opportunity to refocus on the basic values of caring and the reason why many came into the profession.166

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Given the importance of nursing and midwifery workforce retention, the Commonwealth should consider active involvement in the implementation of national nurse leadership programs, based on the successful Essentials of Care and Magnet Hospital initiatives, as there is evidence that these initiatives positively impact on workforce retention rates.

In implementing this recommendation, DoHA and the nursing and midwifery professions should be cognisant of the work currently being undertaken by HWA on this topic. This will ensure that any health leadership networks, educational courses or other activity aimed at developing mid-level health professional managers will be complementary. Additionally, the implementation of this recommendation must have strong input from the nursing and midwifery professions. This may be achieved by consultation with key stakeholder groups and could be overseen by the proposed National Nursing and Midwifery Education Advisory Network (NNMEAN), once established.

During review consultations with private sector health providers, as indicated earlier, it was acknowledged that private sector employers in Australia target specific university programs to recruit nursing and midwifery graduates. Stakeholders stated that they have some concerns about the quality of graduates from some educational institutions, and therefore preferred to develop links to specific educational institutions.

Retention rates amongst these private sector employers are believed to be higher than the public sector. While there is only anecdotal evidence to support this claim, there are a number of factors amongst the private sector workforce that may serve to enhance their retention rates. These include: the specific traits and skills of graduates from particular courses/institutions that are affiliated with successful recruitment and retention, a structured graduate program and support, workplace culture and mentoring programs along with well-resourced recruitment principles and policies, and adequate remuneration policies.

The Nursing Futures Project, undertaken by the University of Adelaide on behalf of DoHA, is about to provide its final report. This study undertook a systematic review of the evidence of factors that impact on quality nursing care. Specifically, it focused on the importance of maximising nurse retention and employee satisfaction to deliver high quality direct patient care. This report will also identify where further research is required to build an evidence base. Importantly, this will include the nursing skill mix and the best use of the enrolled nurse and assistant in nursing roles.

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161 Flynn Murphy, “Personal touch at the practice”, Nursing Review, 1 January 2013

162 MV Force, “The relationship between effective nurse managers and nursing retention”, Journal of Nursing Administration Vol 35, No7/8 July/August 2005.

163 Skills Australia, Australian Workforce Futures: A national workforce development strategy, Skills Australia, Canberra, 2012, p. x

164 L Aiken, A Kelly, and D McHugh, “Nurse outcomes in Magnet and non-Magnet hospitals” Journal of Nursing Administration, October 2011

165 Reproduced from: American Nurses' Credentialing Center, “ Magnet status: What it is, what it is not, and what it could be”, accessed at http://www.truthaboutnursing.org/faq/magnet.html#ixzz248TURa22

166 Directly quoted from: NSW Government’s Essentials of Care Program website, accessed at http://www0.health.nsw.gov.au/nursing/projects/eoc.asp