Chapter 6 - Recruitment, retention and return to nursing

6.1        The nurse of the 21^st century is required to provide high quality care to a discerning consumer whilst dealing with increasingly complex work issues that demand s/he make astute clinical judgements premised on higher-order thinking.[1]

Introduction

6.2        Recruitment and retention of skilled experienced nurses are fundamental issues not only for the future of the Australian nursing workforce but also for the delivery of health care. Catholic Health Australia emphasised the importance of this issue by indicating that ‘for those managing nursing services across both the acute and aged care sector the difficultly in recruiting and retaining these skilled nurses in metropolitan and rural acute and aged care facilities has seriously threatened the provision and level of care given’.[2]

6.3        As noted earlier these issues have been the subject of many reviews in recent years. In the words of one submission ‘the literature on the factors influencing the retention of nurses is robust and extensive with Australian findings echoing the international work’.[3] The reviews have constantly raised a number of major problems and canvassed a range of strategies to address these problems. The recommended strategies have been implemented to differing degrees across jurisdictions.

6.4        The continuation of these major problems has been reinforced through the submissions and evidence received by the Committee from a broad range of groups and individuals involved in the nursing profession. They overwhelmingly express a view that a considerable amount of work is still required to address the issues in a meaningful manner.

6.5        The strategies for nursing recruitment and retention in the workforce simply require these issues of concern to be addressed. They generally fall within the following major problem areas: education - including attrition from undergraduate courses, level of clinical undergraduate training and continuing educational opportunity; adequate remuneration; conditions of employment - including staffing and skill mix, working hours and making nursing a more family friendly profession; and providing a safe, healthy and enjoyable working environment.

6.6        While these problems for nurse recruitment and retention have been identified in the large number of reviews and studies referred to in chapter 1, criticism is often levelled at individual components of the system. For example universities are criticised concerning the educational preparations of nurses, transition from university to nursing practice is a difficulty for many graduates, employers of health care workers provide inadequate career structure and poor working conditions.

6.7        The Committee considers that strategies to address the major problem areas and multiplicity of issues contained within can best be implemented in a holistic manner. All parties involved in the nursing profession must implement strategies in a coordinated manner if long term change and benefit is to be achieved. A band aid approach of addressing issues haphazardly will only prolong the crisis in nursing and lead to further deterioration of the system in the future. Current solutions to nursing shortages such as the increasing use of double-shifts, casual staff, and agency nurses, can only be stopgaps that are not sustainable in the long-term. Such measures must be supported with the introduction of national and State strategies.

6.8        The issues confronting nursing are not unique to any one sector - public, private and aged care are all affected. As noted in the workforce planning section, coordination across all sectors is required to address the issues. The Australian Private Hospitals Association described the situation facing private hospitals:

There has been a lack of an integrated public/private approach to nursing recruitment and retention to date, and a lack of reliable state and national statistics on the current nursing workforce, vacancies, retention rates and numbers of undergraduates training for an acute nursing career. This has left private hospitals with little option but to rely on their own endeavours to recruit and sponsor undergraduates and postgraduates undertaking speciality training. Many hospitals have also had an increasing reliance on agency nurses to fill vacancies and to undertake night and weekend shifts.[4]

6.9        The issues are multi-sectorial, require more than one level of government to address them, and the problem is not just restricted to funding. The need for a broader national approach to improve coordination and planning of nursing policy and workforce issues has been discussed earlier. Issues involving education, including clinical education, transition to practice, continuing education and development, and postgraduate study have also been considered in earlier chapters

6.10      Many witnesses and submissions argued that fundamental to discussion on recruitment and retention was the need for a satisfied nursing workforce that was able to take pride in their work and who could readily encourage others to join the profession. For a range of reasons this fundamental point is not being met with nurses expressing a high level of dissatisfaction with their profession.

6.11      A number of submissions drew attention to the activities of magnet hospitals in the United States as an example of how to successfully provide job satisfaction to the nursing workforce. Magnet hospitals are a group of health care facilities in the USA which have successfully identified and addressed key factors in the recruitment and retention of their nursing staff. They are facilities that are viewed as great places to work where nurses want to work and remain. Their research, that has been extensively documented in nursing literature, has shown that autonomy, status, and collaboration in a professional environment by truly valuing staff views is crucial to a high level of nursing staff job satisfaction.

6.12      Magnet hospitals have demonstrated that the provision of organisational support to enable nurses to fully use their knowledge and expertise leads to high level patient care and staff who remain in the job. Their characteristics include participative and other quality management and human resource practices, employment opportunities through a clinical career ladder, provision of continuing education and training, and flexible working practices.[5]

6.13      Clearly such practices can be successfully implemented in health care facilities if the resolve is present. The University of Technology Sydney commented that many of these characteristics ‘have appeared repeatedly in workforce reports but which are still to be put into common practice’.[6] The Royal College of Nursing has proposed the establishment of a pilot Magnet Recognition Program. The College has identified many of the principles within the Magnet program developed overseas that it believes would be highly beneficial for improving nursing services and client outcomes in Australia.[7]

Recommendation 49: That the Commonwealth Government support the proposal by the Royal College of Nursing to conduct a pilot project in Australia on the Magnet Hospital Recognition Program.

6.14      Evidence suggested that the recent figures that show many undergraduate courses are receiving more applicants than there are available places may understate the difficulties that nursing is encountering in attracting younger school leavers to a career in the profession. During the 1990s many students enrolling in nursing courses were mature age applicants. However, with the elapse of time since the introduction of undergraduate courses, expectations are that the pool of potential mature age applicants is likely to dry-up over the next 5 plus years.[8]

6.15      This scenario will place greater emphasis on the need to recruit young school leavers to nursing courses. The magnitude of this task was illustrated in Queensland where it is estimated that if the number of RN graduates needs to be increased by 30 percent from 1999 to 2010, then the number of students entering nursing courses will need to be doubled from 1 200 to 2 400.[9] Similar increases are expected in other States.

6.16      Recruitment issues are important, linked as they are with the insufficient number of funded undergraduate places available and national nursing workforce planning. However, many submissions argued that as important as recruitment issues are, retention issues need more immediate attention – especially given the large numbers of experienced nurses who are registered and not practicing and the expertise being lost through trained nurses leaving the profession.

6.17      As nursing is principally administered at a State level, variations in pay and employment conditions, career structure, health service management and distribution of resources ensure that many nursing issues differ significantly across States. The Committee has already commented that it considers that all nursing issues need to be approached holistically, in a nationally coordinated and planned manner.

Recruitment

Status of nursing profession

6.18      Professional nursing is an essential resource to the health and well being of the Australian public, yet there is enormous failure on behalf of policy makers and decision takers to recognise the overall contribution that nurses make to health care. There is a lack of public awareness of the many vital services that nurses currently provide. The commonly perceived view of a caring nurse carrying out low level menial work is out dated. Nursing has changed.

6.19      Negative mass media images do not assist in conveying the true nature of current nursing and educating the wider public about the developments that have occurred in nursing.

6.20      To attract and retain new nurses to the profession it is crucial that the true value of nurses is made explicit. Nursing can no longer rely on attracting women to the profession almost by default due to the minimal choice of career opportunities that were previously available. Alternative career opportunities for women are now flourishing in a wide range of professions and are regarded as far more enticing options than nursing. Clinical nursing is and needs to be seen as a career worth pursuing and on a par with career opportunities in other fields.

6.21      Importantly nursing also needs to be seen as a viable career option for men. With less than 10 percent of employed registered nurses being male, recruitment to nursing strategies need to focus on enhancing the attractiveness of nursing as a career for men as they represent a relatively untapped source of recruitment.

6.22      Addressing perceptions about nursing will involve a sustained attempt to alter how those in nursing reflect the profession to outsiders. A positive view is essential. Yet no campaign would be able to convince young people or school leavers that nursing is a worthwhile career option to pursue if the reality being experienced by nurses is not positive. Issues need to be addressed front–on so that nurses’ levels of job satisfaction and confidence with the profession’s future are restored and a truly positive image for nursing as a career can be conveyed.

6.23      The National Nursing Workforce Forum concluded that there needs to be a strategic response on the part of Federal and State governments in collaboration with the profession to implement and sustain a marketing effort that addresses the image of nursing both within the profession itself and to the community at large. The main aim of the strategy is to recruit quality students into nursing as a career and attract existing nurses back into the workforce and for the community to value the contribution of nursing.[10]

6.24      Nursing needs to be repositioned, with structures and supports that value its contribution, recognising it as a highly versatile profession with enormous diversity and opportunity where young people can learn science, technology, caring, critical thinking and decision making and that it is a profession with equal status to other practicing professions within the workplace.

Campaigns

6.25      In many jurisdictions there have been media campaigns to attract nurses with a focus on combining the positive image of nursing to the education levels required and career opportunities apparent in the profession post registration. The Committee received information about a number of positive campaigns being conducted, including:

• Nursing Career, Education and Employment Expos convened by the Royal College of Nursing and with exhibitors from universities, specialty nursing groups, hospitals and other health industry employers;[11]
• The Western Australian marketing program centred on the slogan ‘Are you good enough to be a nurse’;[12]
• ‘Nurses: worth looking after’ – A Queensland Nurses Union campaign directed to improving the pay and conditions of nurses;[13]
• Joint efforts between the NSW Department of Health and the NSW Nurses Association to attract school leavers to a career in nursing.[14]

6.26      The Committee considers that such campaigns are constructive and would be enhanced by the development of a comprehensive national marketing program focussing upon nursing being a favourable career option.

6.27      The Committee was reminded that any marketing strategy ‘must be complemented at the same time by strategies aimed at addressing retention issues if maximum benefit is to be gained from the marketing strategy’.[15] No amount of marketing will be successful if retention issues such a the following are not addressed:

• workload pressures,
• doctor, patient and patient family demands,
• staff shortages without relief,
• higher patient acuity levels,
• long hours and double shifts,
• lack of professional support of clinical nurse specialists and educators, and
• ‘old fashioned’ work practices.

6.28      Representatives of universities and the health care sector do attend ‘career nights’ and arrange displays at schools, though there is scope for greater opportunity of promoting nursing as a career through visits to high schools and colleges, arranging exhibitions and the production of promotional information emphasising the variety of nursing career choices available.

Recommendation 50: That the Commonwealth and States fund regular, sustained campaigns conducted on a nationally coordinated basis to promote the status and positive image of nursing.

Recommendation 51: That a national nursing recruitment strategy be developed by the Commonwealth in consultation with the States and relevant nursing and employer bodies, with recruitment targets established through national workforce planning.

Recommendation 52: That any recruitment strategy and marketing campaigns specifically include encouragement for more males to adopt nursing as a career.

6.29      Use of the Internet can prove to be a valuable medium for promoting and disseminating information about nursing. The Committee’s attention was drawn to a new American website created as part of a national campaign ‘Be a nurse. They dare to Care’. The site offers information about nursing salaries, nursing specialties, future nursing demand, individual nurse profiles, every nursing education program in the country and every scholarship available to nursing students – by region, size of program or scholarship, and types of degree offered.[16] A number of Australian websites are listed in Appendix 4.

Overseas recruitment

6.30      As noted in chapter 2, arrangements within Australia for recruiting nurses from overseas is undertaken primarily on an individual health service or hospital basis and with varying levels of intensity, though Government bodies are reticent to become directly responsible for overseas recruiting campaigns. While the recruitment of nurses can ameliorate the shortage of nurses in the short-term, the Committee does not consider that the employment of overseas nurses is an appropriate mechanism to overcome the long-term shortage of nurses in Australia.

Retention

6.31      Data has shown that a significant number of nurses depart nursing within 12 months of graduating, while the general turnover of experienced nurses is also unacceptably high. Strategies to retain nurses are cost-effective due to the funds and commitment that has already been expended in training nurses being lost, as well as the invaluable experience developed over years in nursing being lost.

6.32      Nurses report a range of reasons for leaving the profession including disillusionment through feeling unappreciated and undervalued for their contribution and commitment, perceived lack of support from their management and lack of respect from doctors, lack of career path for experienced nurses, being overworked and burnt out due often from staff shortages, suffering frustration and physical and emotional exhaustion, and receiving low pay compared with their responsibilities and/or compared with what they could receive in other professions.[17] Disaffected nurses leaving the profession serve only to compound the problems for those remaining.

6.33      The submissions received by the Committee from over 600 nurses in response to an Australian Nursing Federation (ANF) questionnaire provided a similar list of issues impacting on their working life and which are seen as important for them to remain in nursing. The most commonly identified issues were low morale through lack of recognition of their skills and work, low pay scales, large workloads and stress from staff shortages and cost cutting, lack of development and career opportunity, inflexible rosters and shiftwork. Information from these submissions is detailed in Appendix 3.

Nature of nursing

6.34      There is a growing complexity within the role of nursing. A combination of factors are leaving nurses dissatisfied and experiencing a sense of alienation from their work. Nurses are becoming an increasingly educated and experienced workforce, though their role in health care does not appear to be recognising their evolving situation. While the nursing workforce becomes more highly skilled, there is an increasing use of unqualified or semi-skilled persons undertaking nursing duties. This demeans the nurses’ role, as a perception that the delivery of nursing care requires little or no specialist knowledge, skills or academic preparation is reinforced. The time expended by trained nurses constantly having to supervise unqualified health care workers combines with their sense of powerlessness within the health care system to foster the sense of alienation from their work.

6.35      The evolving role of nursing and responsibilities of nurses must be recognised in future planning. It is envisaged that the proportion of assistants in nursing and ENs will increase in coming years compared to RNs. Queensland Health has commented that this change in the composition of the nursing workforce would require a redistribution of the services provided by each component of the nursing workforce. In particular, the RN workforce would focus on the provision of high level nursing services while ENs and assistants in nursing would take over the lower level services currently undertaken by RNs.[18]

Career structure

6.36      The current career structure needs to be reviewed and revised in order to adapt to the evolving role of nursing and to more appropriately acknowledge advanced clinical practice by providing an incentive for clinicians to stay in practice. As the nursing executive at Sir Charles Gairdner Hospital commented:

One of the most significant factors in influencing nurses to remain within the nursing profession is the ability to recognise a potential career path. There are currently limited opportunities within the clinical, research or education arenas at middle to senor levels of nursing and as a result nurses choose either to remain at the clinical level or leave the profession to seek satisfaction in other areas.[19]

6.37      The career pathways within nursing are currently ill defined. Often nurses progress within the health care system in an accidental manner, depending on how they are promoted and the pathways they may choose at the time. It was considered that certain career pathways could be streamlined and that significant incentives could induce people to enter particular career pathways, especially those where there are critical shortfalls within the workforce.

6.38      Nurses lack advice on the career pathways available to them, both within hospitals and in the broader system. Packages need to be developed that provide assistance to workers within the health care system to provide appropriate advice regarding the many, varied career pathways that can be undertaken within nursing.

6.39      A number of suggestions for developing improved career paths were advanced in evidence:

• A nurse’s progression in their career, through recognition and reward, should be based on increasing skills/competencies and qualifications rather than on years of service as is the current system. This should also include a strategy to link competence to salary to enable skilled nursing staff to be paid appropriate to their competence.
• A more structured pathway for nurses to remain within the clinical stream needs to be supported financially and politically. Currently nurses have to leave the clinical stream in order to advance their career. Career pathways, that recognise clinical expertise and enable practitioners to remain in the clinical setting but still pursue career progression, should be established. This would allow for appropriate recognition and time for mentoring and preceptorship as well as clinical expertise.
• There should be multiple entry and exit points into nursing to enable persons to select the level of training to enter nursing, or to upgrade from one level to another ie. an enrolled nurse to a registered nurse, or to transfer from one type of nursing to another. Multiple entry and exit points should be offered within the nursing programs. Multiple career pathways should be constructed that include the introduction of double degrees, accelerated pathways for Nurse Practitioners, and specific streamed processes through which people can gain advanced practitioner status.
• Opportunities for nurse practitioners in specialised nursing functions and rural/regional centres should be accelerated.
• The development of partnerships between the tertiary education and health care sectors - in particular, specialty areas such as mental health, critical care, ICU, perioperative, aged care and midwifery would prove advantageous.
• Governments and professional bodies should have a role in providing information to nurses on career pathways.

Recommendation 53: That the current career structure be reviewed and revised to provide career pathways that include continued clinical practice, enhanced opportunities for postgraduate study and accelerated pathways through which nurses can move to an advanced practitioner status. The career structure needs to recognise the skills obtained through postgraduate study and remunerate them accordingly.

Recommendation 54: That governments and professional nursing bodies provide detailed information to nurses on career pathways.

Transition to practice

6.40      Overcoming difficulties during the first twelve months spent adjusting from university to practice is crucial to retaining nurses. New graduates require support and the development of skills to manage the transitional problems they face. There are many issues in this area including the level of clinical preparation of new graduates, improved and better funded graduate nurse programs, more effective support for new graduates especially through mentorship and preceptorship programs, and enhanced training and remuneration for preceptors. Issues relating to transition to practice have been considered in chapter 3.

Workloads

6.41      Changes in the delivery of health care to reduce the time patients stay in hospitals with resultant greater acuity of patients leads to increased workloads for nurses. Nursing staff shortages, especially the inadequate number of nurses to meet desired nurse:patient ratios and the inappropriate skill mix to provide the necessary clinical support for junior nurses, exacerbate workload problems.

6.42      Workloads must be addressed in relation to their effect on burnout and stress. Burnout contributes to job dissatisfaction, absenteeism and turnover. Burnout is the consequence of specific social and situational factors that can be changed, if the will is there. Social support in the workplace is a critical tool for offsetting burnout in nurses.

6.43      Improved nurse:patient ratios is regarded as a primary mechanism for nurses to control workloads and to be able to properly look after patients. Victoria has introduced measures to improve nurse:patient ratios and reduce workload by adding extra nurses into the public health system.[20]

6.44      Apart from employing more nurses, a number of suggestions were made to address this issue. They included the development and implementation of a patient acuity system which accurately reflects the skill mix required to meet the care needs of patients with nurse working hours, increasing the number of ward clerks in order to increase the effective use of nursing time and to factor in time for communication and interaction by nurses with patients to increase staff job satisfaction.

6.45      The University of Western Sydney suggested that with the ageing of the nursing workforce, one option is to make nursing work more age-friendly to retain older workers.

There are improving technologies which allow older workers to continue to work in care roles. This will not only allow older workers to work longer but it will make nursing work less exposed to risk of accident and injury. As well there are opportunities to develop new nursing specialties, for example case management/coordination, that may be attractive to older workers. This is a quantum leap for the health system and it will need careful consideration and long-term planning to achieve the cultural change.[21]

Recommendation 55: That the Commonwealth and States encourage providers of health care services to promote multidisciplinary team approaches to patient care which recognise all members of the team as valued and valuable.

Remuneration

6.46      Issues of inadequate pay and working conditions are very important to nurses, as they have been fundamental concerns leading to increasing militancy in recent years. Nurse’s work is often perceived as synonymous with ‘women’s work’ and has been underpaid and under valued for far too long.

6.47      Queensland Health has noted that ‘the typical starting salary of graduate nurses appears to be about the same as the typical starting salary of all university graduates. However, comparison of the salaries of all professionals, not just new graduates, shows that the typical salary of a registered nurse appears to be below the typical professional salary.’[22]

6.48      A recent study prepared for the NSW Nurses’ Association (NSWNA) found that while the issue of pay rates relative to other professions and allied health workers is very important, there was much stronger sentiment that nursing rates of pay were quite unfair now compared with those which had prevailed in the past because of the changing nature of nursing work. Nurses are saying that they do not feel that they are financially rewarded for the level of responsibility that they are currently undertaken.[23] As one submission commented, ‘Australia’s health care system is not sustainable without remuneration which compensates for the skill and knowledge required to practice as a nurse’.[24]

6.49      A particular issue of concern for nurses who have undertaken professional development through obtaining postgraduate qualifications is the lack of recognition and appropriate remuneration to reward the skills attained as a result of their commitment to higher education and training.

6.50      Similar issues arise in the area of nursing leadership. The Committee was advised that nursing unit managers (Level 3) who assume advanced levels of responsibility in managing a unit are often getting paid less than their subordinate staff, due primarily to the loss of penalty pay through no longer working shifts or overtime and thus forfeiting penalty pay.[25] Women’s and Children’s Health Victoria noted the unit manager role is central to maintaining clinical practice standards and providing quality nursing services. The role needs to be remunerated accordingly.[26]

6.51      Other issues on remuneration included the salary differential across jurisdictions for the same level of nurse and the disparity between pay for nurses working in aged care. The issue of pay rates for aged care nurses is discussed in chapter 7.

6.52      Many nurses hold the view that the changes required to make nursing more attractive would take some time to achieve. Changes in pay could, however, be achieved almost instantly.

Recommendation 56: That experienced, skilled and educated nurses be recognised and rewarded, both financially and through promotional opportunity, for the work they perform in decision making and the management and coordination of patient care across the continuum of care.

Education

6.53      Health care in the Australian context is dynamic and challenging. Greater access to clinically relevant, vocationally oriented ongoing education and greater recognition for post-graduate study successfully undertaken are important points to encourage nurses to remain in the profession. Nurses need opportunities for continuing education to prepare for, and remain competent throughout their careers in the various scopes of practice.

6.54      Education is the foundation of professional development and the key to empowering the nursing profession. Barriers must be removed so as to ensure nurses reach their full potential. Education programs must be affordable and career structures and organisational structures must be developed that reward commitment to life long learning.[27]

6.55      The importance of continuing education is discussed earlier. However, access to ongoing, and especially postgraduate, education is often financially crippling, thereby depriving many nurses of the opportunity of further study. The provision of additional scholarships or financial assistance and permitting time off for study leave are regarded as necessary improvements to this area.

6.56      The development of close partnerships between academic institutions and the health care sector, as discussed in detail in chapter 5, will help address the nurse retention issue. Such developments are allied to strategies to retain nurses in the workforce and to attract nurses back into the profession in the public, private and aged care sectors.

Unqualified workers

6.57      The increased numbers of workers with little or no formal training being introduced into the health care system as a replacement for qualified nurses or to cover nursing shortages is having an adverse effect on nursing practice and morale. These workers are generally unregulated and unlicensed. This unregulated section of the workforce is discussed in chapters 4 and 7 dealing with EN education and aged care.

Nursing leadership

6.58      Leadership in nursing is a critical issue that must be addressed. It is recognised that the Nurse Unit Manager role is critical in the organisation of care delivery. Nurse Unit Managers must be carefully selected, developed, mentored and rewarded. In many instances unit managers are given an onerous task to perform without being equipped with the skills necessary to lead and manage teams of professionals.

6.59      Nurses today are highly skilled, highly educated and articulate. Clinical nurses, given they ultimately implement decisions, eg new technology, policies, documentation, should be actively involved in high level clinical decision-making.

6.60      It is difficult for nurses to play significant roles in policy-making or communicate effectively with decision-makers because they are under-represented in institutional hierarchies. Thus they have limited power to influence change or make improvements. A broadening of access to senior roles will create opportunities for greater diversity and strength of leaders who wish to remain in their areas of expertise. Good nursing leaders can increase group cohesion and reduce stress. The magnet hospitals experience referred to earlier has shown that leadership which supports and empowers nurses through their involvement in decisions, planning and policy making, improves their motivation, retains their loyalty and reduces staff turnover.

Recommendation 57: That the Commonwealth and States encourage providers of health care services to support nursing leadership by integrating nurses into the organisational hierarchy through their appointment to and meaningful participation in management; and by promoting nurse involvement in decision-making relating to nursing practice and clinical patient care.

Recommendation 58: That the Commonwealth and States ensure that nursing leaders are provided with the necessary in-service training and development to support them in their constantly evolving roles.

Management support

6.61      Many nurses indicated in evidence that much greater support was required within the hospital setting from management, to facilitate a work place environment that encouraged nurses into, and to remain within, the health care system. Many of the issues relating to retention particularly in regard to family friendly policies and occupational health and safety issues are within the control of nurse and hospital managers.

6.62      Evidence to the Committee repeatedly raised these and other points as contributing to reasons why nursing is losing its attractiveness:

• There needs to be support ranging from remuneration issues through to counselling services, education and incentive/reward systems;
• There needs to be appropriate time for nurses to be debriefed over the day’s activities and processes established for mentorship;
• Improved role modelling by management to address particular concerns, such as behavioural issues, time management, patient focus and etiquette, needs to be pursued;
• There also needs to be support for nurses at the hospital level by managers and boards of management during legal issues arising from patient care or when nurses are subjected to aggressive and violent behaviour and harassment.

6.63      A greater number of senior nursing managers are needed in Area Health Services or their equivalent who possess and can apply best practice management standards and well developed risk-management strategies.

Return to nursing – Re-entry and refresher programs

6.64      Returning skilled and experienced nurses to the workforce is a critical aspect of nurse recruitment and retention. Strategies for retaining expensively educated nurses in the system and for returning trained nurses to health care after restoring their competency levels by updating knowledge and skills are cost effective measures. The recruitment and education of new nurses is a much more costly option. Recent research indicates that there is a sizeable pool of trained nurses, who would be willing to return to nursing, particularly in the surgical, midwifery and critical care areas.[28]

6.65      Re-entry and refresher programs are currently loosely arranged, may be offered within individual hospitals, universities or by health services, and with marked jurisdictional variations of form and content.

6.66      The re-entry programs are intended to provide a re-entry avenue for previously Registered or Enrolled Nurses who have allowed their registration to lapse, usually beyond a five-year period. Such programs provide the participants with the opportunities to update nursing knowledge and develop nursing skills to a level of competency that is required for registration within the State and therefore re-entry into the nursing workforce. Re-entry programs usually run for 12 to 18 weeks and may be offered through universities or health care facilities. However, the length, content and competency levels can vary widely between re-entry programs.

6.67      Refresher programs are generally intended for Registered or Enrolled Nurses who have maintained registration but have not worked for less than five years, and who wish to consider returning to nursing. Refresher programs usually take between 6 to 12 weeks to complete and may be provided by both public and private health care facilities. Content usually covers theoretical update on nursing issues and practice and supervised clinical practice.

6.68      Career advisory information needs to be developed in conjunction with return to nursing programs. The New South Wales College of Nursing commented that:

There is a general lack of knowledge about retraining or refreshing in nursing after a period of absence. Many respondents do not know about refresher courses or how to find out about them. Others had sought careers advice but had been unable to find appropriate or adequate information.[29]

6.69      The financial aspects associated with re-entry programs are important. The Committee received evidence on costs that even if a program is provided free of charge, there is usually no income whilst retraining. Significant travel and relocation expenses and personal inconvenience provide added difficulties for those in rural or remote areas. The ANF commented that the cost of such courses may act as a barrier to nurses returning to the workforce and suggested that government and other employers should subsidise programs and offer re-entry program scholarships as recruitment and retention initiatives.[30]

6.70      NSW Health has introduced Nursing Re-Connect which offers a clinically focussed, individually tailored re-entry plan on a full or part time basis in general or specialty areas. Participants are employed and paid while undertaking the program which does not charge course fees.[31] Other jurisdictions also advised that work is in progress to develop consistent standards within re-entry and refresher programs, funding the programs and providing participants with a wage.[32]

6.71      The Australian Private Hospitals Association indicated that the private sector is willing to work with the public system in developing and supporting refresher and re-entry programs to encourage nurses to return to the workforce.[33] Programs in the aged care sector have been considered in the chapter on aged care nursing.

6.72      The Australian Catholic University suggested that funding should be provided to universities rather than hospitals for the education and updating of nurses returning to the workforce. The focus of education would be toward the returning nurse to ensure they received the knowledge and skills that met their needs, by utilising the considerable educational resources available at all universities.[34]

6.73      Nurses returning to the workforce are often doing so after having started a family. They like to work near home and school, work part-time, choose their shifts and be able to work shorter or longer shifts as family commitments alter or their health dictates. These issues are all related to making nursing a more family friendly career.

Recommendation 59: That the Commonwealth and States fund re-entry and refresher programs in all States and Territories, including the employment and payment of salaries for nurses undertaking such programs.

Recommendation 60: That there be greater coordination of re-entry and refresher programs provided through hospitals and tertiary institutions and of the content of these programs.

Making a nursing career more family friendly

Working conditions

6.74      Difficulties with working conditions are conveyed as a most serious problem for the retention of nurses practicing in the profession. More family friendly working conditions are often expressed as the reason why some nurses move to work in the private sector or for agencies or leave the profession altogether. Overcoming issues in this area are at the heart of making nursing more family friendly and encouraging nurses to return to the profession, particularly in the public and aged care sectors.

6.75      The ANF has noted that nurses report that working conditions consisting of inadequate levels of appropriately qualified staff that result in unreasonable workloads lead to nurses returning home to families at the end of a shift too exhausted to undertake family responsibilities or participate fully in family and social activities.

6.76      Nurses report that not only does inadequate staffing levels and unreasonable workloads result in physical and mental levels of exhaustion, they are also the major aspects affecting their job satisfaction. This is due to the impact these aspects have on the level of care nurses are able to provide, in a health care environment characterised by such conditions. Satisfaction with work performed has a positive impact on feelings of self esteem and well being which extend beyond the workplace into family and social life. The job dissatisfaction experienced by many nurses is negatively affecting the way they interact with their families and in their social contacts.

6.77      Flexibility in rostering is a particular area requiring consideration. Long hours and rotating shifts are disruptive to family and social life, with rosters perceived by nurses to be structured to meet workplace needs without their needs being considered in the process. A number of submissions suggested a return to 8, 8, 10 rostering. Nurses at the workplace should have a greater say in the structuring of their rosters.

6.78      There is variance between State awards in relation to mix of shifts in roster periods and minimum breaks between shifts. Some submissions urged the benchmarking of award rostering conditions across the States, such as minimum breaks between shifts, number of consecutive shifts that may be rostered without consultation and the mix of shifts within a roster period.

6.79      Shiftwork remains an unattractive option for many nurses. The unsociable hours that are worked can no longer be accepted as just a part of working as a nurse. Suggestions to make shiftwork more palatable include increasing financial incentives for shiftwork, especially night duty, offering incentives to attract more permanent night staff and providing additional leave to compensate shiftwork.

6.80      Associated with flexible rostering there needs to be greater use of part-time and job-share options to enable registered nurses to work around family commitments whilst developing their careers. Such flexibility needs to be balanced so that full-time staff are not left to continually work unwanted shifts and are not otherwise penalised.

6.81      Reference has been made to the difficulties many nurses have in gaining time-off for study leave, especially for postgraduate studies. Flexible rostering arrangements can assist nurses to undertake further studies.

Parental leave

6.82      Paid maternity and paternity leave is provided within the public sector, yet nurses appear to struggle to receive consistent levels of paid leave across Australia. Paid maternity and paternity leave should be available for all nurses, including those working in the private and aged care sectors. The establishment of a benchmark of 14 weeks paid maternity leave was proposed by the ANF,[35] though a national campaign for 12 weeks covering the entire workforce is currently being undertaken. Any benchmark that is agreed should apply equally across all jurisdictions.

Childcare

6.83      With nursing having a predominantly female workforce many of who undertake the role of child rearing, childcare becomes an essential part of the workplace support infrastructure. Research has shown that many nurses leave nursing temporarily or permanently to have children and that there are inadequate incentives for them to return to nursing following career breaks.

6.84      The issue of childcare was constantly raised as an important aspect of encouraging nurses to remain in or return to the profession. While nurses face similar decisions about childcare as any other worker in respect of the child’s best interests and the affordability of care, rostered working hours considerably reduce their options. Nurses who often work long hours or shifts require extended hours childcare, access to before and after school care, and vacation care. Very few childcare centres offer the flexibility of hours of care to meet such a requirement. Many submissions argued that adequate, affordable, quality childcare must be provided over extended hours at the workplace or, alternatively, childcare assistance could be provided in the form of a direct subsidy.

6.85      A particular issue for women returning to work with babies who require feeding is permitting breast-feeding in the workplace through the provision of an appropriate environment to allow lactation breaks. The ANF and its branches strongly support this position and have a policy endorsing the practice.

Caring for relatives

6.86      As noted previously, nursing is an ageing profession with many nurses having an additional responsibility of caring for elderly parents or relatives. Being able to juggle work and caring for relatives require a delicate balancing of a nurse’s time. This raises issues not just of caring for the elderly, often in a home environment, but also of flexibility of working arrangements. Many nurses will require access to affordable day care facilities that are responsive both to the needs of the elderly person and the needs of the nurse in that they are open for extended hours, as well as for occasional care.

6.87      The Committee considers that nurse employers have the responsibility to commit to ‘family friendly’ practices and introduce them into their workplace. While not directly relevant to Commonwealth responsibilities, the Committee was repeatedly told by nurses and nursing organisations that the need for more ‘family friendly’ practices in the workplace was a significant issue for the retention of nurses.

Recommendation 61: That the following ‘family friendly’ practices be advocated by all levels of government as best practice for all providers of health care services and nurse employers:

• That flexible rostering be introduced or where appropriate developed further, together with the encouragement of greater use of part-time and job-share options.
• That paid maternity and paternity leave be available to all nurses.
• That adequate, affordable, quality childcare be provided over extended hours at the workplace, or through other forms of direct childcare assistance such as the procurement of places at nearby childcare centres.
• That adequate facilities to meet breastfeeding requirements be provided in the workplace.
• That work practices be established to encourage experienced older nurses to remain in the profession.

Improving occupational health and safety

6.88      Providers of health care services have developed occupational health and safety policies in accordance with statutory requirements, though many areas struggle with OH&S issues due to staffing shortages. While monitoring of the work environment and staff behaviour regarding OH&S must be ongoing, the most effective way of improving OH&S performance is through ensuring staffing numbers remain consistent and reliable.

6.89      The work environment can have positive or negative physical, mental and social effects on nurses. Like all employees, nurses should be able to work in an environment that is safe and free from fear and intimidation. Much remains to be done to reduce the high rate of injuries to nurses and enhance their feelings of well-being by improving standards of work environments and through the provision of staff recreational amenities that provide opportunities for health and fitness activities.

Violence in the workplace

6.90      The level of aggression, violence and harassment encountered by nurses in their working environment is a major concern and an influential factor in many leaving their job. The issue has been well researched and documented, with some studies showing that nurses are physically assaulted, threatened and verbally abused at higher rates than other professionals.[36]

6.91      Violent or aggressive behaviour towards nurses is encountered in a number of forms and places. Emergency departments, mental health settings and community practice are particularly hazardous environments. The mainstreaming of mental health and an increase in drug and alcohol induced problems have led to more patients presenting to hospitals with behavioural difficulties that may result in recourse to violence. Nurses are in the frontline of health care and increasingly confronted with verbal or physical abuse from patients or relatives expressing raw emotions in response to the traumas of acute and chronic illness. Many nursing staff are not appropriately trained to manage patients and their relatives who display such an aggressive behavioural disposition. Nursing staff need to be assured that there is adequate security staff backup should they become involved in violent episodes.

6.92      The external environment also needs to be made safer. Shift workers have been violently attacked in car parks while returning to their transport especially in evenings. Car parking should be accessible, well secured and well lit for access at all hours. The Committee heard of examples where hospitals that had experienced trouble within their grounds had introduced 24-hour a day security presence.

6.93      Exposure to danger is especially high in situations where nurses are working as sole practitioners, such as in community or rural nursing. It was strongly argued that nurses should not be placed in the situation of having to work on their own. Where this was not possible, nurses should be given access to communication devices to allow for immediate and effective monitoring of their location and well-being.

6.94      The other major source of concern in this area is horizontal violence or workplace bullying. This may involve a single physical act of violence resulting in a physical or emotional injury or some form of continuing harassment or bullying. Such behaviour includes any threatening statements or behaviour to victimise, threaten, undermine or generally give the worker cause to believe he or she is at some form of risk. This makes the workplace an unpleasant, intimidating or humiliating place to work. Within nursing, it is often reported as the younger nurses or students who encounter problems from hostile and unsupportive older nurses.

6.95      A major contributing factor to the problem of horizontal violence is that nurses need to feel better supported within the hospital system, which currently seems to perpetuate the problem. There needs to be more participative management so that nurses have a voice in the organisational decision making. Adequate role preparation for managers and clinical supervisors is seen as integral to reducing horizontal violence and other system sources of aggression.

Recommendation 62: That governments ensure that providers of health care services guarantee that education and other support measures for managing and responding appropriately to aggressive and violent behaviour are available to, and routinely provided for, nurses as continuing education in the workplace.

Recommendation 63: That the Commonwealth introduce a national reporting system for violence and aggression toward nurses and other health workers in order to understand the factors which give rise to violent incidents, the extent of the problem, and to inform the development of strategies to prevent future violent incidents involving nurses and other health workers.

Manual handling

6.96      Research has shown manual handling to be the major cause of injuries to nurses. Serious manual handling injury is a significant cause of wastage of experienced nurses from the profession. Management of this issue is occurring through the implementation of ‘no lift’ programs, advocated by the ANF, to reduce manual handling injuries resulting from the lifting of patients. ‘No lift’ programs, particularly those adopting a full risk management approach, have been very effective at reducing the number and severity of injuries. The Victorian Nurses’ Back Injury Prevention Project has had promising results with a reduction in patient handling injury and lower back injury claims since the implementation of the no lifting program.[37]

6.97      The NSWNA noted that the management of manual handling risks not only reduces injuries, it provides a more supportive environment that leads to less physical exhaustion of nurses and improved accommodation of post injury rehabilitation programs. It also generates large cost savings through lower workers compensation and rehabilitation costs. Anecdotal reports of reduced staff turnover and absenteeism are commonplace in workplaces that have implemented manual handling risk management systems in consultation with their staff.[38]

6.98      Discussion in chapter 2 on nursing shortages has shown that most health service and aged care facilities are understaffed. Nurses are at greater risk of personal injury when they are stressed, tired and overworked. Nurses are also less likely to use safe manual handling practices including lifting devices when workloads are heavy because they cut corners with safety to save time. Adequate staffing levels and appropriate skills mix are integral to the elimination of manual handling injuries.

6.99      Hospital and nursing home equipment, including safe lifting devices, should be up to date, readily available and regularly maintained. All staff must have access to appropriate education and training on how to use equipment.

Needlestick injuries

6.100         Needlestick injuries are a recognised source of exposure to blood-borne diseases for workers in health care occupations, especially hepatitis B, hepatitis C and HIV. While most workers may not contract infection from such an injury, they all endure a lengthy and expensive process of diagnostic procedures of up to three months with the added psychological trauma of uncertainty during this period before it is known whether a serious disease has been contracted or not.

6.101         The exact level of needlestick injury is difficult to determine. While the Committee’s attention was drawn to a number of studies conducted internationally, the number of published studies relating to Australia remains minimal. Figures provided to the Committee indicated that over 3000 needlestick injuries occurred in 1997 within 56 hospitals participating in an exposure prevention program and that at least 13 000 had occurred in Australian hospitals in 1998. The Committee also received individual statistics from a number of major hospitals. Research has indicated that the actual incidence of needlestick and sharps injuries could be much higher due to under-reporting, with some estimates that it may be by as much as 60 percent.[39]

6.102         The economic implications of such injuries are substantial. The cost of testing and treating injured workers has been assessed internationally and theoretical calculations have also been undertaken in Australia. The cost of treatment for one uncomplicated injury (no transmission of infection) ranged from a ‘conservative’ $550 to over $1 500. Becton, Dickinson estimated that, based on 13 000 injuries and by using the lower cost figure, the economic cost of needlestick and other sharps injuries could be over $6 million per annum. Large compensation payments for those who may contract disease are likely to significantly inflate the economic cost.

6.103         Infection control experts agree that the number of injuries could be drastically reduced by the use of safety technology and education programs. In April 2001 the Federal Needlestick Safety and Prevention Law came into effect in the United States. In Australia action is currently left to individual hospitals or health services.

6.104         The Austin and Repatriation Medical Centre in Melbourne has introduced a needlestick prevention program using safety engineered technology combined with nursing and medical staff training. To pay for the program the hospital has had to prioritise its funding and divert funding from other programs. No additional funding is provided for the program, which is expected to cost about $400 000 per annum. Royal Perth Hospital has introduced a needleless intravenous injection system, with other initiatives including a retractable intravenous insertion needle and a vacu-container blood collection system. Some individual NSW Area Health Services are proactive in providing hospital products designed to reduce needlestick injuries. For example, the Illawarra and Hunter AHSs have mandated OH&S policy changes for the use of safety engineered sharps. These examples are very much a minority.[40]

6.105         The Australian Infection Control Association emphasised that:

safety devices are only one component of the overall occupational health and safety management in terms of occupational exposures...Supplying of safety devices requires education and training in support of these as well as appropriate levels of staffing resources both in numbers or skill mix. The need to work quickly under staffing and other resource pressures all appears to contribute to higher occupational exposure injury rates.[41]

6.106         Becton, Dickinson considered that ‘by delaying the implementation of safety technology, Australian hospitals and health care institutions are exposing themselves, their Directors and taxpayers to expensive litigation under Occupational Health and Safety Acts’.[42]

6.107         The ANF expressed concern that decisions about products designed to reduce needlestick injuries are being made on the basis of cost. The cost of such products needs to be offset against the compensation costs for a nurse or other health worker contracting or fearing a blood borne illness. The ANF commented that while some employers have placed the health and welfare of nurses before cost and upgraded their products, the response is generally inadequate. The Federation argued that if this can not be achieved on a voluntary basis, then it should be made mandatory under occupational health and safety legislation.[43]

Recommendation 64: That the National Occupational Health and Safety Commission urgently develop model uniform OH&S legislation and regulations for the Commonwealth, States and Territories relating to the use of safe needle technologies in Australian hospitals and other health workplaces, and work cooperatively with the States and Territories to improve associated safety education and training programs for health care workers.

Glutaraldehyde and latex

6.108         The ANF has raised the issue of exposure to the disinfecting agent glutaraldehyde and the onset of hypersensitivity conditions. There have been successful British compensation claims for debilitating conditions such as asthma. The ANF notes that some improvements have been made in the Australian health system, such as stringent monitoring processes, better education, improved ventilation and other protective measures. However, the Federation does not consider the risk to nurses acceptable and proposes that glutaraldehyde use be eliminated and safer methods of disinfection used.[44]

6.109         Latex allergies or sensitivity is also seen as an escalating problem for health care workers in Australia. Reactions can range from allergic skin reaction to systemic hypersensitivity. While the use of latex gloves has grown markedly in recent decades, the prevalence of latex allergy/sensitivity is not known, although studies in the United States have estimated that between 5 and 17 percent of the health workforce are affected. Cost is acknowledged as an issue due to the significant differences between products containing latex and those without. However, the ANF notes that this must be weighed against the potential costs of lost productivity and workers’ compensation payments for staff who develop latex sensitivity and allergy through exposure to latex allergens in the workplace.[45]

6.110         In general, all nursing staff should have ready access to appropriate equipment and apparatus and protective attire for use while handling and having exposure to chemicals and toxic substances and bodily fluids. Procedures for reporting hazards needs to be streamlined and readily understood by all nursing staff.

Recommendation 65: That governments ensure that all nurse education curricula include occupational health and safety theory and practice covering aggression management training, use of safety equipment and devices, manual handling training, and competency assessment.

Recommendation 66: That the following ‘occupational health and safety’ practices be advocated by all levels of government as best practice for all providers of health care services and nurse employers:

• That all health and aged care facilities provide nurses with access to peer support, appropriate counselling, post-incident defusing and debriefing, and grievance handling.
• That providers of health care services support their nursing staff in the prosecution of violent offenders.
• That providers of health care services be required to ensure that nurses do not work alone in areas of high risk or where the level of risk is unknown. Where this is not possible, personal duress alarms or similar communications devices should be provided for personnel.
• That staff car parking should be accessible, well secured and well lit for access at all hours. In recurring problem areas, dedicated 24-hour a day security presence should be provided.
• That sufficient funding be available to ensure that hospital equipment, including safe lifting devices, are up to date, readily available for staff use and regularly maintained.
• That research be commissioned into the long-term effects of exposure to glutaraldehyde and that a process be put in place to eliminate the use of glutaraldehyde in health and aged care sectors.
• That alternative equipment be provided for those who are allergic to latex, with a view to eventually replacing the use of latex products by health care workers.

Recommendation 67: That governments ensure that all managers in health services receive training in:

• Management styles that promote leadership and consultation;
• Management skills to include conflict resolution and grievance management, improved human resource management, understanding industrial relations and awards, and information technology skills; and
• Occupational health and safety responsibilities and risk management.

Conclusion

6.111         The Committee notes that recruitment and retention issues have been extensively canvassed in recent reviews, inquiries and research projects. Strategies to address the issues have been identified and recommendations proposed. Action has been undertaken to different degrees across the Commonwealth and States. However the Committee considers that all nursing issues and especially those affecting recruitment and retention, need to be approached holistically, in a nationally coordinated and planned manner.

6.112         The Committee has not attempted in this chapter to reproduce in detail the arguments and discussions from these reviews, a great deal of which was strongly reinforced in the submissions and evidence received by the Committee. Rather, the Committee has attempted to highlight many of the major issues that have been raised. The Committee believes that it is now time for decisive national action and has made recommendations accordingly.

6.113         The Committee considers that the following list identifies major issues requiring strategic action to expand the level of nurse recruitment and retention:

• Promotion of a positive image for nursing and promotion of nursing as a desirable career;
• Development of a skilled nursing workforce that is highly valued within the health care system and by the community generally;
• Introduction of programs to reinvigorate nurse job satisfaction and to bolster morale;
• Expansion of refresher and return to nursing programs;
• Improvement of working conditions, especially workloads and flexibility in rostering and working hours;
• Increasing remuneration;
• Extension of continued education opportunities for professional development;
• Development of improved career pathways and opportunities, with professional recognition of knowledge, skills and education;
• Advancement of effective nursing leadership and management, including greater nurse involvement in decision making both about their professional work and broader health policy;
• Application of more family friendly policies to meet the needs of nurses, including access to childcare;
• Provision of a safe working environment that ensures nurses are free of fear, intimidation and violence.

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